In reply:
In this nicely written and well-intentioned letter, Dr Chertoff seems to miss the intent and message of the “controversy” format. Clearly, we agree that prone positioning has a definite place and is currently underutilized. Those points of agreement were explicit in the pro half of the discussion.1 (In fact, underutilization of this often valuable intervention was the primary motivation more than a dozen years ago for our publishing a physiologic rationale for proning and a detailed instruction set for undertaking it safely.2) But even strong advocates understand that proning should not be universally prescribed. Arguments for caution were set out in the opposing narrative of our controversy, which was deliberately polarized toward the negatives. In doing so, we think we made plain the reasons why some are reticent to undertake prone positioning.
We certainly did rehash the published literature; we are guilty as charged. The objective of the controversy exercise is to use the existing evidence base to support our assigned sides of the argument. The letter's author would prefer to ask interesting but entirely different rhetorical questions: Why not prone? What holds us back? One answer is that PROSEVA,3 although it convincingly aligns with the body of physiologic and clinical science on which it was based, was only one (as yet uncorroborated) positive randomized trial, and it enrolled a highly selected group of subjects. Those who are outside the early-severe-recruitable cohort may do no better or even worse when proned, judging from the subgroup analyses of 2 large Italian trials4,5 and the initial negative study by Guérin et al6 in 2004. Although we have our suspicions, there are no published scientific data that tell us exactly what impedes appropriate use of prone positioning, assuming that we now know which patients constitute that group who should benefit from it. The Lung-Safe survey results are certainly germane to the writer's questions of interest but quite tangential to ours.
In short, we understand and agree with Dr Chertoff's frustration with today's reluctance to adopt useful practices, but his lament seems misdirected. These controversy debates are never meant to settle the question or to reach tight consensus, simply to air the relevant issues.
Footnotes
The authors have disclosed no conflicts of interest.
- Copyright © 2016 by Daedalus Enterprises
References
- 1.
- 2.
- 3.
- 4.
- 5.
- 6.