To review the physiologic rationale, evidence from randomized controlled trials, guideline recommendations, and practical aspects of implementing prone positioning in patients with ARDS.
Approach:
Physiological Rationale: Prone positioning improves oxygenation by enhancing ventilation-perfusion matching and reducing pressure on dependent lung regions.
Evidence from Trials: High-quality evidence shows a mortality benefit in intubated patients with moderate-to-severe ARDS when PP is used early and for prolonged durations.
Guideline Recommendations: PP is recommended by the 2017 ATS/ESICM/SCCM and 2023 ESICM guidelines for patients with moderate-to-severe ARDS.
Implementation Challenges: Despite strong recommendations, the implementation of PP remains inconsistent globally.
Key Findings:
Prone positioning has evolved from a rescue maneuver to a cornerstone intervention in ARDS management.
The PROSEVA trial demonstrated significant mortality benefits with early and prolonged prone positioning.
Awake prone positioning has shown promising results in non-intubated patients during the COVID-19 pandemic.
Interpretation:
The physiological effects of prone positioning in intubated patients include improved oxygenation and reduced lung over-distension, while in non-intubated patients, it may enhance ventilation and reduce respiratory effort.
Limitations:
Implementation of prone positioning is inconsistent across different healthcare settings.
Ongoing questions remain regarding optimal ventilator management during prone positioning.
Conclusion:
Prone positioning is a vital component of lung-protective strategies in ARDS.
