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Prone Ventilation in Acute Respiratory Distress Syndrome
Prone Ventilation in Acute Respiratory Distress Syndrome
original article
A bs t r ac t
Background
Previous trials involving patients with the acute respiratory distress syndrome (ARDS) The authors’ affiliations are listed in the
have failed to show a beneficial effect of prone positioning during mechanical ven- Appendix. Address reprint requests to Dr.
Guérin at Service de Réanimation Médi-
tilatory support on outcomes. We evaluated the effect of early application of prone cale, Hôpital de la Croix-Rousse, 103 Grande
positioning on outcomes in patients with severe ARDS. Rue de la Croix-Rousse, 69004 Lyon,
France, or at [email protected].
Methods
* The Proning Severe ARDS Patients
In this multicenter, prospective, randomized, controlled trial, we randomly as- (PROSEVA) study investigators are listed
signed 466 patients with severe ARDS to undergo prone-positioning sessions of at in the Supplementary Appendix, available
least 16 hours or to be left in the supine position. Severe ARDS was defined as a at NEJM.org.
ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen This article was published on May 20, 2013,
(Fio2) of less than 150 mm Hg, with an Fio2 of at least 0.6, a positive end-expira- at NEJM.org.
tory pressure of at least 5 cm of water, and a tidal volume close to 6 ml per kilogram N Engl J Med 2013.
of predicted body weight. The primary outcome was the proportion of patients who DOI: 10.1056/NEJMoa1214103
died from any cause within 28 days after inclusion. Copyright © 2013 Massachusetts Medical Society.
Results
A total of 237 patients were assigned to the prone group, and 229 patients were as-
signed to the supine group. The 28-day mortality was 16.0% in the prone group and
32.8% in the supine group (P<0.001). The hazard ratio for death with prone position-
ing was 0.39 (95% confidence interval [CI], 0.25 to 0.63). Unadjusted 90-day mortal-
ity was 23.6% in the prone group versus 41.0% in the supine group (P<0.001), with a
hazard ratio of 0.44 (95% CI, 0.29 to 0.67). The incidence of complications did not
differ significantly between the groups, except for the incidence of cardiac arrests,
which was higher in the supine group.
Conclusions
In patients with severe ARDS, early application of prolonged prone-positioning ses-
sions significantly decreased 28-day and 90-day mortality. (Funded by the Programme
Hospitalier de Recherche Clinique National 2006 and 2010 of the French Ministry
of Health; PROSEVA ClinicalTrials.gov number, NCT00527813.)
n engl j med nejm.org 1
The n e w e ng l a n d j o u r na l of m e dic i n e
P
rone positioning has been used for Randomization was computer-generated and strat-
many years to improve oxygenation in pa- ified according to ICU. Patients were randomly
tients who require mechanical ventilatory assigned to the prone group or supine group
support for management of the acute respiratory with the use of a centralized Web-based manage-
distress syndrome (ARDS). Randomized, con- ment system (Clininfo). The protocol, available at
trolled trials have confirmed that oxygenation is NEJM.org, was approved by the ethics committee
significantly better when patients are in the prone Comité Consultatif de Protection des Personnes
position than when they are in the supine posi- dans la Recherche Biomedicale Sud-Est IV in Lyon,
tion.1,2 Furthermore, several lines of evidence have France, and by the Clinical Investigation Ethics
shown that prone positioning could prevent ven- Committee at Hospital de Sant Pau in Barcelona.
tilator-induced lung injury.3-6 In several previous Written informed consent was obtained after the
trials, these physiological benefits did not trans- patients’ next of kin read the informational leaf-
late into better patient outcomes, since no signifi- let. If patients were able to read the leaflet at
cant improvement was observed in patient survival some point after inclusion in the study, they were
with prone positioning.7-10 However, meta-analy- approached to confirm participation in the trial.
