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Evevident
Original paper
2013NEJMPulmonary/Critical Care

PROSEVA

Prone positioning in severe acute respiratory distress syndrome

RCTARDS

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Overview

Early prolonged prone positioning markedly reduced mortality in severe ARDS.

Clinical takeaway

PROSEVA established proning as a mortality-improving intervention for severe ARDS when done early, long enough, and by experienced teams.

Key result

28-day mortality was 16.0% with proning vs 32.8% supine (HR 0.39).

Practice impact

Prone severe ARDS patients early when PaO2/FiO2 remains severely low despite optimized ventilation.

Evidence

Study design

Randomized controlled trial.

Enrollment

466

Follow-up

90 days.

Geography

France, Spain

Clinical question

Does early prolonged prone positioning improve survival in severe ARDS?

Population

  • Intubated patients with severe ARDS (PaO2/FiO2 <150) despite lung-protective ventilation.

Intervention

Early prone positioning in sessions of at least 16 consecutive hours.

Comparator

Supine positioning.

Primary outcome

28-day mortality.

Early prolonged prone positioning roughly halved 28-day and 90-day mortality in severe ARDS.

Hazard ratio / 0.39 / CI 95% CI 0.25-0.63 / p=<0.001

Key results

  • 28-day mortality: 16.0% with proning vs 32.8% supine; HR 0.39 (95% CI 0.25-0.63; p<0.001).
  • 90-day mortality was also lower (23.6% vs 41.0%).
  • Patients were carefully selected and managed by centers experienced in proning.

Harms

  • The overall rate of complications did not differ significantly between groups.
  • Cardiac arrests were less frequent in the prone group; proning carries risks of line/tube dislodgement and pressure injury requiring trained staff.

Clinical Use

When to cite

  • When considering early prolonged prone positioning for severe ARDS after lung-protective ventilation is in place.

Practice impact

  • Prone severe ARDS patients early when PaO2/FiO2 remains severely low despite optimized ventilation.

Applicability

  • Most applicable to intubated patients with severe ARDS (PaO2/FiO2 <150) already receiving lung-protective ventilation.

Limitations

  • Requires trained staff and attention to tube/line complications.
  • Enrolled severe ARDS only, not mild hypoxemia; benefit in milder disease is unproven.
  • Conducted at experienced centers, which may limit generalizability of the large effect size.

Common misinterpretations

  • Proning is a mortality intervention in severe ARDS, not just a rescue maneuver for refractory hypoxemia.
  • Benefit was seen with early, prolonged sessions (>=16 hours), not brief or late proning.

Related evidence

ARDSNet ARMA - Same Disease

Citation

Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159-2168. doi:10.1056/NEJMoa1214103

In patients with severe ARDS, early application of prolonged prone-positioning sessions significantly decreased 28-day and 90-day mortality.