Avoidance of tracheal intubation using awake prone positioning in a case of severe respiratory failure from lung adenocarcinoma

Rationale: The awake prone position (APP) has been recognized for its efficacy in decreasing mortality rates among patients suffering from acute respiratory distress syndrome (ARDS). While APP is frequently employed in non-intubated ARDS patients, its utilization in individuals with lung adenocarcinoma to boost oxygenation is not widely documented. Patient concerns and Diagnoses: A 61-year-old male presented with a 2-month history of cough, sputum, dyspnea, and weight loss. Upon examination, his oxygen saturation was recorded at 80%, and auscultation indicated the presence of numerous moist rales in both pulmonary fields. Chest computed tomography (CT) revealed extensive ground-glass opacities, thickened septa, and right lower lobe consolidation. Bronchoscopy showed a substantial amount of clear, frothy sputum in both lungs; however, polymerase chain reaction analysis of the bronchoalveolar lavage fluid did not identify any microorganisms. A transbronchial lung biopsy confirmed the diagnosis of lung adenocarcinoma. Interventions: Given the patient’s deteriorating respiratory condition, it was determined to initiate prone ventilation. Remarkably, after 30 minutes of commencing prone ventilation, there was a significant improvement in his oxygenation levels. A subsequent reassessment of the lung CT after 2 days of treatment in the prone position demonstrated a reduction in lung lesions and an enhancement in ventilation compared to the initial presentation. Outcomes: After 1 week of daily APP (12 hours/d), oxygenation improved sufficiently to avoid intubation. Following genetic testing results, targeted therapy with vemurafenib was started. The patient was discharged after 1 week of combined treatment. A 1-month follow-up CT demonstrated substantial resolution of pulmonary lesions. Lessons: This case report details the management of a patient with lung adenocarcinoma complicated by acute respiratory failure, who underwent innovative awake prone positioning ventilation. After daily APP treatment for 12 hours over 1 week, significant improvement in oxygenation was observed, and tracheal intubation was successfully avoided. Following 1 week of combined treatment with the targeted drug vemurafenib, the patient was discharged without complications. A follow-up CT scan 1 month later revealed substantial resolution of the pulmonary lesions. Early use of the APP may be a potential treatment option for patients with respiratory failure from lung adenocarcinoma that may avoid progression to tracheal intubation.