ses2,11 have suggested that survival is significantly An investigator at each center was responsible for
improved with prone positioning as compared enrolling patients in the study, following the pro-
with supine positioning among patients with se- tocol, and completing the case-report form. Cen-
verely hypoxemic ARDS at the time of random- ters were regularly monitored by research fellows.
ization. We conducted a prospective, multicenter, Data collectors were aware of the study-group as-
randomized, controlled trial to explore whether signments, but outcomes assessors were not.
early application of prone positioning would im- The trial was overseen by a steering commit-
prove survival among patients with ARDS who, tee that met monthly. An independent data and
at the time of enrollment, were receiving mechan- safety monitoring board, comprising three experts
ical ventilation with a positive end-expiratory pres- in the field, was also set up (a list of board mem-
sure (PEEP) of at least 5 cm of water and in whom bers is provided in the Supplementary Appendix).
the ratio of the partial pressure of arterial oxygen There was no commercial support. No one who is
(Pao2) to the fraction of inspired oxygen (Fio2) was not listed as an author contributed to the writing
less than 150 mm Hg. of this manuscript. All authors vouch for the ac-
curacy of the data and analysis and the fidelity of
Me thods the study to the protocol.
Patients Protocol
We included in the study adults who met the fol- After a patient was determined to be eligible, a
lowing criteria: ARDS, as defined according to the stabilization period of 12 to 24 hours was man-
American–European Consensus Conference cri- dated. Inclusion in the study was confirmed only
teria12; endotracheal intubation and mechanical at the end of this period (Fig. S1 in the Supplemen-
ventilation for ARDS for less than 36 hours; and tary Appendix).
severe ARDS (defined as a Pao2:Fio2 ratio of Patients assigned to the prone group had to be
<150 mm Hg, with an Fio2 of ≥0.6, a PEEP of turned to the prone position within the first hour
≥5 cm of water, and a tidal volume of about 6 ml after randomization. They were placed in a com-
per kilogram of predicted body weight; the cri- pletely prone position for at least 16 consecutive
teria were confirmed after 12 to 24 hours of me- hours. Participating centers were given guidelines
chanical ventilation in the participating intensive(see the Supplementary Appendix) to ensure stan-
care unit [ICU]). Exclusion criteria are listed in dardization of prone placement. Standard ICU
the Supplementary Appendix, available with the beds were used for all patients. Patients assigned
full text of this article at NEJM.org. to the supine group remained in a semirecumbent
position.
Trial Design Mechanical ventilation13 was delivered in a
Patients were recruited from 26 ICUs in France volume-controlled mode with constant inspira-
and 1 in Spain, all of which have used prone po- tory flow, with tidal volume targeted at 6 ml per
sitioning in daily practice for more than 5 years. kilogram of predicted body weight13 and the PEEP
level selected from a PEEP–Fio2 table14 (Table S1 of less than 55 mm Hg, with an Fio2 of 1.0;
in the Supplementary Appendix). The goal was to maximal PEEP according to the PEEP–Fio2 table;
maintain an end-inspiratory plateau pressure of administration of inhaled nitric oxide at a con-
the respiratory system (PplatRS), measured after centration of 10 ppm; infusion of intravenous
a 1-second period of no air flow, of no more than almitrine bismesylate at a dose of 4 μg per kilo-
30 cm of water and an arterial plasma pH of 7.20 gram per minute; and performance of respirato-
to 7.45. Physiological variables were measured at ry recruitment maneuvers to increase the amount
predetermined times in both groups. In the su- of aerated lung.
pine group, measurements were performed every Weaning from mechanical ventilation was con-
6 hours; in the prone group, measurements were ducted in the same way for both groups (see the
performed just before the patient was turned to Supplementary Appendix). Details regarding the
the prone position, after 1 hour of prone position- management of sedation and the use of neuro-
ing, just before the patient was turned back to muscular blocking agents are also provided in
the supine position, and 4 hours after the patient the Supplementary Appendix. The investigators
was returned to the supine position. Adjustments assessed patients at least every morning until day
of ventilator settings in specific situations are de- 28 or discharge from the ICU.
tailed in the Supplementary Appendix.
