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

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 Pao(2):FiO(2) 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. (J Trauma Acute Care Surg. 2012;72: 1634-1639. Copyright (C) 2012 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Therapeutic study, level IV.