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Dear editor, We have read with exceptional interest the manuscript of Lin Ding et al. because the use of noninvasive ventilation (NIV) and high flow-nasal cannula (HFNC) combined with the prone position (PP) could avoid intubation of patients with acute respiratory distress syndrome (ARDS) [1]. The prone position is associated with a decrease in mortality in patients with ARDS, as demonstrated by Guerin in 2013 and the Formal Guide to the treatment of ARDS recommended the use of the PP for at least 16 h a day when P/F < 150 (moderate-severe ARDS) [2]. A study with a sample of 20 healthy patients shows an increase in lung volume at the end of expiration (LVEE) and a decrease in respiratory rate using HFNC demonstrated by electrical impedance tomography and that a PP resulted a more homogeneous distribution of the LVEE than the supine position [3]. The etiology of ARDS reported by Ding and colleagues [1] includes infectious pathologies in all cases, demonstrating that an early PP strategy with HFNC or NIV is safe and effective in patients with moderate ARDS and with SpO2 > 95% in which intubation could be avoided. The mortality of ARDS associated with infectious etiology (pneumonia, influenza, and sepsis) is considerably higher (35.1% for pulmonary infection and 28.1% for sepsis) than that reported for noninfectious causes such as pneumonitis (6.4%) and trauma (2.5%) [4]; therefore, an early PP strategy combined with HFNC could theoretically be effective in these cases, even with P/F < 100. We present a multicenter retrospective series of 6 cases of patients with severe ARDS with a noninfectious etiology compiled in 2017 and 2018 in hospitals of the 2nd level of care to which the PP was applied with HFNC or NIV. The PP was applied for 2–3 h every 12 h for 2 days, and in 3 cases, it was possible to avoid intubation; the causes were thoracic trauma with pulmonary contusions, lupus pneumonitis, bone marrow transplantation, and atelectasis of unknown cause (Table 1) (Fig. 1). The PP with HFNC or NIV seems to be a promising strategy to avoid intubation and its complications in patients with severe ARDS of noninfectious etiology, and a randomized controlled study is required to assess its safety and efficacy. The results of the OPTIPRONE study on the use of PP combined with HFNC in patients with ARDS with PaO2/FiO2 < 200 [5] are expected.

Prone positioning combined with high-flow nasal cannula in severe noninfectious ARDS