1.
Running head: PRONE POSITIONING IN ARDS PATIENTS 1
Increasing Utilization of Prone Positioning in ARDS Patients
Rachel Bowe
NURS/HCPI 552: Scholarship Integration and Application
November, 22 2016
Dr. Jodie Gary

2.
PRONE POSITIONING IN ARDS PATIENTS 2
Abstract
Prone positioning is a recommended treatment for acute respiratory distress syndrome (ARDS)
but is not widely utilized in the critical care setting due to its complexity. This treatment could
reduce the mortality rate of ARDS patients and should be utilized in hospital protocols. The
proposed plan is to have a multi-disciplinary critical care team develop a prone positioning
protocol for their hospital unit. The protocol will then be taught and tested over via exam and
simulation. It will be implemented for 90 days then the results reviewed for potential needed
alterations. This could ultimately reduce the mortality for ARDS patients.

3.
PRONE POSITIONING IN ARDS PATIENTS 3
Increasing Utilization of Prone Positioning in ARDS Patients
ARDS is a life-threatening condition, according to Henderson, Griesdale, Dominelli, &
Ronco, (2014) the “current estimates of mortality associated with ARDS range from to 22% to
44%” (p. 213). It is vital to the patient’s survival that this be diagnosed and treated promptly and
effectively. One treatment recommended but underutilized is prone positioning of the patient.
Henderson et al. (2014) discussed the various benefits of prone positioning in ARDS patients due
to the anatomical position of the lungs and heart. This reveals that more lung tissue is available
for oxygenation when the patient is prone rather than supine. This poses the clinical question, in
mechanically ventilated ARDS patients, how does intermittent prone positioning compared to
continuous supine positioning affect oxygenation and mortality rate? Chertoff (2016) revealed
that this beneficial procedure was performed on less than 20% of ARDS patients. The severity
of these patients combined with the complexity of the treatment could be a reason for
underutilization. This project will help to implement an ARDS prone positioning protocol into a
hospital ICU setting where it is currently not performed or not frequently performed. By doing
this the ultimate goal is to decrease the mortality rate for the hospital’s ARDS patients.
Synthesis of Evidence
In all of the compiled evidence there were two themes that emerged, prone positioning
could reduce mortality rate related to ARDS and it could improve oxygenation. The evidence
discussed is summarized in an evidence grid (see Appendix A for the Evidence Grid). Literature
from Melnyk and Fineou-Overholt (2015) was used to determine all levels of evidence.
Various quantitative articles were reviewed to provide evidence regarding the effects of
prone positioning in ARDS patients. Cornejo et al. (2013) performed a level III quantitative
study that revealed prone positioning along with an increased positive end expiratory pressure

4.
PRONE POSITIONING IN ARDS PATIENTS 4
(PEEP) used in mechanically ventilated ARDS patients led to increased lung tissue being
oxygenated as well as a decrease risk for alveolar hyperinflation which leads to damage. Guerin
et al. (2013) performed a level II multicenter prospective randomized control trial (RCT) that
proved the 28 day mortality rate and the 90 day mortality rate both decreased with the early
application of prone positioning in mechanically ventilated ARDS patients. Kimmon et al.
(2015) conducted a level IV retrospective review study which determined that prone positioning
for long durations (24 hours) combined with veno-venous extracorporeal membrane oxygenation
(VV-ECMO) improved oxygenation and respiratory compliance. Robak et al. (2011) executed a
level II prospective randomized cross-over study that revealed that when prone positioning was
combined with semi-recumbent positioning oxygenation improved in mechanically ventilated
ARDS patients. All four of these studies reiterate the above themes of reduced mortality rate and
improved oxygenation with the use of prone positioning intermittently.
One level VI descriptive qualitative study by Engstrom, Nystrom, Sundelin, & Rattray
(2013) revealed the various methods that could be used by healthcare providers to help with the
experience of being mechanically ventilated. This study illuminated multiple ways that
physicians and nurses alike could improve the experience. Among these were improved
communication methods, providing continuity among the staff providing care, allowing for
patients to keep diaries, and maintaining a consistent environment. Prone positioning while
being mechanically ventilated requires tedious attention to the patient and considerable
confusion for the patient if they are sedated lightly enough to remember the ordeal. It is
imperative that the healthcare providers be aware of these potential improvements to help keep
the patient relaxed and calm so the treatments can provide the most benefit.

