Community Experience With Acute Respiratory Distress Syndrome in the Prone Position

Mechanical ventilation in the prone position has been shown to improve outcomes in randomized trials of patients with moderate to severe acute respiratory distress syndrome and is recommended in clinical practice guidelines. However, data is lacking on the results of attempts to implement this practice in the community outside of clinical trials. To describe our early outcomes implementing mechanical ventilation in the prone position. DESIGN: Retrospective cohort study. SETTING: Medical intensive care unit of a large community-based teaching hospital. PARTICIPANTS: All patients ventilated in the prone position between June 2013 and October 2016. MEASUREMENTS AND MAIN RESULTS: We describe patient characteristics, mortality, and frequency of complications (such as skin breakdown and accidental extubation) at our center. Eighty-one patients with a mean age of 55 years underwent mechanical ventilation in the prone position during the study period. Most patients also received vasopressors, neuromuscular blockade, and steroids. Overall mortality was 43%. The duration of the first proning session ranged from 1.5 to 40.5 hours. Mortality was lower (34%) in those ventilated in the prone position for more than 16 hours during the first session. In the 50 patients without treatment limitations, only 14% expired. There were no accidental extubations during prone positioning. Most of those who died had limitations placed on treatment prior to death. CONCLUSIONS: Overall mortality was higher in our cohort than in the randomized trial. However, differences such as lack of stabilization period, different cultures impacting end-of-life decisions, and timing of enrollment in the course of illness limit interpretation of this comparison. This exercise allows identification of areas for future quality improvement efforts such as increasing the duration of some proning sessions. Complications of prone positioning were uncommon.