Implementing Prone Positioning in Your Unit: What Do You Need to Know?

2020 ◽  
Vol 14 (3) ◽  
pp. 130-140
Author(s):  
Kathleen Vollman
Keyword(s):  
Distress Syndrome ◽  
Routine Practice ◽  
List Type ◽  
Prone Positioning ◽  
Multiprofessional Team ◽  
Screening Strategies ◽  
Randomized Control ◽  
Implementation Plans ◽  
Recommended Therapy ◽  
Indications For Use

Prone positioning for patients with acute respiratory distress syndrome (ARDS) has been occurring for over 30 years. A recent randomized control trial showing significant impact on 30- and 90-day mortality has placed it into international guidelines as a strongly recommended therapy. The current coronavirus pandemic shined a light on prone positioning as a lifesaving technique to improve oxygenation. This has resulted in worldwide implementation in intensive care units (ICUs). To incorporate prone positioning into moderate and severe ARDS patients' routine practice, the multiprofessional team must address many factors. They include: Understanding why prone positioning works and the evidence to supports its use with moderate to severe ARDS patients.Identify screening strategies to determine which patients the position should be initiated early in the course of their disease.Multiprofessional development of a protocol is required to address indications for use, methods, frequency of prone positioning, contraindications, equipment needed, preparation of the patient to prevent injury, and care of the patient while in the prone position as indications for stopping the procedure.Development of education and implementation plans to ensure the successful integration of the new practice.

scholarly journals Proning related bilateral anterior ischaemic optic neuropathy in a patient with COVID-19 related acute respiratory distress syndrome

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Kirsty Michelle Clarke ◽  
Vivi Riga ◽  
Amy-lee Shirodkar ◽  
Joel Meyer
Keyword(s):  
Mechanical Ventilation ◽  
Acute Respiratory Distress Syndrome ◽  
Visual Field ◽  
Respiratory Distress Syndrome ◽  
Distress Syndrome ◽  
Vision Loss ◽  
Prone Positioning ◽  
Disc Oedema ◽  
Ischaemic Optic Neuropathy ◽  
The Right

Abstract Background Non-arteritic ischaemic optic neuropathy (NAION) is a rare but harmful complication of prone positioning. Prone mechanical ventilation is a therapeutic strategy which has been used extensively during the COVID-19 pandemic to treat acutely hypoxemic patients with COVID-19 related acute respiratory distress syndrome (ARDS). Though a small number of cases of unilateral NAION have been reported in patients testing positive for the SARS-CoV-2 virus, we describe what is to our knowledge, the first reported case of bilateral NAION occurring in a patient proned extensively for the treatment of COVID-19 related ARDS. We consider the potential aetiological factors leading to NAION after prone mechanical ventilation in patients with COVID-19 and suggest strategies to protect against its development. Case presentation : We report a case of severe, irreversible, visual impairment secondary to bilateral anterior ION in a fifty-five-year-old male who underwent eight episodes of prone mechanical ventilation to treat COVID-19 related ARDS. Once weaned from his sedation he reported bilateral painless vision loss, and bedside ophthalmological assessment identified a reduced visual acuity of 3/30 unaided in the left eye and counting fingers in the right. Dilated indirect ophthalmoscopy revealed inferotemporal optic disc oedema with splinter haemorrhages in the right eye and mild disc oedema, temporal pallor, and nerve fibre layer haemorrhages inferiorly in the left eye. Humphrey visual field 24 − 2 testing confirmed a severely constricted visual field with macular sparing on the right and depressed inferonasal vision with preserved peripheral vision on the left eye. OCT disc imaging shortly after diagnosis revealed bilateral disc swelling and flame haemorrhages in the right eye. Conclusions NAION is a devastating, but preventable complication of prone positioning, which may pose significant risk of vision loss in patients with COVID-19 related ARDS.

An Evidence-Based Protocol for Manual Prone Positioning of Patients With ARDS

2021 ◽  
Vol 41 (6) ◽  
pp. 55-60
Author(s):  
Patrick Ryan ◽  
Cynthia Fine ◽  
Christine DeForge
Keyword(s):  
Mechanical Ventilation ◽  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Distress Syndrome ◽  
Medical Center ◽  
Academic Medical Center ◽  
Prone Positioning ◽  
Hypoxemic Respiratory Failure ◽  
Unplanned Extubations

Background Manual prone positioning has been shown to reduce mortality among patients with moderate to severe acute respiratory distress syndrome, but it is associated with a high incidence of pressure injuries and unplanned extubations. This study investigated the feasibility of safely implementing a manual prone positioning protocol that uses a dedicated device. Review of Evidence A search of CINAHL and Medline identified multiple randomized controlled trials and meta-analyses that demonstrated both the reduction of mortality when prone positioning is used for more than 12 hours per day in patients with acute respiratory distress syndrome and the most common complications of this treatment. Implementation An existing safe patient-handling device was modified to enable staff to safely perform manual prone positioning with few complications for patients receiving mechanical ventilation. All staff received training on the protocol and use of the device before implementation. Evaluation This study included 36 consecutive patients who were admitted to the medical intensive care unit at a large academic medical center because of hypoxemic respiratory failure/acute respiratory distress syndrome and received mechanical ventilation and prone positioning. Data were collected on clinical presentation, interventions, and complications. Sustainability Using the robust protocol and the low-cost device, staff can safely perform a low-volume, high-risk maneuver. This method provides cost savings compared with other prone positioning methods. Conclusions Implementing a prone positioning protocol with a dedicated device is feasible, with fewer complications and lower costs than anticipated.