5.
PRONE POSITIONING IN ARDS PATIENTS 5
A level I meta-synthesis of RCTs by Abroug, Ouanes-Besbes, Dachraoui, Ouanes, and
Brochard (2011) revealed that when only considering the ARDS diagnosed patients that prone
positioning reduced the mortality rate. Another level I meta-synthesis of RCTs by Hu et al.
(2014) discovered that high PEEP levels along with longer duration of prone positioning
improved the mortality rate. Both of these align with the theme that prone positioning can help
in reducing the mortality rate of ARDS patients.
The national guideline provided by Dellinger et al. (2012) reveals that when the
PaO2/FiO2 ratio, or the ratio of oxygen in the blood to the oxygen that is inhaled, falls below a
certain range (100 mm Hg) that prone positioning should be provided. The stipulation that the
unit be proficient with this procedure is made to prevent endangering patients due to
inexperienced staff performing a complicated procedure. The national guideline indicates the
accepted plan of care nationally for ARDS. The implication that is made is that if the PaO2/FiO2
ratio is too low that prone positioning can increase it back to an acceptable level. This falls in
line with the theme of improving oxygenation for mechanically ventilated ARDS patients.
The various studies reviewed revealed that there is sufficient evidence indicating that
prone positioning is beneficial to the mechanically ventilated ARDS patient. This follows the
current suggested practice in the national guideline. This evidence directly applies to the
proposed clinical question regarding intermittent prone positioning in ARDS patients. The major
themes located within the compiled evidence correlates with the proposed outcomes of prone
positioning in the research question provided which include improved oxygenation and reduced
mortality rate related to ARDS.
Project Plan

6.
PRONE POSITIONING IN ARDS PATIENTS 6
The project to increase the utilization of prone positioning in ARDS patients arose from
attempting to determine if mechanically ventilated ARDS patients had improved oxygenation
and reduced mortality rate when intermittent prone positioning was utilized rather than
continuous supine positioning. Based on the complied evidence the two themes that emerged
were that prone positioning reduced ARDS mortality rate and improved oxygenation. These
results provide incentive for the proposed project.
Lewin’s theory of change was used as the theoretical framework on which the project
was designed. Shirley (2013) discussed the main components of Lewin’s theory as unfreezing,
moving, and refreezing. This means there must be a stage in which the need for change is
recognized and a plan is made. Next there must be a transition from status quo to the new
method determined in stage one. Finally, the new methods must be accepted and embedded in
the status quo. These three steps were the basis on which the plan was created.
The project will include three key steps which include planning and preparation,
education and implementation, and evaluation. The process will begin with an interdisciplinary
critical care team coming together to create a prone positioning ARDS protocol for their unit.
This will include indications, contraindications, the turning process, potential adverse effects and
their interventions, and what to monitor. Once this is established the unit will be educated by the
team in a didactic session that culminates in an exam on which they must score a 100 to be
considered successful. If staff does not score a 100 they will be given remediation material and
they must retest within 7 days. Once all staff has passed the written exam there will be a live
simulation in which the unit must perform prone positioning on an intubated patient. The patient
will be a standardized patient that can provide unique feedback to the team. They will be
monitored by the protocol creation team and grading on specific criteria. If the team is

7.
PRONE POSITIONING IN ARDS PATIENTS 7
unsuccessful in the simulation they will be provided with immediate remediation by staff and
then allowed to retry the simulation. Due to safety concerns of patients the project cannot move
forward until the whole team is successful in this simulation. Once this is determined to be a
success there will be an implementation date within 14 days of the simulation to begin using the
protocol. Once the protocol has begun it will be monitored for 90 days then reviewed to
determine any needed alterations. The project proposal plan includes grading criteria and
monitoring specifics (see Appendix B for the project proposal plan).
Implementation
During this project the major agents of change will be the interdisciplinary team that
creates the protocol. This team will include at least one member from each discipline involved
in the procedure including but not limited to physician, nursing, respiratory therapy, pharmacy,
and nursing support. This will allow clinical expertise and knowledge of the unit to be involved
in the creation of the new protocol. The team will not only create the protocol but will be
responsible for educating the staff on the protocol and grading the simulation. Another agent of
change will be the unit supervisor/director and the nursing director for the unit. The leaders will
need to be willing to assist with the implementation of this change.
The main barriers related to this project will be the inexperience with the procedure and
the trepidation that accompanies it. To combat the trepidation there will be offered practice
sessions in which the staff can practice with a mannequin or other staff to develop muscle
memory and familiarity with the procedure. Another barrier related to this change could be the
desire of some staff to remain with the status quo. To overcome this barrier it will be important
for there to be evidence proving the effectiveness of this intervention. Also, an open door policy

