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Minerva Anestesiologica 2010 June;76(6):448-54

Copyright © 2010 EDIZIONI MINERVA MEDICA

language: English

Prone positioning improves survival in severe ARDS: a pathophysiologic review and individual patient meta-analysis

Gattinoni L. ^{1, 2}, Carlesso E. ², Taccone P. ¹, Polli F. ², Guérin C. ³, Mancebo J. ⁴ ✉

¹ Department of Anesthesia, Intensive e Subintensive Resuscitation and Pain Therapy, Cà Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy; ² Department of Anesthesiology, Intensive Care and Dermatological Sciences, University of Milan, Milan, Italy; ³ Division of Resuscitation and Respiratory Assistance, Croix-Rousse Hospital, Lyon, France; ⁴ Division of Intensive Care, Sant Pau Hospital, Barcelona, Spain

Prone positioning has been used for over 30 years in the management of patients with acute respiratory distress syndrome (ARDS). This maneuver has consistently proven capable of improving oxygenation in patients with acute respiratory failure. Several mechanisms can explain this observation, including possible intervening net recruitment and more homogeneously distributed alveolar inflation. It is also progressively becoming clear that prone positioning may reduce the nonphysiological stress and strain associated with mechanical ventilation, thus decreasing the risk of ventilator-induced lung injury, which is known to adversely impact patient survival. The available randomized clinical trials, however, have failed to demonstrate that prone positioning improves the outcomes of patients with ARDS overall. In contrast, the individual patient meta-analysis of the four major clinical trials available clearly shows that with prone positioning, the absolute mortality of severely hypoxemic ARDS patients may be reduced by approximately 10%. On the other hand, all data suggest that long-term prone positioning may expose patients with less severe ARDS to unnecessary complications.