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In ARDS patients, the change from supine to prone position generates a more even distribution of the gas–tissue ratios along the dependent–nondependent axis and a more homogeneous distribution of lung stress and strain. The change to prone position is generally accompanied by a marked improvement in arterial blood gases, which is mainly due to a better overall ventilation/perfusion matching. Improvement in oxygenation and reduction in mortality are the main reasons to implement prone position in patients with ARDS. The main reason explaining a decreased mortality is less overdistension in non-dependent lung regions and less cyclical opening and closing in dependent lung regions. The only absolute contraindication for implementing prone position is an unstable spinal fracture. The maneuver to change from supine to prone and vice versa requires a skilled team of 4–5 caregivers. The most frequent adverse events are pressure sores and facial edema. Recently, the use of prone position has been extended to non-intubated spontaneously breathing patients affected with COVID-19 ARDS. The effects of this intervention on outcomes are still uncertain.

To face these problems, we implemented a pronation protocol that allows to extend the time for the prone position beyond 16 h, aiming to reduce the number of pronation cycles per patient. [...]the aim of this report was to assess the feasibility and efficacy of prone position ventilation beyond the usual 16 h. We retrospectively collected data from 10 critically ill patients intubated and mechanically ventilated for SARS-CoV-2. [...]in the condition of work overload for healthcare assistants, this strategy might reduce the number of pronation cycles needed for a single patient. [...]we showed that prolonged prone position up to 36 h is feasible, safe, and may offer potential clinical and organizational advantages.

The baby lung was originally defined as the fraction of lung parenchyma that, in acute respiratory distress syndrome (ARDS), still maintains normal inflation. Its size obviously depends on ARDS severity and relates to the compliance of the respiratory system. CO 2 clearance and blood oxygenation primarily occur within the baby lung. While the specific compliance suggests the intrinsic mechanical characteristics to be nearly normal, evidence from positron emission tomography suggests that at least a part of the well-aerated baby lung is inflamed. The baby lung is more a functional concept than an anatomical one; in fact, in the prone position, the baby lung “shifts” from the ventral lung regions toward the dorsal lung regions while usually increasing its size. This change is associated with better gas exchange, more homogeneously distributed trans-pulmonary forces, and a survival advantage. Positive end expiratory pressure also increases the baby lung size, both allowing better inflation of already open units and adding new pulmonary units. Viewed as surrogates of stress and strain, tidal volume and plateau pressures are better tailored to baby lung size than to ideal body weight. Although less information is available for the baby lung during spontaneous breathing efforts, the general principles regulating the safety of ventilation are also applicable under these conditions.

Care for patients with acute respiratory distress syndrome (ARDS) has changed considerably over the 50 years since its original description. Indeed, standards of care continue to evolve as does how this clinical entity is defined and how patients are grouped and treated in clinical practice. In this narrative review we discuss current standards – treatments that have a solid evidence base and are well established as targets for usual care – and also evolving standards – treatments that have promise and may become widely adopted in the future. We focus on three broad domains of ventilatory management, ventilation adjuncts, and pharmacotherapy. Current standards for ventilatory management include limitation of tidal volume and airway pressure and standard approaches to setting PEEP, while evolving standards might focus on limitation of driving pressure or mechanical power, individual titration of PEEP, and monitoring efforts during spontaneous breathing. Current standards in ventilation adjuncts include prone positioning in moderate-severe ARDS and veno-venous extracorporeal life support after prone positioning in patients with severe hypoxemia or who are difficult to ventilate. Pharmacotherapy current standards include corticosteroids for patients with ARDS due to COVID-19 and employing a conservative fluid strategy for patients not in shock; evolving standards may include steroids for ARDS not related to COVID-19, or specific biological agents being tested in appropriate sub-phenotypes of ARDS. While much progress has been made, certainly significant work remains to be done and we look forward to these future developments.

This study aimed to evaluate the short-term effect of prone positioning on oxygen saturation, arterial blood gas parameters, and respiratory rate in intensive care patients with COVID-19-induced acute respiratory distress syndrome (ARDS). This randomized experimental study used a six-measure time series design with control and intervention groups. A total of 90 intubated patients diagnosed with COVID-19 and ARDS were enrolled, with 45 patients in the experimental group and 45 in the control group. The experimental group received a 30-minute prone positioning session, while no intervention was applied to the control group. Data were collected using a Demographic Information Form and a structured form to record oxygen saturation, blood gas parameters, and respiratory rate. This study was registered at ClinicalTrials.gov (Identifier: NCT06997666; first posted on 28/05/2025). Age and gender were comparable between groups ( p  > 0.05). Patients in the experimental group demonstrated higher mean values of peripheral oxygen saturation (SpO₂), arterial oxygen saturation (SaO₂), and partial pressure of oxygen (PaO₂), along with lower PaCO₂ and respiratory rates. No significant changes were observed in sodium or lactate levels. All effects observed were immediate and short-term. No adverse events or unintended effects were reported. A single short-duration session of prone positioning resulted in immediate physiological improvements in oxygenation, ventilation parameters, and respiratory rate in patients with COVID-19-related ARDS. Further studies are needed to assess long-term clinical outcomes and sustained benefits.