The criteria for stopping prone treatment were Data Collection
any of the following: improvement in oxygenation At the time of admission, we recorded data on age,
(defined as a Pao2:Fio2 ratio of ≥150 mm Hg, with sex, the setting from which the patient was admit-
a PEEP of ≤10 cm of water and an Fio2 of ≤0.6; in ted to the ICU, the context for admission to the
the prone group, these criteria had to be met in the ICU, McCabe score14 (which ranges from A to C,
supine position at least 4 hours after the end of with A indicating no underlying disease that com-
the last prone session); a decrease in the Pao2:Fio2 promises life expectancy, B an estimated life expec-
ratio of more than 20%, relative to the ratio in the tancy with the chronic disease of <5 years, and C an
supine position, before two consecutive prone ses- estimated life expectancy with the chronic disease
sions; or complications occurring during a prone of <1 year), ventilator settings, time from intuba-
session and leading to its immediate interruption. tion to randomization, height, predicted body
Complications leading to the immediate interrup- weight, and the Simplified Acute Physiology Score
tion of prone treatment included nonscheduled (SAPS) II15 (which ranges from 0 to 164, with high-
extubation, main-stem bronchus intubation, en- er scores indicating greater severity of symptoms).
dotracheal-tube obstruction, hemoptysis, oxygen We also recorded the number of lung quadrants
saturation of less than 85% on pulse oximetry or a involved on chest radiography, results of measure-
Pao2 of less than 55 mm Hg for more than 5 min- ments of arterial blood gases, PplatRS, arterial
utes when the Fio2 was 1.0, cardiac arrest, a heart blood lactate levels, the cause of ARDS, the Sepsis-
rate of less than 30 beats per minute for more related Organ Failure Assessment (SOFA) score16
than 1 minute, a systolic blood pressure of less (which ranges from 0 to 24, with higher scores in-
than 60 mm Hg for more than 5 minutes, and dicating more severe organ failure), the lung injury
any other life-threatening reason for which the score (which ranges from 0 to 4, with higher scores
clinician decided to stop the treatment. indicating more severe lung injury),17 and the time
After patients in the prone group were turned at which the first prone session was started.
to the supine position, the prone session could The following events were recorded daily un-
be resumed at any time before the planned as- til day 28: attempts at extubation, administration
sessment at 4 hours in the supine position if the of inhaled nitric oxide, infusion of almitrine bis-
criteria for oxygen saturation level, Pao2, or both mesylate, use of extracorporeal membrane oxygen-
were met. The prone-positioning strategy was ap- ation (ECMO), infusion of sedatives and neuro-
plied every day up to day 28, after which it was muscular blockers, complications, and the SOFA
used at the clinician’s discretion. Patients in the score. Ventilator settings, PplatRS, static compli-
supine group could not be crossed over to the ance of the respiratory system, and the results of
prone group except as a rescue measure in case of measurements of arterial blood gases were re-
life-threatening hypoxemia when all the following corded daily during the first week as indicated
criteria were met simultaneously: a Pao2:Fio2 ratio above. Data quality was verified by the research
234 Were assigned to supine group 240 Were assigned to prone group
5 Were excluded
3 Were excluded
3 Had PaO2:FIO2 >150 mm Hg
2 Were enrolled before 12-hr
1 Was enrolled before 12-hr
stabilization period was over
stabilization period was over