scholarly journals Right Ventricular Function in Acute Respiratory Distress Syndrome: Impact on Outcome, Respiratory Strategy and Use of Veno-Venous Extracorporeal Membrane Oxygenation

2022 ◽  
Vol 12 ◽  
Author(s):  
Matthieu Petit ◽  
Edouard Jullien ◽  
Antoine Vieillard-Baron
Keyword(s):  
Pulmonary Hypertension ◽  
Extracorporeal Membrane Oxygenation ◽  
Right Ventricle ◽  
Pulmonary Circulation ◽  
Distress Syndrome ◽  
Cor Pulmonale ◽  
Prone Positioning ◽  
Acute Cor Pulmonale ◽  
Membrane Oxygenation ◽  
The Right

Acute respiratory distress syndrome (ARDS) is characterized by protein-rich alveolar edema, reduced lung compliance and severe hypoxemia. Despite some evidence of improvements in mortality over recent decades, ARDS remains a major public health problem with 30% 28-day mortality in recent cohorts. Pulmonary vascular dysfunction is one of the pivot points of the pathophysiology of ARDS, resulting in a certain degree of pulmonary hypertension, higher levels of which are associated with morbidity and mortality. Pulmonary hypertension develops as a result of endothelial dysfunction, pulmonary vascular occlusion, increased vascular tone, extrinsic vessel occlusion, and vascular remodeling. This increase in right ventricular (RV) afterload causes uncoupling between the pulmonary circulation and RV function. Without any contractile reserve, the right ventricle has no adaptive reserve mechanism other than dilatation, which is responsible for left ventricular compression, leading to circulatory failure and worsening of oxygen delivery. This state, also called severe acute cor pulmonale (ACP), is responsible for excess mortality. Strategies designed to protect the pulmonary circulation and the right ventricle in ARDS should be the cornerstones of the care and support of patients with the severest disease, in order to improve prognosis, pending stronger evidence. Acute cor pulmonale is associated with higher driving pressure (≥18 cmH2O), hypercapnia (PaCO2 ≥ 48 mmHg), and hypoxemia (PaO2/FiO2 < 150 mmHg). RV protection should focus on these three preventable factors identified in the last decade. Prone positioning, the setting of positive end-expiratory pressure, and inhaled nitric oxide (INO) can also unload the right ventricle, restore better coupling between the right ventricle and the pulmonary circulation, and correct circulatory failure. When all these strategies are insufficient, extracorporeal membrane oxygenation (ECMO), which improves decarboxylation and oxygenation and enables ultra-protective ventilation by decreasing driving pressure, should be discussed in seeking better control of RV afterload. This review reports the pathophysiology of pulmonary hypertension in ARDS, describes right heart function, and proposes an RV protective approach, ranging from ventilatory settings and prone positioning to INO and selection of patients potentially eligible for veno-venous extracorporeal membrane oxygenation (VV ECMO).

scholarly journals Acute respiratory distress syndrome in a case of diabetic ketoacidosis requiring ECMO support

2021 ◽  
Vol 2021 ◽  
Author(s):  
Milad Darrat ◽  
Brian Gilmartin ◽  
Carmel Kennedy ◽  
Diarmuid Smith
Keyword(s):  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Diabetic Ketoacidosis ◽  
Distress Syndrome ◽  
Early Recognition ◽  
Ecmo Support ◽  
List Type ◽  
Life Threatening ◽  
Life Threatening Complication

Summary Acute respiratory distress syndrome (ARDS) is a rare but life-threatening complication of diabetic ketoacidosis (DKA). We present the case of a young female, with no previous diagnosis of diabetes, presenting in DKA complicated by ARDS requiring extra corporeal membrane oxygenation (ECMO) ventilator support. This case report highlights the importance of early recognition of respiratory complications of severe DKA and their appropriate management. Learning points ARDS is a very rare but life-threatening complication in DKA. The incidence of ARDS remains unknown but less frequent than cerebral oedema in DKA. The mechanism of ARDS in DKA has multifactorial aetiology, including genetic predisposition. Early recognition and consideration of rare pulmonary complication of DKA can increase survival rate and provide very satisfactory outcomes. DKA patients who present with refractory ARDS can be successfully rescued by ECMO support.

Prone Positioning has no Effect on Mortality in ARDS

2008 ◽  
Vol 9 (3) ◽  
pp. 264-265
Author(s):  
Alex Puxty ◽  
Chris Cairns ◽  
Malcolm Daniel
Keyword(s):  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Distress Syndrome ◽  
Simplified Acute Physiology Score ◽  
Prone Positioning ◽  
Level Of Evidence ◽  
Subsequent Change ◽  
Saps Ii ◽  
Change In Practice

In patients with acute respiratory distress syndrome (ARDS), prone positioning improves oxygenation but has no impact on mortality, except perhaps in those with Simplified Acute Physiology Score (SAPS) II >50. Level of evidence: 1+ (SR based on small RCTs, conducted prior to ARDSNet – subsequent change in practice)

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