To the Editor:
We thank the letter’s authors for their interest in our manuscript1 and for the opportunity to clarify our findings.
In our manuscript, we referenced several studies focused on prone position ventilation (PPV) strategy, although we did not cite the 52-patient pilot randomized trial performed by Page and colleagues.2 In this trial, patients were randomized to a PPV session of 24 h vs 16 h, with duration of PPV as the primary outcome measure. The pilot trial was not powered to detect mortality differences between groups, although the trial did demonstrate safety of longer-duration prone positioning and highlighted its feasibility. Although in our observational study we defined prolonged PPV as a prone duration lasting at least 24 h before supination, in practice many clinicians at our institution left patients in PPV until there was evidence of clinical stability. As a consequence, the median duration of the first prone session in the prolonged PPV group was 40 h, whereas for the intermittent PPV group it was 17 h. There is heterogeneity in the literature regarding optimal prolonged PPV strategy—whether it should be based on strict time cutoffs for PPV or leaving a patient in PPV pending durable clinical improvement. Additional studies are necessary to address the remaining important questions regarding prolonged PPV, such as whether a prone duration longer than 24 h is beneficial, whether supination can cause harm, and metrics to identify the appropriate timing for supination.
Funding/Support
D. O. is supported by the NIH (T32HL116725). G. A. A. is supported by the NIH (5KL2TR002542-02).
Financial/Nonfinancial Disclosures
See earlier cited article for author conflicts of interest.
Acknowledgments
Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.
References
- 1.Okin D., Huang C.Y., Alba G.A., et al. Prolonged prone position ventilation is associated with reduced mortality in intubated COVID-19 patients. Chest. 2023;163(3):533–542. doi: 10.1016/j.chest.2022.10.034. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Page D.B., Vijaykumar K., Russell D.W., et al. Prolonged prone positioning for COVID-19-induced acute respiratory distress syndrome: a randomized pilot clinical trial. Ann Am Thorac Soc. 2022;19(4):685–687. doi: 10.1513/AnnalsATS.202104-498RL. [DOI] [PMC free article] [PubMed] [Google Scholar]