1 Received NIV >24 hr
1 Had guardianship issues
Hazard Ratio
or Odds Ratio
Supine Group Prone Group with the Prone
Outcome (N = 229) (N = 237) Position (95% CI) P Value
Mortality — no. (% [95% CI])
At day 28
Not adjusted 75 (32.8 [26.4–38.6]) 38 (16.0 [11.3–20.7]) 0.39 (0.25–0.63) <0.001
Adjusted for SOFA score† 0.42 (0.26–0.66) <0.001
At day 90
Not adjusted 94 (41.0 [34.6–47.4]) 56 (23.6 [18.2–29.0]) 0.44 (0.29–0.67) <0.001
Adjusted for SOFA score† 0.48 (0.32–0.72) <0.001
Successful extubation at day 90 — 145/223 186/231 0.45 (0.29–0.70) <0.001
no./total no. (% [95% CI]) (65.0 [58.7–71.3]) (80.5 [75.4–85.6])
Time to successful extubation,
assessed at day 90 —
days
Survivors 19±21 17±16 0.87
Nonsurvivors 16±11 18±14
Length of ICU stay, assessed at
day 90 — days
Survivors 26±27 24±22 0.05
Nonsurvivors 18±15 21±20
Ventilation-free days
At day 28 10±10 14±9 <0.001
At day 90 43±38 57±34 <0.001
Pneumothorax — no. (% [95% CI]) 13 (5.7 [3.9–7.5]) 15 (6.3 [4.9–7.7]) 0.89 (0.39–2.02) 0.85
Noninvasive ventilation — no./
total no. (% [95% CI])
At day 28 10/212 (4.7 [1.9–7.5]) 4/228 (1.8 [0.1–3.5]) 0.36 (0.07–3.50) 0.11
At day 90 3/206 (1.5 [0.2–3.2]) 4/225 (1.8 [0.1–3.5]) 1.22 (0.23–6.97) 1.00
Tracheotomy — no./total no.
(% [95% CI])
At day 28 12/229 (5.2 [2.3–8.1]) 9/237 (3.8 [1.4–6.0]) 0.71 (0.27–1.86) 0.37
At day 90 18/223 (8.1 [4.5–11.7]) 15/235 (6.4 [3.3–9.5]) 0.78 (0.36–1.67) 0.59
* Plus–minus values are means ±SD. Hazard ratios are shown for mortality and successful extubation; odds ratios are
shown for other outcomes. CI denotes confidence interval.
† There were no significant differences between the groups in organ dysfunction as assessed from the SOFA score (Table S4
in the Supplementary Appendix).
prone group than in the supine group. The par- mortality persisted at day 90 (Table 3). A com-
tial pressure of arterial carbon dioxide and static parison of the two survival curves showed the
compliance of the respiratory system were simi- same significant difference (Fig. 2). After adjust-
lar in the two groups. ment for the SOFA score and the use of neuro-
muscular blockers and vasopressors at the time
Primary and Secondary Outcomes of inclusion, mortality remained significantly low-
Mortality at day 28 was significantly lower in the er in the prone group than in the supine group
prone group than in the supine group: 16.0% (38 (Table S5 in the Supplementary Appendix). The
of 237 participants) versus 32.8% (75 of 229) rate of successful extubation was significantly
(P<0.001) (Table 3). The significant difference in higher in the prone group (Table 3). The duration
Prone group
0.8
patients with severe ARDS were selected on the
basis of oxygenation together with PEEP and Fio2
0.6 levels. Second, patients were included after a
Supine group
12-to-24-hour period during which the ARDS
0.4 criteria were confirmed. This period may have
contributed to the selection of patients with more
severe ARDS19 who could benefit from the ad-
0.2 P<0.001
vantages of the prone positioning, such as relief
of severe hypoxemia and prevention of ventilator-
0.0 induced lung injury. A previous study has shown
0 10 20 30 40 50 60 70 80 90
that prone positioning, as compared with supine
Days
positioning, markedly reduces the overinflated
No. at Risk lung areas while promoting alveolar recruitment.5
Prone group 237 202 191 186 182
Supine group 229 163 150 139 136 These effects (reduction in overdistention and
recruitment enhancement) may help prevent ven-
Figure 2. Kaplan–Meier Plot of the Probability of Survival from Randomiza-
AUTHOR: Guérin Revised tilator-induced lung injury by homogenizing the
tion to Day 90.
