The use of prone positioning has become a standard of care for improving oxygenation in mechanically ventilated patients with moderate-to-severe acute respiratory distress syndrome (ARDS). While offering significant benefits for pulmonary function, the procedure presents numerous challenges that necessitate a highly coordinated and meticulous approach from the care team. Neglecting the critical details can lead to severe and potentially permanent complications, including pressure sores, nerve damage, and cardiopulmonary compromise. The following considerations are crucial for ensuring patient safety and maximizing therapeutic benefit.
Collaborative Team and Pre-procedure Planning
Before a patient is placed in the prone position, a coordinated team and thorough preparation are essential. This process minimizes the risk of harm to both the patient and the caregivers involved. The turning procedure itself requires adequate staffing, typically involving five or more trained team members, with one dedicated leader managing the patient's head and airway.
Preparing for the Prone Turn
- Risk Assessment: A comprehensive assessment must be performed, considering the patient's comorbidities, hemodynamic stability, body habitus, and potential contraindications such as an open abdomen or unstable spine.
- Patient and Family Education: Explain the rationale, benefits, and procedural steps to the patient and family. This is especially important for awake, non-ventilated patients who can assist with the process.
- Gather Equipment: A designated 'PRONE kit' or checklist can ensure all necessary supplies are ready, including specialized positioning pillows, foam dressings, monitoring cables, and extra sheets.
- Pre-Turn Checks: Prior to the maneuver, baseline vital signs and a full skin assessment should be documented. All tubes, lines, and drains should be secured, with their position noted, and potentially disconnected if not vital for the turn.
Pressure Injury Prevention and Patient Positioning
Pressure injuries are one of the most common complications of prone positioning, especially during prolonged sessions. Meticulous attention to padding and regular repositioning is vital to protect vulnerable areas.
Key Areas for Protection
- Face: Use a specialized head positioner to keep the head in a neutral position, avoiding direct pressure on the eyes, nose, cheeks, and mouth. Pad bony prominences like the forehead and chin. The head should be repositioned every 2-4 hours to alternate pressure points.
- Torso and Pelvis: Utilize chest and pelvic supports or positioning pillows that extend from the clavicles to the iliac crests, allowing the abdomen to hang freely. This prevents increased intra-abdominal pressure and allows for better ventilation and venous return. In females, ensure breasts are free of pressure.
- Extremities: Pad the knees, ankles, and toes. Elevate the shins to prevent pressure on the knees and feet. The arms should be in a 'swimmer' position, with one arm up and the other down, and alternated every 2 hours to avoid nerve damage. Never abduct the arms beyond 90 degrees.
- Medical Devices: Protect skin under and around all medical devices, such as endotracheal tubes, monitoring cables, and catheters, with thin prophylactic dressings.
Airway and Respiratory Management
Managing the airway of a proned patient is complex and requires specialized expertise, typically from a respiratory therapist or anesthesiologist.
Maintaining Airway Patency and Security
- Tube Security: Ensure the endotracheal tube is securely fastened before and after the turn. Taping is often preferred over commercial holders to prevent pressure injuries.
- Airway Monitoring: The designated team member at the head of the bed must maintain control of the airway throughout the turning process. Continuous vigilance is required to check for tube displacement, kinking, or obstruction.
- Secretions Management: In the prone position, secretions tend to drain differently. Increased suctioning frequency may be necessary to maintain airway patency.
- Post-Prone Extubation: After an extended period in the prone position, facial and tongue swelling can occur. The patient should be evaluated for edema before extubation, as it may necessitate delayed extubation or reintubation.
Hemodynamic and Gastrointestinal Monitoring
Significant physiological changes can occur when a patient is in the prone position, affecting hemodynamics and gastrointestinal function.
Cardiovascular and Perfusion Stability
- Baseline Measurements: Obtain baseline vital signs and hemodynamic measurements before proning to evaluate the patient's response.