Background The effects of awake prone position on the breathing pattern of hypoxemic patients need to be better understood. We conducted a crossover trial to assess the physiological effects of awake prone position in patients with acute hypoxemic respiratory failure. Methods Fifteen patients with acute hypoxemic respiratory failure and PaO 2 /FiO 2  < 200 mmHg underwent high-flow nasal oxygen for 1 h in supine position and 2 h in prone position, followed by a final 1-h supine phase. At the end of each study phase, the following parameters were measured: arterial blood gases, inspiratory effort (Δ P ES ), transpulmonary driving pressure (Δ P L ), respiratory rate and esophageal pressure simplified pressure–time product per minute (sPTP ES ) by esophageal manometry, tidal volume ( V T ), end-expiratory lung impedance (EELI), lung compliance, airway resistance, time constant, dynamic strain ( V T /EELI) and pendelluft extent through electrical impedance tomography. Results Compared to supine position, prone position increased PaO 2 /FiO 2 (median [Interquartile range] 104 mmHg [76–129] vs. 74 [69–93], p  < 0.001), reduced respiratory rate (24 breaths/min [22–26] vs. 27 [26–30], p  = 0.05) and increased Δ P ES (12 cmH 2 O [11–13] vs. 9 [8–12], p  = 0.04) with similar sPTP ES (131 [75–154] cmH 2 O s min −1 vs. 105 [81–129], p  > 0.99) and Δ P L (9 [7–11] cmH 2 O vs. 8 [5–9], p  = 0.17). Airway resistance and time constant were higher in prone vs. supine position (9 cmH 2 O s arbitrary units −3 [4–11] vs. 6 [4–9], p  = 0.05; 0.53 s [0.32–61] vs. 0.40 [0.37–0.44], p  = 0.03). Prone position increased EELI (3887 arbitrary units [3414–8547] vs. 1456 [959–2420], p  = 0.002) and promoted V T distribution towards dorsal lung regions without affecting V T size and lung compliance: this generated lower dynamic strain (0.21 [0.16–0.24] vs. 0.38 [0.30–0.49], p  = 0.004). The magnitude of pendelluft phenomenon was not different between study phases (55% [7–57] of V T in prone vs. 31% [14–55] in supine position, p  > 0.99). Conclusions Prone position improves oxygenation, increases EELI and promotes V T distribution towards dependent lung regions without affecting V T size, Δ P L , lung compliance and pendelluft magnitude. Prone position reduces respiratory rate and increases Δ P ES because of positional increases in airway resistance and prolonged expiratory time. Because high Δ P ES is the main mechanistic determinant of self-inflicted lung injury, caution may be needed in using awake prone position in patients exhibiting intense Δ P ES . Clinical trail registeration : The study was registered on clinicaltrials.gov (NCT03095300) on March 29, 2017.

PurposeSevere acute respiratory distress syndrome (ARDS) with PaO2/FiO2 < 80 mmHg is a life-threatening condition. The optimal management strategy is unclear. The aim of this meta-analysis was to compare the effects of low tidal volumes (Vt), moderate Vt, prone ventilation, and venovenous extracorporeal membrane oxygenation (VV-ECMO) on mortality in severe ARDS.MethodsWe performed a frequentist network meta-analysis of randomised controlled trials (RCTs) with participants who had severe ARDS and met eligibility criteria for VV-ECMO or had PaO2/FiO2 < 80 mmHg. We applied the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to discern the relative effect of interventions on mortality and the certainty of the evidence.ResultsTen RCTs including 812 participants with severe ARDS were eligible. VV-ECMO reduces mortality compared to low Vt (risk ratio [RR] 0.77, 95% confidence interval [CI] 0.59–0.99, moderate certainty) and compared to moderate Vt (RR 0.75, 95% CI 0.57–0.98, low certainty). Prone ventilation reduces mortality compared to moderate Vt (RR 0.78, 95% CI 0.66–0.93, high certainty) and compared to low Vt (RR 0.81, 95% CI 0.63–1.02, moderate certainty). We found no difference in the network comparison of VV-ECMO compared to prone ventilation (RR 0.95, 95% CI 0.72–1.26), but inferences were based solely on indirect comparisons with very low certainty due to very wide confidence intervals.ConclusionsIn adults with ARDS and severe hypoxia, both VV-ECMO (low to moderate certainty evidence) and prone ventilation (moderate to high certainty evidence) improve mortality relative to low and moderate Vt strategies. The impact of VV-ECMO versus prone ventilation remains uncertain.