8.
PRONE POSITIONING IN ARDS PATIENTS 8
will be maintained throughout the entirety of the project to allow any and all staff to voice
question and preferences about the new protocol.
The staff that will be made aware of this includes the patient care staff on the unit as well
as the unit supervisors and directors, hospital administration, and any quality improvement
coordinators. The supervisors, administration, and coordinators will be updated in a team
meeting as well as regular memos to keep them up to date. As stated before, the information will
taught to the unit staff in a lecture provided by the creation team. It will then be reinforced with
a live simulation. Accompanying these learning sessions, the new protocol will be added to the
existing protocol resource for the staff to review and reference. All of the material used to create
the protocol will be available as well to the staff for reference.
Proposed Evaluation and Conclusion
The new protocol will be put into place and monitored for 90 days. The data to be
monitored is included in the project proposal plan. The data will be recorded in an online
spreadsheet that can track the trends of the data. The data will be collected by one team member
from the patient’s medical chart. After this 90 day period the same interdisciplinary team along
with unit supervisors and directors and the quality improvement coordinator will come together
to review the data. At this time the team will determine if the new protocol was successful in
improving oxygenation and reducing the ARDS mortality rate in mechanically ventilated ARDS
patients. The team will then make any necessary amendments to the new protocol based on staff
feedback or the collected data. The protocol will then be included in the unit’s protocol resource
permanently or until research deems it necessary to perform another change.
The change in protocol will hopefully increase the utilization of an intervention that can
improve oxygenation and reduce the mortality related to ARDS. Any intervention that can

9.
PRONE POSITIONING IN ARDS PATIENTS 9
reduce the mortality rate of such a life-threatening syndrome should be implemented in every
hospital that can manage it. This change will allow for the improvement of patient outcomes and
satisfaction which is the ultimate goal for every healthcare professional and healthcare
organization.

10.
PRONE POSITIONING IN ARDS PATIENTS 10
References
Abroug, F., Ouanes-Besbes, L., Dachraoui, F., Ouanes, I., & Brochard, L. (2011). An updated
study-level meta-analysis of randomised controlled trials on proning in ARDS and acute
lung injury. Critical Care, 15(1), 1-9.
Chertoff, J. (2016). Should early prone positioning be a standard of care in ards with refractory
hypoxemia? Wrong question. Respiratory Care, 61(11), 1564. doi:10.4187/respcare.05259
Cornejo, R. A., Díaz, J. C., Tobar, E. A., Bruhn, A. R., Ramos, C. A., González, R. A., ... &
Arellano, D. H. (2013). Effects of prone positioning on lung protection in patients with
acute respiratory distress syndrome. American Journal of Respiratory and Critical Care
Medicine, 188(4), 440-448.
Dellinger, R. P., Levy, M. M., Rhodes, A., Annane, D., Gerlach, H., Opal, S. M., … Moreno, R.
(2012). Surviving sepsis campaign guidelines committee including the pediatric
subgroup. Surviving Sepsis Campaign: International Guidelines for Management of
Severe Sepsis and Septic Shock: 2012.41(2), 580-637.
Engström, Å., Nyström, N., Sundelin, G., & Rattray, J. (2013). People's experiences of being
mechanically ventilated in an ICU: a qualitative study.Intensive and Critical Care
Nursing, 29(2), 88-95.
Guérin, C., Reignier, J., Richard, J. C., Beuret, P., Gacouin, A., Boulain, T., ... & Clavel, M.
(2013). Prone positioning in severe acute respiratory distress syndrome. New England
Journal of Medicine, 368(23), 2159-2168.
Henderson, W. R., Griesdale, D. E., Dominelli, P., & Ronco, J. J. (2014). Does prone positioning
improve oxygenation and reduce mortality in patients with acute respiratory distress
syndrome?. Canadian Respiratory Journal, 21(4), 213-215.

