2. Prone Positioning
A therapeutic maneuver to improve
oxygenation and pulmonary mechanics in
patients with acute lung injury or acute
respiratory distress syndrome (ARDS)
Also known as proning
3. Mechanics
Improves oxygenation in patients by
shifting blood flow to regions of the lung
that are better ventilated
Facilitates better movement of the
diaphragm by allowing the abdomen to
expand more fully
4. Frequency and Duration of Therapy
The amount of time will be prescribed by
ICU physician (Orlando Health Critical
Check)
5. Criteria
Acute onset of respiratory failure
Hypoxemia
Radiologic evidence of diffuse bilateral
pulmonary infiltrates
6. Indication
Therapy for refractory hypoxemia when
conventional mechanical ventilation
strategy is not adequate in patients with
severe ARDS
7. Contraindications
Patients whose heads cannot be
supported in a facedown position
Patients who are unable to tolerate a
head-down position
Increased intracranial pressure
Unstable spine, chest, or pelvis
Unstable bone fractures
16. Prior to the Turn
Ensure emergency equipment is available
Correctly position all tubes and invasive lines
Electrodes for cardiac monitoring moved to
the back
If on a low air-loss surface, maximally inflate
Always turn the patient in the direction of
the mechanical ventilator
17. Prior to the Turn
Make sure the patient`s tongue is inside
his mouth
Suction patient
Secure the patient`s ET or tracheostomy
Perform anterior body wound care and
dressing changes
18. Prior to the Turn
Empty ileostomy or colostomy drainage
bags
Make sure that the brake of the bed is
engaged
Position staff appropriately
19. After the Turn
Immediately assess the patient
Cushion head and ear
Allow abdomen to protrude
Ensure body alignment- position arms –
swimmer position
Reverse trendelenburg
Re-assess ventilator parameters
20. Points To Remember
Reposition the patient`s head and
extremities every two hours
Give oral care and suction the patient, as
needed
Patients may require increased sedation
during proning
21. Points To Remember
To reduce the risk of aspirating gastric
contents during the turning procedure,
turn off the tube feeding one hour before
turning the patient.
Monitor the patient`s response to
proning - VS, pulse oximetry, and mixed
venous O2 saturation.
22. Documentation
Patient`s response to therapy
Ability to tolerate the turning procedure
Length of time in the position and
positioning schedule
Monitoring
Complications
Interventions
23. References
Lynn-McHale, W. (2009). Prone Positioning (5th ed.).
Lippincott Williams and Wilkins.
Orlando Health. (2010, May 19). Manual Pronation
Therapy for Refractory Hypoxemia in the 5B ICU at ORMC.
Orlando Health Critical Check . Orlando, Florida, United
States of America: Orlando Health.
The Acute Respiratory Distress SyndromeNetwork.
(2000). Ventilation with Lower Tidal Volumes as
Compared with Traditional Tidal Volumes for Acute Lung
Injury and Acute Respiratory Distress Syndrome. New
England Journal of Medicine , 1301-1308.
Hinweis der Redaktion
The procedure involves physically turning a patient from a supine position to a facedown position (prone position)
The team normally involves ICU physician, ICU RNs, RT, Clin Tech
Prone positioning often improves oxygenation in patients who have ARDS by shifting blood flow to regions of the lung that are less severely injured and thus better aerated
Normally performed 6 or more hours/day (for as long as 10 days, until the requirement for a high concentration of inspired oxygen resolves)
Hypoxemia, specifically a PaO2/FIO2 ratio of 300 or less for acute lung injury or a PaO2/FIO2 ratio of 200 or less for ARDS – Dr Mohan P:F ratio < 100
To support mechanically ventilated patients with ARDS who require high concentrations of inspired oxygen while avoiding ventilator-induced lung injury
(Prone positioning may correct severe hypoxemia and help maintain adequate oxygenation (PO2 greater than 60%) while avoiding ventilator-induced lung injury.
Mechanical ventilation usually corrects tissue hypoxemia but may also cause ventilator-induced lung injury – lower tidal volume reduces ventilator-induced lung injury (The Acute Respiratory Distress Syndrome Network, 2000)
Left ventricular failure (non-pulmonary respiratory failure)
Reversible dependent edema of the face (forehead, eyelids, conjunctiva, lips, and tongue) and anterior chest wall
Hemodynamically unstable patients (SBP < 90 mm Hg) despite aggressive fluid resuscitation and vasopressors should be thoroughly evaluated before being placed in the prone position
ICU RNs – preparing the pt, securing tubes and lines, monitoring VS, turning and positioning the patient
RT – ETT securement, ventilator manipulation/maintenance, suctioning/oral care
ICU physician-available for emergencies
Clin Tech – general assistance
1. Emergency equipment available – have resuscitation bag and mask available at the bedside
1. Make sure the patient`s tongue is inside his mouth; if edematous or protruding, insert a bite block
2. Suction patients- ET and orally. Be prepared for secretions. Protect patient`s skin from secretions
3. Secure the patient`s ET or tracheostomy to prevent dislodgement
4. Change anterior dressing to prevent premature turning if wound is leaking
Position staff appropriately; a minimum of three people is required: one on either side of the bed and one at the head of the bed
Immediately assess the patient. Assess all lines and tubes. Assess patient`s response to therapy. Assess for skin breakdown and facial edema
Position the patient by turning and cushioning head and ear (prevent skin breakdown)
Position arms – swimmer – place one arm above head and one at side (ventilator side), avoid overextension to prevent nerve and joint damage
Reverse trendelenburg – to reduce edema and risk of aspiration
Reposition the patient`s head and extremities every two hours (hourly) while in the prone position to prevent facial breakdown. As one person lifts the patient`s head, the second person moves the headpieces to provide head support in a different position
The feeding can be safely restarted once the patient is positioned
The patient`s VS should return to normal within 10 mins. of being placed prone. During the initial proning, arterial blood gases should be obtained within 30 mins. of proning and within 30 mins. prior to returning the patient to the supine position
