Prone Positioning in Moderate-Severe ARDS: Preliminary Data From a Community-Based Teaching Hospital

Abstract

SESSION TITLE: ARDS and Acute Lung Injury SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: In 2013, after publication of a randomized controlled trial that demonstrated a mortality benefit to ventilation in the prone versus supine position in ARDS, critical care physicians at our institution began to implement this approach. Prior to this, we rarely used prone positioning in our medical ICU and we did not know if the mortality and low complication rate observed in the trial, at centers with >5 years of experience with proning, could be replicated at our institution or what impact this intervention would have on functional outcomes. METHODS: We conducted a retrospective cohort study of all proned patients from June 2013 to November 2014 at Christiana Care Health System. Patients were identified by respiratory care data. We collected demographic data, pre- and post- proning data, respiratory mechanics, diagnoses, complications, and outcomes including mortality, length of stay, and distance walked prior to discharge. Descriptive statistics are used to describe our cohort. RESULTS: Thirty seven patients underwent ventilation in the prone position. Of these, 23 (62%) survived to hospital discharge. The mean age was 56.3 years and 60% were male. The mean sequential organ failure score was 8.6. Immediately prior to proning, the mean positive end expiratory pressure was 14, mean driving pressure was 14 centimeters of water, mean partial pressure of arterial oxygen to fraction of inspired oxygen was 100 and mean tidal volume was 5.5 ml/kg of predicted body weight. Patients were proned for a mean of 41 hours. One patient received extracorporal membrane oxygenation, 31 (84%) received neuromuscular blocking agents, 6 (16.2%) received inhaled nitric oxide, and 21(57%) received steroids. None developed ventilator associated pneumonia or had cardiac arrests while proned. In terms of complications, 6 patients had dependent edema, 7 had dislodged devices, and 2 had skin breakdown. The mean hospital and ICU length of stays were 23 and 14, respectively. A total of 23 patients were able to ambulate a mean of 138 feet prior to hospital discharge. CONCLUSIONS: Hospital mortality was higher in this cohort than the 28-day mortality reported in the trial. However, serious complications from prone positioning were uncommon. The higher mortality rate could be due to differences in clinical care including use of adjuvent therapies or differences in patient selection. Additionally, during our study period in December 2013, we implemented a protocol for ventilation in the prone position. We plan additional data collection and analysis to determine is outcomes differ before and after protocol implementation.All of the survivors were ambulatory prior to hospital discharge. CLINICAL IMPLICATIONS: It is feasible to implement a proning protocol at a community hospital with limited prior experience; however, close monitoring of outcomes is needed to determine whether expected benefits are achieved. DISCLOSURE: The following authors have nothing to disclose: Fahmida Khan, Christa Fistler, Jefferson Mixell, Patricia McGraw, Michael Vest No Product/Research Disclosure Information