The effects of lateral-prone positioning on mechanical power and respiratory mechanics in acute respiratory distress syndrome patients: insights and research extensions

We sincerely thank Ling Zeng and Fanjun Zeng for their thoughtful and constructive comments on our study. We were pleased to report that lateral-prone positioning was associated with reduced mechanical power (MP) compared to traditional prone positioning in patients with acute respiratory distress syndrome (ARDS) (1). To ensure data integrity, all respiratory mechanics assessments and MP calculations were conducted by certified respiratory therapists and independently verified by a senior attending physician.

Despite our careful design, we acknowledge several limitations in our study, which we aim to address in future research:

First, while MP is a useful composite parameter indicating susceptibility to ventilator-induced lung injury (VILI), it reflects a probability of injury development rather than established pathology and is not a direct diagnostic marker. In future studies, we plan to incorporate real-time electrical impedance tomography (EIT) to assess regional ventilation heterogeneity resulting from positional changes (2). Additionally, emerging contrast-enhanced EIT techniques using hypertonic saline boluses allow bedside evaluation of regional lung perfusion (3). Integrating these tools will enable us to explore how various prone strategies affect ventilation-perfusion matching, an exciting direction for future investigation.

Second, our study population consisted predominantly of ARDS patients with viral pneumonia (>90%), which limits generalizability to other ARDS subtypes (e.g., sepsis- or trauma-induced). To improve external validity, we are planning a large-scale randomized controlled trial (RCT) that will include stratified analyses based on ARDS etiology (pneumonia vs. non-pneumonia) and severity (PaO₂/FiO₂ ≤150 mmHg vs. >150 mmHg).

Third, we recognize the importance of long-term clinical outcomes. Future studies will expand clinical endpoints to include ventilator liberation success (48-hour extubation failure rate), intensive care unit (ICU) length of stay, and 90-day mortality to better capture the prognostic implications of different prone positioning strategies.

Fourth, to enhance patient safety monitoring, upcoming research will include standardized Braden Scale assessments for pressure injury risk and documentation of hemodynamic instability events (defined as mean arterial pressure <65 mmHg) (4,5).

In conclusion, we modestly acknowledge the limitations of our current study and appreciate the opportunity to reflect on them. We are committed to addressing these issues in future work to advance the understanding and optimization of prone positioning strategies in ARDS.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Thoracic Disease. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1251/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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