FIGURE: 2 of 2
distribution of stress and strain within the
SIZE
lungs. In our trial, alveolar recruitment was not
ARTIST: ts
4 col
directly assessed. However, studies have shown
TYPE:of invasive
Line mechanical
Combo 4-C ventilation,
H/T 22p3 length of stay that lung recruitability correlates with the extent
in the ICU, incidence
AUTHOR, of pneumothorax, rate of use
PLEASE NOTE: of hypoxemia20,21 and that the transpulmonary
of noninvasive
Figure has been redrawnventilation after
and type has been
Please check carefully.
extubation, and
reset. pressure along the ventral-to-dorsal axis is more
tracheotomy rate did not differ significantly be- homogeneously distributed in the prone position
JOB: tween the two groups (TableISSUE:
36823 3). 06-06-13 than in the supine position.22 We therefore sug-
gest that prone positioning in our patients induced
Complications a decrease in lung stress and strain.
A total of 31 cardiac arrests occurred in the su- Third, as in previous investigations,9,10 we
pine group, and 16 in the prone group (P = 0.02). used long prone-positioning sessions. Fourth, the
There were no significant differences between prone position was applied for 73% of the time
the groups with respect to other adverse effects ascribed to the intervention and was concentrated
(Table S6 in the Supplementary Appendix). over a period of a few days. Fifth, in our trial,
the tidal volume was lower than in previous tri-
Discussion als,9,10 and the PplatRS was kept below 30 cm of
water. However, because all patients were returned
Survival after severe ARDS was significantly high- to the supine position at least once a day, the
er in the prone group than in the supine group. effect of the prone position itself cannot be dis-
Furthermore, the effect size was large despite the tinguished from the effects of being moved from
fact that mortality in the supine group was lower the supine to the prone position over the course
than anticipated. of a day.
Our results are consistent with findings from We should acknowledge that the technical
previous meta-analyses2,11 and an observational aspects of prone positioning are not simple and
Videos showing study,18 even though prior randomized trials have that a coordinated team effort is required (see
prone positioning failed to show a survival benefit with prone po- Videos 1 and 2, available at NEJM.org). All cen-
of patients with
ARDS are
sitioning. Meta-analyses of ARDS studies have ters participating in this study were skilled in
available at suggested that the outcomes with prone posi- the process of turning patients from the supine
NEJM.org tioning are better in the subgroup of patients with to the prone position, as shown by the absence
severe hypoxemia.2,11 However, when we stratified of adverse events directly related to repositioning.
our analysis according to quartile of Pao2:Fio2 Because the experience of the units may explain
the low rate of complications, our results cannot adjustment for these covariates, mortality was
necessarily be generalized to centers without significantly lower in the prone group.
such experience. We should also emphasize that In conclusion, this trial showed that patients
our results were obtained in the subgroup of se- with ARDS and severe hypoxemia (as confirmed
verely ill patients with ARDS. by a Pao2:Fio2 ratio of <150 mm Hg, with an
It could be argued that our results can be ex- Fio2 of ≥0.6 and a PEEP of ≥5 cm of water) can
plained by higher mortality in the control group. benefit from prone treatment when it is used
However, mortality at day 28 in the supine group early and in relatively long sessions.
