Effects of Systematic Prone Positioning in Hypoxemic Acute Respiratory Failure: A Randomized Controlled Trial
CONTEXT A recent trial showed that placing patients with acute lung injury in the prone position did not increase survival; however, whether those results hold true for patients with hypoxemic acute respiratory failure (ARF) is unclear. OBJECTIVE To determine whether prone positioning improves morta...
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Veröffentlicht in: | JAMA : the journal of the American Medical Association 2004-11, Vol.292 (19), p.2379-2387 |
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Zusammenfassung: | CONTEXT A recent trial showed that placing patients with acute lung injury in
the prone position did not increase survival; however, whether those results
hold true for patients with hypoxemic acute respiratory failure (ARF) is unclear. OBJECTIVE To determine whether prone positioning improves mortality in ARF patients. DESIGN, SETTING, AND PATIENTS Prospective, unblinded, multicenter controlled trial of 791 ARF patients
in 21 general intensive care units in France using concealed randomization
conducted from December 14, 1998, through December 31, 2002. To be included,
patients had to be at least 18 years, hemodynamically stable, receiving mechanical
ventilation, and intubated and had to have a partial pressure of arterial
oxygen (PaO2) to fraction of inspired oxygen (FIO2) ratio of 300 or less and no contraindications to lying
prone. INTERVENTIONS Patients were randomly assigned to prone position placement (n = 413),
applied as early as possible for at least 8 hours per day on standard beds,
or to supine position placement (n = 378). MAIN OUTCOME MEASURES The primary end point was 28-day mortality; secondary end points were
90-day mortality, duration of mechanical ventilation, incidence of ventilator-associated
pneumonia (VAP), and oxygenation. RESULTS The 2 groups were comparable at randomization. The 28-day mortality
rate was 32.4% for the prone group and 31.5% for the supine group (relative
risk [RR], 0.97; 95% confidence interval [CI], 0.79-1.19; P = .77). Ninety-day mortality for the prone group was 43.3%
vs 42.2% for the supine group (RR, 0.98; 95% CI, 0.84-1.13; P = .74). The mean (SD) duration of mechanical ventilation
was 13.7 (7.8) days for the prone group vs 14.1 (8.6) days for the supine
group (P = .93) and the VAP incidence was
1.66 vs 2.14 episodes per 100-patients days of intubation, respectively (P = .045). The PaO2/FIO2 ratio was significantly higher in the prone group during
the 28-day follow-up. However, pressure sores, selective intubation, and endotracheal
tube obstruction incidences were higher in the prone group. CONCLUSIONS This trial demonstrated no beneficial outcomes and some safety concerns
associated with prone positioning. For patients with hypoxemic ARF, prone
position placement may lower the incidence of VAP. |
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ISSN: | 0098-7484 1538-3598 |
DOI: | 10.1001/jama.292.19.2379 |