Excerpt
A recent international multicenter prospective study enrolling 29,144 patients who received invasive or non-invasive ventilation reported that acute respiratory distress syndrome (ARDS) was present in 23% of the mechanically ventilated patients [
1]. In recent years, the ARDS mortality rate ranged between 28% and 35% [
1,
2] with lower survival in patients with more severe ARDS [
1]. The main supportive therapy in ARDS is invasive mechanical ventilation combining lung protective ventilation to prevent ventilator-associated lung injury with a restrictive fluid therapy to limit/prevent lung edema [
3,
4]. However, the optimal approach for lung protective ventilation is still questionable [
5]. The recent American/European guideline and an expert opinion on respiratory support in ARDS patients recommended a low tidal volume ventilation (i.e., 6 ml/kg of ideal body weight, or lower in case of plateau pressure higher than 30 cm H
2O) with positive end-expiratory pressure (PEEP) adjusted according to the respiratory mechanics (lung and chest wall elastance), driving pressure, gas exchange, and lung imaging [
6,
7]. In addition, in case of severe ARDS the use of prone position, according to previous positive studies [
8‐
10], has been recommended. However, the use of prone position in daily clinical practice in ARDS ranges between 7% and 8% of the mechanically ventilated patients [
1,
2]. In the current issue of
Intensive Care Medicine, Guerin et al. reports the results of a prospective observational international study (APRONET study) evaluating the prevalence of the application of prone position in ARDS patients, the reasons for not applying it, and the related complications [
11]. This 1-day prevalence study was repeated four times between April 2016 and January 2017. Intubated/tracheostomized ARDS patients, according to the Berlin definition, were screened. Up to 141 intensive care units (ICUs) from 20 countries participated, with 735 enrolled ARDS patients, reporting an ARDS prevalence between 8.9% and 13.3%. At least one proning session was completed in 13.7% of the patients; the rate of proning significantly differed among mild, moderate, and severe ARDS patients (5.9%, 10.3%, and 32.9%, respectively). The main reasons for not proning were the absence of severe hypoxemia according to clinical judgment (64%), a mean arterial pressure lower than 65 mmHg (5.7%), and end of life decision (4.2%). Complications of the prone position session were observed in 11.9% of proned patients, mainly related to hypoxemia and the endotracheal tube. …