was similar to that among controls in recent tri- Dr. Guérin reports receiving grant support from Air Liquide;
als.23,24 Furthermore, although the mortality in Dr. Mercat, receiving consulting fees from Faron Pharmaceuti-
cals, grant support from Covidien and General Electric, patent
the control group was lower than that used to royalties on a method for evaluating positive end-expiratory pres-
compute the power of this study, we calculated sure that is licensed to General Electric, and reimbursement for
that the power of our study was 99%. travel expenses from Covidien and Maquet; Dr. Jaber, receiving
consulting fees from Maquet and Dräger, lecture fees from Fisher
The study has several limitations. Although and Paykel, Abbott Laboratories, and Philips Respironics, and re-
we planned to record the data of patients who imbursement for travel expenses from Pfizer; and Dr. Mancebo,
were eligible but not included, only a few ICUs receiving fees for serving on the data and safety monitoring board
of Air Liquide, consulting fees from Faron Pharmaceuticals,
complied with this request, making it impossi- ALung, and Philips Respironics, and grant support to his institu-
ble to fully appreciate the physiological condition tion from Covidien and General Electric. No other potential con-
of the excluded patients. In addition, fluid bal- flict of interest relevant to this article was reported.
Disclosure forms provided by the authors are available with
ance and the cumulative dose of catecholamines the full text of this article at NEJM.org.
were not assessed. The imbalance between the We thank all the physicians, including those on night duty,
groups in baseline SOFA score, vasopressor use, and nurses in the participating centers for the care provided to
patients during the study; the Réseau Européen en Ventilation
and the use of neuromuscular blockers could also Artificielle network; and Carolyn Newey for help in editing an
have influenced the results. However, even after earlier version of the manuscript.
Appendix
The authors’ affiliations are as follows: Réanimation Médicale, Hôpital de la Croix-Rousse, Hospices Civils de Lyon; Université de Lyon;
and Creatis INSERM 1044, Lyon (C.G., J.-C.R., F.B., G.B., V.L., L.B.); Réanimation Polyvalente, and Clinical Research in Intensive Care
and Sepsis (CRICS) Group, La Roche-Sur-Yon (J. Reignier); Réanimation Polyvalente, Roanne (P.B.); Réanimation Médicale, Hôpital
Pontchaillou, Rennes (A.G.); Réanimation Polyvalente, and CRICS Group, Hôpital d’Orléans, Orleans (T.B.); Réanimation Médicale,
Hôpital Bretonneau, CRICS Group, and Université de Tours, Tours (E.M.); Réanimation Polyvalente, Hôpital de Chambéry, Chambery
(M.B.); L’Université Nantes Angers Le Mans, Université d’Angers, Centre Hospitalier Universitaire Angers, Réanimation Médicale, An-
gers (A.M.); Réanimation Polyvalente, and CRICS Group, Hôpital d’Angoulême, Angouleme (O.B.); Réanimation Polyvalente Centre
d’Investigation Clinique 0801 and CRICS Group, Hôpital de Limoges, Limoges (M.C.); Réanimation Médicale, Hôpital de Poitiers, and
CRICS Group, and University of Poitiers, Poitiers (D.C.); Réanimation Chirurgicale, Hôpital Saint Eloi, INSERM Unité 1046, and Univer-
sité de Montpellier, Montpellier (S.J.); Réanimation Polyvalente, Hôpital Saint Joseph et Saint Luc, Lyon (S.R.); Réanimation Polyvalente,
Hôpital d’Annecy, Annecy (M.S.); Réanimation Médicale, Hôpital Pellegrin, and Université de Bordeaux, Bordeaux (G.H.); Réanimation
Polyvalente, Hôpital de Nîmes, and Université de Nîmes-Montpellier, Nimes (C.B.); Réanimation Polyvalente, Hôpital de Cergy-Ponto-
ise, Cergy-Pontoise (J. Richecoeur); Réanimation des Urgences, Hôpital de la Timone, and Université de la Méditerranée, Marseille
(M.G.); Service d’Hygiène Hospitalière, Groupement Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre Bénite (R.G.); and Centre de
Coordination et de Lutte contre les Infections Nosocomiales Sud-Est, Hôpital Henri Gabrielle, Saint Genis-Laval (L.A.) — all in France;
and Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona (J.M.).
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