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LetterCorrespondence

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

Jason Chertoff
Respiratory Care November 2016, 61 (11) 1564; DOI: https://doi.org/10.4187/respcare.05259
Jason Chertoff
University of Florida College of Medicine Department of Internal Medicine Division of Pulmonary and Critical Care Medicine Gainesville, Florida
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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

Footnotes

  • Dr Chertoff has disclosed no conflicts of interest.

  • Copyright © 2016 by Daedalus Enterprises

References

  1. 1.↵
    1. Marini JJ,
    2. Josephs SA,
    3. Mechlin M,
    4. Hurford WE
    . Should early prone positioning be a standard of care in ARDS with refractory hypoxemia? Respir Care 2016;61(6):818–829.
    OpenUrlAbstract/FREE Full Text
  2. 2.↵
    1. Hu SL,
    2. He HL,
    3. Pan C,
    4. Liu AR,
    5. Liu SQ,
    6. Liu L,
    7. et al
    . The effect of prone positioning on mortality in patients with acute respiratory distress syndrome: a meta-analysis of randomized controlled trials. Crit Care 2014;18(3):R109.
    OpenUrlPubMed
  3. 3.
    1. Gattinoni L,
    2. Taccone P,
    3. Carlesso E,
    4. Marini JJ
    . Prone position in acute respiratory distress syndrome: rationale, indications, and limits. Am J Respir Crit Care Med 2013;188(11):1286–1293.
    OpenUrlCrossRefPubMed
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    1. Dickinson S,
    2. Park PK,
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    . Prone-positioning therapy in ARDS. Crit Care Clin 2011;27(3):511–523.
    OpenUrlPubMed
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    1. Bloomfield R,
    2. Noble DW,
    3. Sudlow A
    . Prone position for acute respiratory failure in adults. Cochrane Database Syst Rev 2015;(11):CD008095.
  6. 6.
    1. Benson AB,
    2. Albert RK
    . Prone positioning for acute respiratory distress syndrome. Clin Chest Med 2014;35(4):743–752.
    OpenUrlPubMed
  7. 7.↵
    1. Bellani G,
    2. Laffey JG,
    3. Pham T,
    4. Fan E,
    5. Brochard L,
    6. Esteban A,
    7. et al
    . Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA 2016;315(8):788–800.
    OpenUrlCrossRefPubMed
  8. 8.
    1. Beitler JR,
    2. Shaefi S,
    3. Montesi SB,
    4. Devlin A,
    5. Loring SH,
    6. Talmor D,
    7. Malhotra A
    . Prone positioning reduces mortality from acute respiratory distress syndrome in the low tidal volume era: a meta-analysis. Intensive Care Med 2014;40(3):332–341.
    OpenUrlCrossRefPubMed
  9. 9.
    1. Alsaghir AH,
    2. Martin CM
    . Effect of prone positioning in patients with acute respiratory distress syndrome: a meta-analysis. Crit Care Med 2008;36(2):603–609.
    OpenUrlCrossRefPubMed
  10. 10.↵
    1. Mora-Arteaga JA,
    2. Bernal-Ramírez OJ,
    3. Rodríguez SJ
    . The effects of prone position ventilation in patients with acute respiratory distress syndrome: a systematic review and metaanalysis. Med Intensiva 2015;39(6):359–372.
    OpenUrlPubMed
  11. 11.↵
    1. Guérin C,
    2. Reignier J,
    3. Richard JC,
    4. Beuret P,
    5. Gacouin A,
    6. Boulain T,
    7. et al
    . Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013;368(23):2159–2168.
    OpenUrlCrossRefPubMed
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Respiratory Care: 61 (11)
Respiratory Care
Vol. 61, Issue 11
1 Nov 2016
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Should Early Prone Positioning Be a Standard of Care in ARDS With Refractory Hypoxemia? Wrong Question
Jason Chertoff
Respiratory Care Nov 2016, 61 (11) 1564; DOI: 10.4187/respcare.05259

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Should Early Prone Positioning Be a Standard of Care in ARDS With Refractory Hypoxemia? Wrong Question
Jason Chertoff
Respiratory Care Nov 2016, 61 (11) 1564; DOI: 10.4187/respcare.05259
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