To explore if the pressure-controlled ventilation (PCV) and pressure-controlled ventilation-volume guaranteed (PCV-VG) modes are superior to volume-controlled ventilation (VCV) in optimizing intraoperative respiratory mechanics in infants and young children in the prone position. A single-center prospective randomized study. Children's Hospital, Zhejiang University School of Medicine. Pediatric patients aged 1 month to 3 years undergoing elective spinal cord detethering surgery. Patients were randomly allocated to the VCV group, PCV group and PCV-VG group. The target tidal volume (VT) was 8 mL/kg and the respiratory rate (RR) was adjusted to maintain a constant end tidal CO2. The primary outcome was intraoperative peak airway pressure (Ppeak). Secondary outcomes included other respiratory and ventilation variables, gas exchange values, serum lung injury biomarkers concentration, hemodynamic parameters and postoperative respiratory complications. A total of 120 patients were included in the final analysis (40 in each group). The VCV group showed higher Ppeak at T2 (10 min after prone positioning) and T3 (30 min after prone positioning) than the PCV and PCV-VG groups (T2: P = 0.015 and P = 0.002, respectively; T3: P = 0.007 and P = 0.009, respectively). The prone-related decrease in dynamic compliance was prevented by PCV and PCV-VG ventilation modalities at T2 and T3 than by VCV (T2: P = 0.008 and P = 0.015, respectively; T3: P = 0.015 and P = 0.014, respectively). Additionally, there were no significant differences in other secondary outcomes among the three groups. In infants and young children undergoing spinal cord detethering surgery in the prone position, PCV-VG may be a better ventilation mode due to its ability to mitigate the increase in Ppeak and decrease in Cdyn while maintaining consistent VT. •Studies of ventilation strategies in infants and young children during prone position are limited.•VCV mode showed higher Ppeak and lower Cdyn than PCV-VG and PCV modes during prone position.•VCV and PCV-VG modes showed more stable tidal volume than PCV mode during prone position.

Prone positioning for whole-breast irradiation (WBI) reduces dose to organs at risk, but reduces set-up speed, precision, and comfort. We aimed to improve these problems by placing patients in prone crawl position on a newly developed crawl couch (CrC). A group of 10 right-sided breast cancer patients requiring WBI were randomized in this cross-over trial, comparing the CrC to a standard prone breastboard (BB). Laterolateral (LL), craniocaudal (CC) and anterioposterior (AP) set-up errors were evaluated with cone beam CT. Comfort, preference and set-up time (SUT) were assessed. Forty left and right-sided breast cancer patients served as a validation group. For BB versus CrC, AP, LL and CC mean patient shifts were − 0.8 ± 2.8, 0.2 ± 11.7 and − 0.6 ± 4.4 versus − 0.2 ± 3.3, − 0.8 ± 2.5 and − 1.9 ± 5.7 mm. LL shift spread was reduced significantly. Nine out of 10 patients preferred the CrC. SUT did not differ significantly. The validation group had mean patient shifts of 1.7 ± 2.9 (AP), 0.2 ± 3.6 (LL) and − 0.2 ± 3.3 (CC) mm. Mean SUT in the validation group was 1 min longer (P < 0.05) than the comparative group. Median SUT was 3 min in all groups. The CrC improved precision and comfort compared to BB. Set-up errors compare favourably to other prone-WBI trials and rival supine positioning.

In local and global disaster scenes, rapid recognition of victims’ breathing is vital. It is unclear whether the footage transmitted from small drones can enable medical providers to detect breathing. This study investigated the ability of small drones to evaluate breathing correctly after landing on victims’ bodies and hovering over them. We enrolled 46 medical workers in this prospective, randomized, crossover study. The participants were provided with envelopes, from which they were asked to pull four notes sequentially and follow the written instructions (“breathing” and “no breathing”). After they lied on the ground in the supine position, a drone was landed on their abdomen, subsequently hovering over them. Two evaluators were asked to determine whether the participant had followed the “breathing” or “no breathing” instruction based on the real-time footage transmitted from the drone camera. The same experiment was performed while the participant was in the prone position. If both evaluators were able to determine the participant’s breathing status correctly, the results were tagged as “correct.” All experiments were successfully performed. Breathing was correctly determined in all 46 participants (100%) when the drone was landed on the abdomen and in 19 participants when the drone hovered over them while they were in the supine position (p < 0.01). In the prone position, breathing was correctly determined in 44 participants when the drone was landed on the abdomen and in 10 participants when it was kept hovering over them (p < 0.01). Notably, breathing status was misinterpreted as “no breathing” in 8 out of 27 (29.6%) participants lying in the supine position and 13 out of 36 (36.1%) participants lying in the prone position when the drone was kept hovering over them. The landing points seemed wider laterally when the participants were in the supine position than when they were in the prone position. Breathing status was more reliably determined when a small drone was landed on an individual’s body than when it hovered over them.