11.
PRONE POSITIONING IN ARDS PATIENTS 11
Hu, S. L., He, H. L., Pan, C., Liu, A. R., Liu, S. Q., Liu, L., ... & Qiu, H. B. (2014). The effect of
prone positioning on mortality in patients with acute respiratory distress syndrome: a
meta-analysis of randomized controlled trials. Critical care, 18(3), 1-10.
Kimmoun, A., Roche, S., Bridey, C., Vanhuyse, F., Fay, R., Girerd, N., … Levy, B. (2015).
Prolonged prone positioning under VV-ECMO is safe and improves oxygenation and
respiratory compliance. Annals of Intensive Care, 5(35).
http://doi.org.ezproxy.library.tamu.edu/10.1186/s13613-015-0078-4
Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing
& healthcare: A guide to best practice (3rd ed.). Philadelphia, PA: Lippincott Williams
& Wilkins.
Robak, O., Schellongowski, P., Bojic, A., Laczika, K., Locker, G. J., & Staudinger, T. (2011).
Short-term effects of combining upright and prone positions in patients with ARDS: a
prospective randomized study. Critical Care, 15(5), 1-7.
Shirey, M.R.. (2013). Lewin’s theory of planned change as a strategic resource. Journal of Nursing
Administration, 43(2), 69-72. doi: 10.1097/NNA.0b013e31827f20a9

12.
Running head: PRONE POSITIONING IN ARDS PATIENTS 12
Appendix A: Evidence Grid
Complete
APA Citation
Hypothesis,
Research Question,
Problem Statement
or Stated Purpose
Frame
work, Model,
or Theoretical
underpinning
Sample:
 size of sample
 important
demographics
 inclusion and
exclusion criteria
Study
Design
Data Collection:
 Instruments used
 Variables and measurement
 Procedures used
Implications
 Statistical results
or findings
 Conclusions related
to practice
Abroug,F.,
Ouanes-Besbes,L.,
Dachraoui, F.,
Ouanes, I., &
Brochard, L.
(2011). An updated
study-level meta-
analysis of
randomised
controlled trials on
proning in ARDS
and acute
lung injury. Critical
Care, 15(1), 1-9.
Meta-analysis to
determine if RCTs
showreduction
mortality rate trend in
prone ventilation of
ARDS or ALI patients
Random effects
model
 7 RCTs with 1,675
adult patients
(N=1675) total this
includes 862 who
were ventilated in the
prone position
 RCTs the compared
supine versus prone
positioning in ARDS
patients were
included
 Two subgroups were
formed in the
resulting RCTs: those
that limited the
results to only ARDS
patients and those
that included all
hypoxemic patients
Meta-analysis
of RCTs
 Three investigators separately
found and evaluated studies for
outcomes relating to ARDS and
prone positioning. They
evaluated the study design,
sample population and disease
severity determined by
PaO2/Fio2 ratio, prone
positioning duration, and ICU
mortality. Each RCT was then
rated on a 0-5 scale with 5 being
the best.
 Regarding ICU
mortality (OR=0.9,
P=0.39)
 Regarding ICU
mortality of ARDS
patients only
(OR=0.71, P=0.048)
 Conclusion: If only
ARDS patients are
considered then long
periods of prone
positioning reduce
ICU mortality.
Cornejo, R. A.,
Díaz, J. C., Tobar,
E. A., Bruhn, A.
R., Ramos, C. A.,
González, R. A., ...
& Arellano, D. H.
(2013). Effects of
prone positioning
on lung protection
in patients with
acute respiratory
A study to determine if
high PEEP and prone
positioning have an
effect on lung usage
and hyperinflation
Not stated  24 adult patients in
one hospitalwho
were mechanically
ventilated for 24-72
hours,and required
lung CT scan for
clinical purposes
were included in the
study (N=24)
 Excluded patients
were those that were
Not Stated  Patients were kept deeply sedated
and underneuromuscular
paralysis during the study
 Volume control mode on the
ventilator with tidal volume of 6
ml/kg of ideal body weight was
maintained.
 Patients had whole-lung CT scan
with intermittent sessions of
breath holding at airway
pressures of5, 15, and 45 cm
Increasing PEEP from
5-15 cm H2O supine
 Decreased non-
aerated tissue
(P<0.001)
 Increased tidal
hyperinflation
(P=0.004)
Increasing PEEP from
5-15 cm H2O prone
 Decreased non-

