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Prone positioning improves oxygenation in adult burn patients with severe acute respiratory distress syndrome

Hale, Diane F. MD; Cannon, Jeremy W. MD; Batchinsky, Andriy I. MD; Cancio, Leopoldo C. MD; Aden, James K. PhD; White, Christopher E. MD; Renz, Evan M. MD; Blackbourne, Lorne H. MD; Chung, Kevin K. MD

Journal of Trauma and Acute Care Surgery: June 2012 - Volume 72 - Issue 6 - p 1634–1639
doi: 10.1097/TA.0b013e318247cd4f

BACKGROUND Prone positioning (PP) improves oxygenation and may provide a benefit in patients with acute respiratory distress syndrome (ARDS). This approach adds significant challenges to patients in intensive care by limiting access to the endotracheal or tracheostomy tube and vascular access. PP also significantly complicates burn care by making skin protection and wound care more difficult. We hypothesize that PP improves oxygenation and can be performed safely in burn patients with ARDS.

METHODS PP was implemented in a burn intensive care unit for 18 patients with severe refractory ARDS. The characteristics of these patients were retrospectively reviewed to evaluate the impact of PP on Pao2:FiO2 ratio (PFR) during the first 48 hours of therapy. Each patient was considered his or her own control before initiation of PP, and trends in PFR were evaluated with one-way analysis of variance. Secondary measures of complications and mortality were also evaluated.

RESULTS Mean PFR before PP was 87 (±38) with a mean sequential organ failure assessment score of 11 (±4). PFR improved during 48 hours in 12 of 14 survivors (p < 0.05). Mean PFR was 133 (±77) immediately after PP, 165 (±118) at 6 hours, 170 (±115) at 12 hours, 214 (±126) at 24 hours, 236 (±137) at 36 hours, and 210 (±97) at 48 hours. At each measured time interval except the last, PFR significantly improved. There were no unintended extubations. Facial pressure ulcers developed in four patients (22%). Overall, 14 survived 48 hours (78%), 12 survived 28 days (67%), and six survived to hospital discharge (33%).

CONCLUSIONS PP improves oxygenation in burn patients with severe ARDS and was safely implemented in a burn intensive care unit. Mortality in this population remains high, warranting investigation into additional complementary rescue therapies.

LEVEL OF EVIDENCE Therapeutic study, level IV.

From the Department of Surgery (D.F.H., J.W.C.), Brooke Army Medical Center, Fort Sam Houston, Texas; Uniformed Services University of the Health Sciences (J.W.C., E.M.R.), Bethesda, Maryland; and U.S. Army Institute of Surgical Research (A.I.B., L.C.C., J.K.A., C.E.W., E.M.R., L.H.B., K.K.C.), Fort Sam Houston, Texas.

Submitted: August 19, 2011; Revised: December 19, 2011; Accepted: December 21, 2011.

Supported by the Clinical Trials Task Area, United States Army Institute of Surgical Research.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army, Department of the Air Force, and the Department of Defense.

This study was conducted under a protocol reviewed and approved by the US Army Medical Research and Materiel Command Institutional Review Board, and in accordance with the approved protocol.

Address for reprints: Kevin K. Chung, MD, US Army Institute of Surgical Research, 3698 Chambers Pass, San Antonio, TX 78234-6315; email:

© 2012 Lippincott Williams & Wilkins, Inc.