Routine pediatric lung therapies do not improve ventilator-free days

Results from the largest international clinical trial of its kind show that early, routine use of prone positioning and/or high-frequency oscillatory ventilation (HFOV) do not increase ventilator-free days for children with pediatric acute respiratory distress syndrome (PARDS).

Published in The Lancet and led by senior author Martha A.Q. Curley, PhD, RN, FAAN, Professor in the Department of Family and Community Health and the Ruth M. Colket Endowed Chair in Pediatric Nursing at Children’s Hospital of Philadelphia, the PROSpect trial evaluated 424 children across 75 hospitals in 18 countries. The study challenges decades of clinical practice by demonstrating that these therapies do not improve child outcomes compared to usual care that includes supine positioning or conventional mechanical ventilation. 

Key findings:

• Primary outcomes: There were no significant differences in ventilator-free days through day 28 between prone and supine positioning, or between HFOV and conventional mechanical ventilation.
• Mortality: Overall, 28-day mortality was 10%, with no significant differences across groups.
• Safety: Prone positioning was linked to higher rates of airway obstruction and pressure-related skin injuries, while HFOV was associated with increased hemodynamic instability.

PROSpect provides the strongest evidence to date on early, first-line strategy decisions in moderate-to-severe PARDS. While prone positioning and HFOV remain important tools in a clinician’s toolkit-particularly as rescue therapies when safe limits of lung-protective ventilation cannot be maintained-our findings indicate that routine, first-line application of these therapies are not supported by clinical evidence.” 

Martha A.Q. Curley, PhD, RN, FAAN, Professor, Department of Family and Community Health and the Ruth M. Colket Endowed Chair in Pediatric Nursing, Children’s Hospital of Philadelphia

While these techniques may remain valuable as rescue therapies, the findings suggest that the routine, application of both prone positioning and the use of HFOV should be de-implemented to minimize patient risks and refine pediatric critical care protocols.