13.
PRONE POSITIONING IN ARDS PATIENTS 13
distress syndrome.
American journal
of respiratory and
critical care
medicine, 188(4),
440-448.
under 18 years of age,
were pregnant, or
prone positioning was
contraindicated
H2O
 Cine-CTs on a fixed thoracic
transverse slice at PEEP of 5 and
15 cm H2O
 CT images were repeated in
supine and prone positions
 A 45 cm H2O recruitment
maneuver was done before each
PEEP change
 Lung recruitability was defined
by the change in percentage of
non-aerated lung between PEEP
of 5 and 45 cm H2O
 Cyclic recruitment/decruitment
was defined by the tidal change
in percentage of non-aerated
tissue
 Tidal hyperinflation was defined
by the tidal changes in
percentage of hyperinflated
tissue
 Sidak’s post hoc analysis used to
perform two way ANOVA
 Wilcoxon Mann-Whitney test
used for comparison of patients
with high and low lung
recruitability
aerated tissue
(P=0.028)
High PEEP and prone
positioning together
 Decreased cyclic
recruitment/decruitm
ent (P=0.003)
Prone positioning
increases the amount
of lung tissue utilized
and decreases
hyperinflation and
alveolar damage with
high PEEP in ARDS
patients
Dellinger, R. P.,
Levy, M. M.,
Rhodes, A.,
Annane,D.,
Gerlach, H., Opal,
S. M., … Moreno,
R. (2012).
Surviving Sepsis
Campaign
Guidelines
Committee
including the
Pediatric
In sepsis induced
ARDS prone
positioning is
recommended for
PaO2/FiO2 ratio of
<100 mm Hg if the
unit is experienced
with this procedure.

14.
PRONE POSITIONING IN ARDS PATIENTS 14
Subgroup.
Surviving sepsis
campaign:
international
guidelines for
management of
severe sepsis and
septic shock:
2012.41(2):580-
637.
Engström, Å.,
Nyström, N.,
Sundelin, G., &
Rattray, J. (2013).
People's
experiences of
being mechanically
ventilated in an
ICU: a qualitative
study.Intensive and
Critical Care
Nursing, 29(2), 88-
95.
This study is meant to
improve clinical
practice for
mechanically
ventilated patients by
reviewing personal
experiences of
mechanically
ventilated patients.
Not Stated 8 patients (N=8) who
were previously
mechanically ventilated
in one ICU were
contacted. They had to
be ventilated for at least
24 hours,they had to
remember parts of their
stay,and had to have
been cared for in the
past year.
Qualitative
descriptive
 Individual 30-60 minute
interviews using a question guide
were conducted and recorded.
Interviews were conducted it he
home, the ICU, and in other
settings. The interviews were
then transcribed word for word
and analyzed.
 The interviews were read
multiple times by 3 of the authors
until themes were created.
 From the created themes
emerged sub-categories.
2 themes emerged that
were then divided into
sub categories. Topics
noted include
communication,
vulnerability/depende
ncy, feeling safe,
being in an unknown
environment, families,
perceptions of time,
and diaries.
The implications for
care include
communication
methods, continuity
among staff, patient
diaries, and consistent
environment.
Guérin, C.,
Reignier, J.,
Richard, J. C.,
Beuret, P.,
Gacouin, A.,
Boulain, T., … &
Clavel, M. (2013).
Prone positioning
in severe acute
respiratory distress
syndrome. New
England Journal of
This study aimed to
prove that early
application of prone
positioning in ARDS
patients can decrease
the mortality rate for
any cause within 28
days of intubation and
after 90 days after
extubation.
Not Stated 466 adult severe ARDS
patients (N=466)
 Mechanically
ventilated less than
36 hours
 Severe ARDS:
PaO2/FiO2 ratio <150
mm Hg, FiO2 >0.6,
PEEP >5 cm H2O,
and tidal volume of 6
ml/kg of ideal body
weight
Multicenter
prospective
randomized
control trial
 Computer randomized patients
into supine or prone groups.
 12-24 hour period for patient to
stabilize then inclusion into the
study determined. Pronation had
to be initiated within first hour of
randomization and remained
prone for at least 16 consecutive
hours.
 Supine patients remained in a
semi-recumbent position.
 Ventilation for both groups
28 day mortality
 16.0% in the prone
group
 32.8% in the supine
group
 P<0.001
90 day mortality
 23.6% in the prone
group
 41.0% in the supine
group
 P<0.001

