To The Editor:
We read with interest the article published in CHEST (March 2023) by Okin et al.1 In this report, the authors retrospectively compared outcomes of patients with COVID-19-induced ARDS who received either traditional prone positioning as described in the PROSEVA study or prolonged prone ventilation.2 In a cohort of 267 patients, they found an association between better outcomes and treatment with prolonged prone ventilation. Because this was an observational study, the authors are correct not to infer causality from these associations, and we agree with their appeal for future, randomized trials to address the question of whether prolonged prone positioning therapy positively impacts patient outcomes.
However, we respectfully disagree with the authors’ assertion that no prior studies have directly compared 16 h proning sessions with a prolonged proning approach. In 2022, we published a small (n = 52) pilot trial in which patients with severe COVID-19-induced ARDS were randomized to receive 16 h or 24 h sessions of prone positioning therapy.3 We found that randomization to a prolonged prone positioning strategy was feasible. Similar to Okin and colleagues,1 we also found that assignment to a prolonged prone positioning strategy was associated with fewer position changes (thus possibly reducing nurse and therapist resources required), and that the intervention appeared to be safe. Unlike the observations of Okin and colleagues,1 our randomized trial did not find a difference between groups in 30-day mortality (53.8% for prolonged proning vs 57.4% for traditional duration), or other clinically important outcomes. Because our pilot trial was not powered to detect differences in survival, this does not exclude a potential benefit from prolonged prone positioning therapy.
We applaud the authors for a valuable study that contributes important data to the question of the optimal duration of prone positioning therapy, and we agree that further study of this question is merited.
Financial/Nonfinancial Disclosures
None declared
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.Guerin C., Gaillard S., Lemasson S., et al. Effects of systematic prone positioning in hypoxemic acute respiratory failure: a randomized controlled trial. JAMA. 2004;292(19):2379–2387. doi: 10.1001/jama.292.19.2379. [DOI] [PubMed] [Google Scholar]
- 3.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]