The Rise of Prone Positioning

Prone positioning has transitioned from a salvage procedure for ARDS, to a more routine part of the armamentarium (including , neuromuscular blockade, inhaled prostacyclin, APRV) based on the dramatic success seen in the study by Claude Guérin published in the New England Journal of medicine in 2013. In this trial involving 466 patients, a mortality benefit of over 50 % was seen at 28-days and 90-days.

Prone Positioning Swimmer Crawl

Prone positioning improves lung compliance and ventilation-perfusion matching by reducing the posterior atelectatic lung. This is because the heart and anterior lung fields are placed down, instead of acting with gravity to compress the larger posterior lungs. Therefore, more of the lung parenchyma is ventilated, and at a fixed tidal volume the lung will suffer less barotrauma.

Placing a patient in the prone position requires significant effort and has serious risks. Close attention to lines, drains, and airway is critical, as is obsessive attention to pressure point padding and prevention of ulcers. Because of the “unnatural ICU position”, and the risks involved, ICU staff (physicians, nurses, respiratory therapists) have a natural reluctance for prone positioning despite its potential benefits.

Pre-Prone Planning

Should be considered a procedure, with planning, consent, and timeout. Since prone positioning is usually considered are ventilator optimization, inhaled prostacyclins, deep sedation and neuromuscular blockade have already been done, the patient is often has poor oxygenation, and tenuous respiratory and cardiovascular condition. Given the risks, careful planning and preparations are critical.

  • Identify physician to authorize and supervise procedure (attending or fellow).
  • Order for prone positioning should be entered into the patient’s chart.
  • Review inclusion & contraindications.
  • Discuss risk/benefits of the procedure with the patient’s decision maker.
  • A central venous catheter, arterial catheter, urethral catheter, and feeding tube should be placed before proning.
  • Gather staff that will be available for the 15-20 minutes to perform the proning. This usually involves 3-4 nurses, physician, and respiratory therapist.

Gather Equipment Required for Proning

  • Pillows (3-4).
  • Flat sheets (2).
  • Dry flow pads (2-3).
  • ECG leads/patches.
  • ETT holder (twill tape, E-tab, etc).
  • Extra ventilator circuit including suction catheter.
  • Doughnut pillow for head.
  • Ensure oral suction and ETT suction available (either inline or catheter).
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