15.
PRONE POSITIONING IN ARDS PATIENTS 15
Medicine,368(23),
2159-2168.
26 ICUs in France, 1
ICU in France
remained at the following
settings:volume control mode,
tidal volume 6 ml/kg of ideal
body weight, and PEEP selected
from the PEEP-FiO2 ratio table
provided.
 At admission to the ICU the
following data was collected:
age, sex, reason for admission,
McCabe score,what setting the
patient came from, ventilator
settings,time from intubation to
randomization, height, ideal body
weight, ABGs, arterial blood
lactate levels, chest radiography,
and the simplified acute
physiology score (SAPS), and
the sepsis related organ failure
assessment (SOFA)
 Daily (for 28 days)the following
were recorded: attempts at
extubation, complications, use of
ECMO, sedative and
neuromuscular blocker use,
administration of inhaled nitric
oxide, infusion of almitrine
bismesylate, the ventilator
setting,ABGs, static compliance
of the respiratory system, arterial
blood lactate levels, and the
SOFA score
Early application of
prone positioning can
significantly decrease
the 28 day and 90 day
motility rate for severe
ARDS patients.
Hu, S. L., He, H.
L., Pan, C., Liu, A.
R., Liu, S. Q., Liu,
L., ... & Qiu, H. B.
(2014). The effect
of prone
positioning on
mortality in
patients with acute
Determine if the
improved mortality
rate for ARDS patients
with prone positioning
is affected by PEEP
levels and duration of
positioning.
Random effects
model was used
for cases of
heterogeneity
and fixed
effects model
was used in all
other instances
9 RCTs with a total of
2,242 patients
including adults and
pediatric populations
(N=2,242)
 Inclusion criteria:
clinical RCT
comparing prone
versus supine position
Meta-analysis
of RCTs
 2 researchers used a 5 point scale
to evaluate the trials separately.
The data was then extracted
(mortality rates, sample sizes,
control groups,PEEP levels,
PaO2/FiO2 ratios, prone
positioning duration, length of
stay,length of intubation, plateau
pressure and tidal volume, cases
 Prone 28 day
mortality of ARDS
patients with
PaO2/FiO2 <100 mm
Hg (P=0.003)
 Prone 60 day
mortality with PEEP
>10 cm H2O
(P=0.04)

16.
PRONE POSITIONING IN ARDS PATIENTS 16
respiratory distress
syndrome: a
meta-analysis of
randomized
controlled
trials. Critical
care, 18(3), 1-10.
in ARDS, acute
respiratory failure, or
acute lung injury
patients. The
definition of ARDS
was similar. The data
for 28-30 day
mortality, 60 day
mortality, or 90 day
mortality was
available, and the
sample size for each
group was identified
 Exclusion criteria: the
article was not a
clinical RCT, the full
text was not
available, the
mortality data was
not provided, supine
positioning was not
used as the control,
and there was
significant additional
therapies provided to
individual groups.
of organ dysfunction,and
demographic information.
 The k statistic was used to
evaluate the methodological
quality assessment and trial
selection similarity between the
two investigators.
 Cochrane Collaboration’s
RevMan Softward 5.2.3 was used
for the recommendations of
methods for the meta-analysis of
the effects
 Mantel-Haenszel X2 test and the
I2 test were used for
heterogeneity and inconsistency
evaluation
 Prone 90 day
mortality with PEEP
>10 cm H2O
(P<0.0001)
 28 day mortality
when prone >12
hrs/day (P=0.04)
 Prone positioning
reduced mortality in
severe ARDS
patients especially
when combined with
high PEEP levels.
Longer duration of
prone positioning
improve the
mortality rate as
well.
Kimmoun, A.,
Roche, S., Bridey,
C., Vanhuyse, F.,
Fay, R., Girerd, N.,
… Levy, B. (2015).
Prolonged prone
positioning under
VV-ECMO is safe
and improves
oxygenation and
respiratory
compliance. Annals
of Intensive
Care, 5(35).
Study meant to
determine if prolonged
prone positioning
during VV-ECMO
improved oxygenation
and respiratory system
compliance.
Not Stated  17 patients (N=17)
who received VV-
ECMO and prone
positioning
 Exclusion: patients
under vasopressor
treatment, recent
open chest cardiac
surgery
 Inclusion: at least one
failed weaning
attempt after day 7 of
ECMO or refractory
hypoxemia occurred.
Retrospective
review
 All patients on volume control
mode with tidal volume of 1.5-3
ml/kg of ideal body weight,
respiratory rate of 8-12
breaths/minute, PEEP 10-18 for a
pPlat at 25 cm H2O, and FiO2 set
to maintain SpO2 88-95%
 Followed PROSEVA guidelines
for prone positioning
 Parameters recorded before
prone positioning,after 24 hours
of positioning, and 24 hours after
returning to supine positioning.
 Recorded ABG, ventilator
 After 24 hour prone
positioning
PaO2/FiO2 ratios
increased from 111
to 173 mmHg
(P<0.0001)
 After 24 hour of
prone positioning
respiratory
compliance
increased form 18-
32 ml/cmH2O
(P<0.0001)
 24 hours after return

