Should Early Prone Positioning Be a Standard of Care in ARDS With Refractory Hypoxemia? Wrong Question

To the Editor:

Marini et al¹ offer a comprehensive and thorough review of the decades of research surrounding prone positioning in ARDS. The authors meticulously recite the literature and data to formulate an extensive list of the pros and cons surrounding prone positioning's utility in the management of ARDS. Although well-articulated and accurately presented, my main contention is that the authors recited studies and data that have already been presented in prior reviews and meta-analyses.^2–10 Instead of summarizing and regurgitating what has already been discussed about prone positioning, I wish that the authors had used their forum to discuss what I believe to be most intriguing about this topic: the barriers to its widespread adoption. As the authors mention, PROSEVA definitively showed a significant survival benefit in a select subgroup of subjects with severe ARDS.¹¹ In fact, with a 50% reduction in mortality and a hazard ratio of 0.39, prone positioning for patients with severe ARDS may be more beneficial than any other previously studied intervention for this subgroup of patients.¹¹ The authors neglected to present LUNG-SAFE, which demonstrated that only 16.4% of severe ARDS patients are actually proned.⁷ As an exercise to highlight my point, try to imagine the uproar if only 16.4% of patients with hyperlipidemia refractory to lifestyle changes were prescribed statin therapy or if 16.4% of patients with diabetes and chronic kidney disease were prescribed angiotensin-converting enzyme inhibitors (ACE inhibitors); my guess is that these dismal rates would quickly be addressed. So some paramount questions continue to remain after reading the authors' review and they are: (1) In the appropriate patient, why is prone positioning so underutilized in ARDS management? (2) What studies can we as clinician researchers and educators perform to address this underutilization? (3) What interventions can be performed that address the barriers to widespread adoption and improve the utilization rate of prone positioning? (4) What studies can we perform to test the efficacy of these interventions? Needless to say, there exists an understudied and poorly elucidated discrepancy between prone positioning's effectiveness and utilization. So, in addition to asking whether prone positioning should be the standard of care in ARDS, as proposed by Marini et al,¹ it is also imperative to include researching and addressing the reasons why prone positioning is so unpopular.⁷

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