Proning Ventilated Patients In ARDS

Definition

Proning is the process of turning a patient with accurate, safe movements from their back onto their abdomen (stomach) so the individual is lying face down for therapeutic purposes.

Indications

The main indication for proning is to improve respiratory conditions:

1. To improve oxygenation.
2. To improve respiratory mechanics.
3. To homogenize the pleural pressure gradient, the alveolar inflation, and the ventilation distribution.
4. To increase lung volume and reduce the amount of atelectatic regions.
5. To facilitate the drainage of secretions.
6. To reduce ventilator-associated lung injury.

Contraindications

Some of the contraindications are but not limited to:

1. Raised intracranial pressure
2. Massive hemoptysis
3. Tracheostomy or tracheal surgery
4. Severe facial trauma
5. Eye trauma or injury
6. Unstable C spine
7. New pacemaker insertion (within 2 days)
8. Pregnancy
9. Anterior chest tube
10. ЕСМО
11. Open abdomen/recent abdominal surgery

Obtain supplies

• Obtain sufficient supply of pillows (4-6), sheets.
• Obtain foam head support.
• Position the patient so that the shoulders are at the edge of the bed with the head extended slightly beyond the head of the bed.
• Pillows can be used to help raise the chest and pelvis off the bed. This reduces pressure points and abdominal pressures.
  Reduction in abdominal pressures may improve ventilation.

Proning team

Most hospitals use a proning team typically consisting of six to 8 experts including:

• Registered nurses mostly with critical care training
• Respiratory therapists
• Physical therapists
• Physicians (Mostly Intensivists or anaesthetists)

Preparation of Patient and Team Members

Check for indication and rule out contraindications, usually moderate to severe respiratory distress is an indication.

• Obtain order.
• Assemble equipment at bedside and make sure lines, tubing, are safe and secure.
• Ensure that patient has adequate sedation and paralytic ordered.
• Stop enteral feeding.
• Remove the headboard from the bed.
• A minimum of 6 staff members and a respiratory therapist/nurse to manage the endotracheal tube are required to prone a ventilated patient.
• A respiratory therapist/critical care nurse acts as an Airway Manager” is at head of bed.
• 2-3 staff members on each side of the bed depending on the size of the patient and equipment involved.
• Additional staff members may be required if the patient is very large or has complex lines and tubes.
• During turning, the person responsible for the airway provides the team direction regarding when to turn.
• The critical care nurse has to assess the devices and lines and advise turning team considering line safety.

Perform Safety Pause

• Review plan and safety procedures with team.
• Review complications that can happen and ensure appropriate personnel and equipment is available prior to turning including:
• Accidental extubation (reintubation equipment available, bag-mask).
• Rapid supination plan in the event of cardiac arrest.
• Accidental loss of other lines and tubes (e.g., central venous, arterial or dialysis lines, chest tubes).

Procedure

1. Turn the patient to one side and apply ECG leads to the patient’s back. When finished, remove all chest electrodes, to prevent pressure ulcers when prone.
2. Examine patient’s chest to identify areas vulnerable to pressure such as ports or lines and use padding to prevent pressure.
3. Align all lines and tubes that are located above the patient’s waist straight upward toward the head of the bed and align all lines and tubes that are located below the waist straight down toward the foot of the bed to prevent dislodgement and entanglement.
4. Respiratory therapist or physician should evaluate endotracheal tube securement and mark tube length at lip line/teeth and document.
5. Place Pillows on the patient: With the patient in supine position, place one or two pillows across the upper chest. This will ensure the chest and shoulders are elevated off the bed for airway maintenance. Place another pillow horizontally across the iliac crest and a third across the upper thighs. Place a thinner pillow over the shins. If the patient has a femoral line, position pillows around the device to ensure the femoral line is protected from pressure.
6. Position arms along the side of the body with fingers pointing toward toes keeping arms as close to body as possible.
7. Turn patient prone and supine with their face looking in the direction of the ventilator.
8. Position by crossing feet at the ankles by placing the foot opposite to the ventilator on top.
9. Cover the entire patient with a sheet from the head to foot of the bed. But fold the section of the sheet that is above the shoulders so that the patient’s head is not covered.
10. Sandwich patient between sheets, by grabbing both the top and bottom sheets together. Along both sides of the patient, tightly roll the sheets together like a tortilla wrap to sandwich patient firmly between the sheets so as to maintain alignment of the spine and keep patient safe.
11. Slide patient away from ventilator by turning the patient in such a way as to face the ventilator. This ensures enough slack for the ventilator tubing and helps in preventing accidental extubation. Moving the patient away from the ventilator ensures sufficient bed surface for pronation.
12. The team leader calls for a first turn after consulting with the airway manager. Count to ensure unison in movement.
13. Complete the pronation by slowly turning the patient prone and holding tightly onto the linen roll at each side to secure patient.
    “Airway Manager” to provide feedback on speed of turn according to airway always needs by supporting the endotracheal tube and maintaining neck alignment.
14. Assess the Airway by checking for ET tube mark at lip line/teeth, kinks in tube, breath sounds pressure points around ET tube and securement device.
15. Moving the patient to the top of the bed with shoulders at the edge of the mattress and head extending beyond the mattress can be very effective placed on a bedside table with donut pillows for support. The bedside table, if used, should be placed
    below the level of the mattress. Position the bedside table lower than the mattress while the patient’s head is supported. Place two pillows on the bedside table and adjust the level so that the patient’s head is relaxed. The shoulders and elbows
    can be gently flexed in this position and brought upward on each side of the patient’s head.
16. Once the bed/table position is optimized, ensure that the table is locked and secured.
17. Alternatively, the head can be positioned on the bed turned to one side or positioned using donut foam pillows.
18. Place bed in reverse Trendelenburg position.
19. Position patient in prone position as long as the physician orders.

Care of Prone Patients

Patients should have their head repositioned QH. This can usually be managed by turning from one side to the other. Avoid positioning over lines. Ensure patient is on paralytics and adequate sedation. Ensure arterial blood gases are drawn as per hospital protocol.

Ensure pressure relief at any sensitive points. Ensure ECG electrodes, lines, tubes, and Foley catheters removed from under the patient or padded adequately.

Ensure bilateral feet in dorsiflexion by placing a rolled towel or small pillow under the shin to raise ankles off the bed. Place arms in a swimmer’s position (one arm placed over the head and the other arm placed on the side) for better alignment.

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
4. Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
5. Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
6. Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
7. AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
8. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

Stories are the threads that bind us; through them, we understand each other, grow, and heal.

JOHN NOORD

Connect with “Nurses Lab Editorial Team”

I hope you found this information helpful. Do you have any questions or comments? Kindly write in comments section. Subscribe the Blog with your email so you can stay updated on upcoming events and the latest articles.