In their article in the May 2016 issue of Intensive Care Medicine, Dr. Bihari et al. propose ten hypothetical studies that may have the potential to improve management of acute respiratory distress syndrome (ARDS) in the future . Although well articulated and accurately presented, my main contention is that in their ten studies the authors focused on topics that have already been investigated and addressed in prior trials, studies, reviews, and meta-analyses [2, 3]. Instead of fixating on the pathophysiology of ARDS, which so many investigators have already done, I wish that the authors had used their forum to discuss what I believe to be most intriguing about ARDS: the barriers to prone positioning’s widespread adoption in everyday clinical practice. As the authors mention, PROSEVA definitively showed a significant survival benefit from prone positioning in a select subgroup of patients with severe ARDS . In fact, with a 50 % reduction in mortality and a hazard ratio of 0.39, prone positioning for patients with severe ARDS may be more beneficial than any other previously studied intervention for this subgroup of patients . Unfortunately, as seen in the LUNG-SAFE trial, which demonstrated that only 16.4 % of severe ARDS patients are actually proned, prone positioning is presumably vastly underutilized . To my disappointment, instead of addressing this perplexing underutilization phenomenon with potential studies, the authors provided its readers with ten studies that ignore LUNG-SAFE’s disconcerting results . As an exercise to highlight my point, try to imagine the uproar if only 16.4 % of patients with hyperlipidemia refractory to lifestyle changes were prescribed statin therapy, or 16.4 % of patients with diabetes and chronic kidney disease were prescribed angiotensin converting enzyme inhibitors (ACE inhibitors); my guess is that these dismal rates would quickly be addressed. So, some paramount questions continue to remain after reading the authors’ ideas for future ARDS studies and they are: (1) In the appropriate patient, why is prone positioning so underutilized in ARDS management? (2) What studies can we as clinician researchers and educators perform to address this underutilization? (3) What interventions can be performed that address the barriers to widespread adoption and improve the utilization rate of prone positioning? (4) What studies can we perform to test the efficacy of these interventions? Needless to say, there exists an understudied and poorly elucidated discrepancy between prone positioning’s effectiveness and utilization. In addition to the ten studies proposed by Bihari et al., it is also imperative to include researching and addressing the reasons why prone positioning is so unpopular. Perhaps follow-up confirmatory studies to PROSEVA and LUNG-SAFE are required to promote prone positioning’s popularity in severe ARDS management.
- 2.Timsit JF, Perner A, Bakker J, Bassetti M, Benoit D, Cecconi M et al (2015) Year in review in Intensive Care Medicine 2014: III. Severe infections, septic shock, healthcare-associated infections, highly resistant bacteria, invasive fungal infections, severe viral infections, Ebola virus disease and paediatrics. Intensive Care Med 41(4):575–588CrossRefPubMedPubMedCentralGoogle Scholar