Letters: February 2014

Ineffective Medical Practices

Re: Page 7 in October AACN Bold Voices

The December article about ineffective medical practices refers to an analysis of articles published in The New England Journal of Medicine. The lead researcher cites practices that “were instituted in error, never helped patients, and have eroded trust in medicine” and includes prone positioning of ventilated patients.

However, the June 6, 2013, issue of the same journal published an article, “Prone Positioning in Severe Acute Respiratory Distress Syndrome,” that says the early application of prolonged prone positioning shows significant improvements in mortality.

Lisa Callinan
East Meadow, N.Y.

This article is incorrect or, at best, misleading. According to the new Berlin Definition of ARDS, the term “acute lung injury” is no longer used.

In a prospective randomized control study by Guerin et al, published in the June issue of The New England Journal of Medicine, prone therapy showed a statistically significant (P<0.001) 50 percent reduction in mortality in patients with severe ARDS.

As the study shows, prone therapy is a positioning maneuver that can be lifesaving when done early. My facility is using it with great success.

Eric Moss
Carmel, Ind.

December’s article references literature published between 2001–2010 when the term “acute lung injury” was in use. We appreciate your alerting readers about the Berlin ARDS definitions and the Guerin study.

Some studies, such as Guerin, support the use of prone positioning. Yet user experience, the risk of potentially injurious complications and outcomes vary among users.

The 2012 guidelines from the Surviving Sepsis Campaign recommend prone positioning for sepsis-induced ARDS in centers with experience when the patients are at injurious levels of oxygen or plateau pressures and who are not at high risk for adverse consequences from prone positioning.

We encourage clinicians from all relevant disciplines to collaborate in the management of patients who may benefit from prone positioning, and implement care according to current evidence and best practices as they continue to be reported. See this issue’s digital edition for links to the three sources. — Ed.

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