- Continuous Monitoring: Closely monitor the patient's vital signs, especially during the first hour after turning, to ensure they tolerate the position hemodynamically. A sudden decrease in blood pressure or heart rate is a sign of instability and may necessitate returning the patient to a supine position.
- Venous Return: The prone position can decrease venous return and cardiac output, especially if the abdomen is compressed. Specialized tables or bolsters that decompress the abdomen are crucial.
Nutrition and GI Intolerance
- Enteral Feeding: Current guidelines suggest resuming enteral feeding once the patient is positioned. However, signs of gastrointestinal intolerance, such as abdominal distension or vomiting, should be monitored.
- Feeding Management: Consider a reverse Trendelenburg position (15-25 degrees head elevation) to help with gastric emptying. If intolerance persists, a post-pyloric feeding tube may be necessary.
Prone vs. Supine Positioning: A Comparison of Risks
| Feature | Prone Positioning | Supine Positioning |
|---|---|---|
| Surgical Access | Excellent for posterior anatomy (spine, head, neck). | Excellent for anterior anatomy (chest, abdomen). |
| Ventilation/Perfusion | Improves distribution and aeration of dorsal lung segments. | Can lead to compression of dorsal lung regions. |
| Pressure Injuries | Primarily on anterior surfaces: face, chest, breasts, pelvis, knees, toes. | Primarily on posterior surfaces: occiput, sacrum, heels. |
| Airway Security | Challenging; high risk of tube kinking or displacement. | Generally more accessible and stable. |
| Hemodynamic Effects | Potential for reduced cardiac output, especially if abdomen is compressed. | Higher risk of right ventricular dysfunction in certain ARDS patients. |
| Monitoring Access | More difficult to access central lines and chest. | Easier access to anterior vital monitoring points. |
| Complications | Increased risk of ocular injury, nerve injury, and facial edema. | Lower risk of facial swelling and direct ocular pressure. |
Conclusion
Caring for a patient in a prone position is a complex, high-risk, high-reward procedure that demands meticulous preparation, execution, and monitoring. The benefits in oxygenation, especially for patients with severe ARDS, are substantial, but they are inextricably linked to the ability of the healthcare team to prevent common and serious complications. The key considerations involve not only the mechanical aspects of turning and positioning but also continuous vigilance over the patient's physiological responses. Constant hemodynamic monitoring, careful airway management, and scrupulous skin integrity checks are not optional steps but cornerstones of safe prone care. A well-trained, collaborative team is the single most important factor in navigating the dangers and maximizing the life-saving potential of prone positioning. For more information, the Anesthesia Patient Safety Foundation offers detailed articles on the dangers of the prone position.
What are the key considerations when caring for a patient in a prone position? A Procedural List
Before the Turn:
- Team Collaboration: Assemble a multi-professional team of at least 5-6 trained personnel, including a designated airway manager.
- Patient Preparation: Empty all drains, secure all tubes/lines, and apply prophylactic foam dressings to the face and bony prominences.
- Pre-Turn Assessment: Record baseline vital signs, hemodynamic measurements, and a full skin assessment.
During the Turn:
- Airway First: The airway manager maintains control of the endotracheal tube, ensuring it is secure and accessible.
- Coordinated Movement: Use a designated leader to call out the steps, with team members working in unison to smoothly roll the patient.
- Decompress Abdomen: Utilize chest and pelvic supports to allow the abdomen to hang freely, preventing increased intra-abdominal pressure.
After the Turn:
- Vital Signs Check: Monitor vital signs closely, especially during the first hour, to confirm hemodynamic stability.
- Protect Pressure Points: Reposition the patient's head and arms in a 'swimmer' position every 2 hours, ensuring padding is correctly placed under all bony prominences.
- Eye Care: Check eyes daily for any signs of pressure, and apply eye lubricant and tape eyelids shut horizontally to prevent corneal abrasions.
- Resume Care: Reconnect all lines and drains, and resume enteral feeding as per protocol, monitoring for intolerance.
- Post-Prone Assessment: Before returning the patient to supine, re-evaluate for potential edema, especially of the face and airway.
