LAUSR

A recent international multicenter prospective study enrolling 29,144 patients who received invasive or noninvasive ventilation reported that acute respiratory distress syndrome (ARDS) was present in 23% of the mechanically ventilated patients [1]. In recent years, the ARDS mortality rate ranged between 28% and 35% [1, 2] with lower survival in patients with more severe ARDS [1]. The main supportive therapy in ARDS is invasive mechanical ventilation combining lung protective ventilation to prevent ventilator-associated lung injury with a restrictive fluid therapy to limit/prevent lung edema [3, 4]. However, the optimal approach for lung protective ventilation is still questionable [5]. The recent American/ European guideline and an expert opinion on respiratory support in ARDS patients recommended a low tidal volume ventilation (i.e., 6 ml/kg of ideal body weight, or lower in case of plateau pressure higher than 30 cm H2O) with positive end-expiratory pressure (PEEP) adjusted according to the respiratory mechanics (lung and chest wall elastance), driving pressure, gas exchange, and lung imaging [6, 7]. In addition, in case of severe ARDS the use of prone position, according to previous positive studies [8–10], has been recommended. However, the use of prone position in daily clinical practice in ARDS ranges between 7% and 8% of the mechanically ventilated patients [1, 2]. In the current issue of Intensive Care Medicine, Guerin et al. reports the results of a prospective observational international study (APRONET study) evaluating the prevalence of the application of prone position in ARDS patients, the reasons for not applying it, and the related complications [11]. This 1-day prevalence study was repeated four times between April