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The PROSEVA trial transformed the role of prone positioning in severe ARDS. Adults with severe hypoxaemic ARDS were randomised to repeated prone-positioning sessions lasting at least 16 hours or to continued supine ventilation. Both groups received lung-protective ventilation, creating a clinically relevant comparison within modern ARDS care. Early, prolonged proning significantly reduced mortality, with the strongest benefit seen in severe ARDS. The physiologic rationale is that turning the patient prone redistributes stress and strain within the lung, improves ventilation-perfusion matching and can reduce regional overdistension while recruiting dependent lung units. The practical message is that proning is not merely a rescue manoeuvre for refractory hypoxaemia; in appropriately selected patients with severe ARDS, it is an evidence-based treatment that should be started early and delivered for sufficiently long sessions. Successful implementation depends on trained staff, airway security, pressure-injury prevention and coordinated monitoring. PROSEVA also demonstrates why individual components of ARDS care should not be interpreted in isolation—the mortality benefit emerged in the context of low tidal-volume ventilation and other supportive measures. For clinicians, prolonged prone positioning remains one of the highest-yield nonpharmacologic interventions for severe ARDS.
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The PROSEVA trial transformed the role of prone positioning in severe ARDS. Adults with severe hypoxaemic ARDS were randomised to repeated prone-positioning sessions lasting at least 16 hours or to continued supine ventilation. Both groups received lung-protective ventilation, creating a clinically relevant comparison within modern ARDS care. Early, prolonged proning significantly reduced mortality, with the strongest benefit seen in severe ARDS. The physiologic rationale is that turning the patient prone redistributes stress and strain within the lung, improves ventilation-perfusion matching and can reduce regional overdistension while recruiting dependent lung units. The practical message is that proning is not merely a rescue manoeuvre for refractory hypoxaemia; in appropriately selected patients with severe ARDS, it is an evidence-based treatment that should be started early and delivered for sufficiently long sessions. Successful implementation depends on trained staff, airway security, pressure-injury prevention and coordinated monitoring. PROSEVA also demonstrates why individual components of ARDS care should not be interpreted in isolation—the mortality benefit emerged in the context of low tidal-volume ventilation and other supportive measures. For clinicians, prolonged prone positioning remains one of the highest-yield nonpharmacologic interventions for severe ARDS.
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