Prone Positioning in Severe Acute Respiratory Distress Syndrome (PROSEVA)
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Educational summary — always verify with primary sourceEarlier trials of prone positioning in ARDS showed physiological benefit (improved oxygenation) but no mortality benefit. PROSEVA was designed with stricter inclusion criteria (severe ARDS only, P/F <150) and a longer proning duration.
Multicenter RCT (26 ICUs in France and Spain, n=466) comparing prone positioning ≥16 hours/day vs. supine positioning in patients with severe ARDS (P/F ratio <150, FiO₂ ≥0.6, PEEP ≥5).
28-day mortality was dramatically lower in the prone group (16.0% vs 32.8%, p<0.001). 90-day mortality also lower (23.6% vs 41.0%). NNT ≈ 6. Prone group had more cardiac arrests during proning but no difference in overall complications.
Prone positioning ≥16 hours/day should be used in all patients with severe ARDS (P/F <150) who are on lung-protective ventilation. This is a strong recommendation in current ATS/SCCM guidelines.
Performed in experienced centers with dedicated prone teams — results may not generalize to all ICUs. Requires significant nursing expertise and resources.
The NNT of 6 is remarkable for a critical care intervention. Know the threshold: P/F <150 on FiO₂ ≥0.6 and PEEP ≥5. Duration must be ≥16 hours.
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