Paediatric ARDS: prone positioning and oscillation did not add ventilator-free days, and added harms

Design

International, 2×2 factorial, response-adaptive phase 3 randomised trial (PROSpect)

Population

424 children with early moderate-to-severe paediatric ARDS in 75 PICUs

Primary outcome

Ventilator-free days to day 28

Effect

Prone vs supine shift 0.0 (−0.8 to 1.0); HFOV vs conventional −0.3 (−1.5 to 0.5)

PROSpect was an international two-by-two factorial randomised trial in 75 paediatric ICUs. Children aged two weeks to 20 years with early moderate-to-severe paediatric ARDS were assigned to prone or supine positioning, and to high-frequency oscillatory or conventional ventilation. It stopped early for futility and slow enrolment after 424 of 600 planned patients.

Ventilator-free days to day 28 did not differ between prone and supine (median 17.9 against 17.4; location shift 0.0, 95% CI −0.8 to 1.0) or between oscillation and conventional ventilation (17.3 against 18.0; −0.3, −1.5 to 0.5). Day-28 mortality was 10% with no differences. Proning increased artificial airway obstruction (rate ratio 4.83) and pressure injuries (relative risk 6.13); oscillation increased haemodynamic instability (rate ratio 1.84).

In adults, early proning in severe ARDS is supported by trial evidence; this trial does not support transferring that routinely to children. Proning remains available as a rescue for individual children, but not as a default first-line step.

• Do not prone children with early moderate-to-severe ARDS routinely as a first-line strategy.
• If proning a child, watch closely for tube obstruction and pressure injuries.
• Reserve high-frequency oscillation for rescue; it raised haemodynamic instability.
• Keep to lung-protective conventional ventilation as the baseline approach.

Why it matters

Adult ARDS evidence is often borrowed for children; here it did not transfer.

Don't overread it

Stopped early at 424 patients; it does not rule out benefit in selected children as rescue.

The statistics, in plain English

A Hodges–Lehmann shift of 0.0 with an interval from −0.8 to 1.0 means the median difference in ventilator-free days was essentially zero. Stopping early reduces power, but the intervals are narrow enough to make a meaningful benefit unlikely.

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