International recommendations are to leave the patient in PP for at least 12 h. However, the optimal duration of PP sessions remains unclear. Its use in mild-to-moderate ARDS remains debated. This is why its use is highly recommended in severe ARDS. PP is thus one of the three therapeutics to have shown a positive effect on ARDS mortality, with the reduction of the tidal volume (VT) and the early use of neuromuscular blocking agents (NMBA), although this is partly challenged by a recent study. Two meta-analyses and then the PROSEVA trial showed a beneficial effect on the outcome of moderate-to-severe ARDS with a reduction in mortality. Lung expansion would be more homogeneous with improved ventilation/perfusion ratios and reduced VILI. The compliance of the respiratory system would increase despite a decrease in the compliance of the chest wall. It would reduce pulmonary stress and strain by reducing the overdistension of aerated non-dependent zones while allowing recruitment of atelectatic dependent zones. It could also prevent ventilator-induced lung injury (VILI). Randomized controlled trials have confirmed that oxygenation is improved in the PP compared to the supine position (SP). Prone position (PP) has been part of respiratory management of moderate-to-severe acute respiratory distress syndrome (ARDS) for several years. Trial registration The trial has been registered on 28 June 2016 in (NCT 02816190) ( ). PP sessions should be prolonged at least 24 h and be extended in the event that the P aO 2/F iO 2 ratio at 24 h remains below 150, especially since no criteria can predict which patient will benefit or not from it. The evolution of the respiratory parameters during the first session and also during the pooled sessions did not find any predictor of response to PP, whether before, during or 2 h after the return in SP. The beneficial physiological effects continued after 16 h of PP and at least up to 24 h in some patients. They presented a significant increase in pH, static compliance and P aO 2/F iO 2 with a significant decrease in P aCO 2, P plat, phase 3 slope of the volumetric capnography, P etCO 2, V D/ V T-phy and Δ P. 103 patients (ARDS 95%) were included performing 231 PP sessions with a mean length of 21.5 ± 5 h per session. Dynamic parameters were recorded before proning and every 30 min during the session until 24 h. Pulmonary mechanics, data from volumetric capnography and arterial blood gas were recorded before prone positioning, 2 h after proning, before return to a supine position (SP) and 2 h after return to SP. We included in the study all prone-positioned patients in our ICU between June 2016 and January 2018. It was a prospective, monocentric, physiological study. We searched to evaluate the time required to obtain the maximum physiological effect, and to search for parameters related to patient survival in PP. Prone position (PP) is highly recommended in moderate-to-severe ARDS.
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