17.
PRONE POSITIONING IN ARDS PATIENTS 17
Retrieved from
http://doi.org.ezpro
xy.library.tamu.edu
/10.1186/s13613-
015-0078-4
setting,VV-ECMO parameters,
and respiratory compliance (tidal
volume/pPlat)
 Measure pPlat with end
inspiratory pause of 1 sec minus
total PEEP
 Measure total PEEP with
expiratory pause of 5 sec
 Chest CT applicable if received
within 3 days prior to prone
positioning. Can be analyzed to
determine amount of non-aerated
lung tissue.
to supine tidal
volume increased
from 3.0 to 3.7
ml/kg (P<0.005)
 24 hours after return
to supine PaO2/FiO2
ratio increased by
over 20% in 14/14
late sessions and
7/13 early sessions
(P=0.01)
 Ct scans showed
high percentage of
non-aerated lung
tissue in 52% of
patients.
 Prone positioning
for long durations
(24 hours) improved
oxygenation and
respiratory
compliance in
combination with
VV-ECMO
Robak, O.,
Schellongowski,
P., Bojic, A.,
Laczika, K.,
Locker, G. J., &
Staudinger, T.
(2011). Short-term
effects of
combining upright
and prone positions
in patients with
ARDS: a
prospective
randomized
study.Critical
Care, 15(5), 1-7.
Determine the effects
on oxygenation of
combining prone and
semi-recumbent
positioning in
mechanically
ventilated ARDS or
ALI patients.
Not Stated  20 patients with
ALI/ARDS (N=20)
 Exclusion: ECMO,
improvement, death,
diagnosis of ARDS
made more than 72
hours ago, younger
than 18 or older than
89 years of age, or
pregnant
 Inclusion: Diagnoses
of ALI or ARDS,
prone positioning
prescribed by
intensivist
Prospective
randomized
cross-overstudy
 20 patients randomized
 Basal measurement of PaO2/FiO2
ratio, ABG, and analysis of lung
compliance taken at supine then
repeated hourly throughout the
study
 One group: prone position for 2
hours then prone with semi-
recumbent for 6 hours.
 Second group: prone with semi-
recumbent positon for 2 hours
then prone position for 6 hours.
 Bicore measure systemused to
measure compliance with the
occlusion method by holding the
inspiratory/expiratory hold
 14 patients (70%)
improved with prone
positioning
 17 patients (85%)
responded to prone
and semi-recumbent
positioning
combined
 Combining semi-
recumbent and prone
positioning in
mechanically
ventilated ARDS
patients can improve
oxygenation.

18.
PRONE POSITIONING IN ARDS PATIENTS 18
function on ventilator
 All patients continuously
monitored on ECG, pulse
oximetry, and indwelling arterial
catheter
 PEEP adjusted by increments of
2 cm H2O to remain at FiO2 at
0.6 or less with SpO2 >91%
 Tidal volumes at 6 ml/kg ideal
body weight
 Respiratory rate set to maintain
PaCO2 levels to prevent
respiratory acidosis and
hyperinflation
 Ventilator setting unchanged
during study

19.
Running head: PRONE POSITIONING IN ARDS PATIENTS 19
Appendix B: Project Proposal Guide
A critical care multi-disciplinary
team will utilize research to
develop a prone positioning
protocolfor the unit.
All involved staff will take a
didactic course over theprone
positioning protocoltaught by
the appropriatedeveloping staff.
At the completion of thecourse
all staff will take a
comprehensive exam over the
material. A score of 100 must be
achieved to comlete the course.
If the staff member does not
achieve a score of 100
remediation material will be
provided to the staff and they
will be required to retest within 7
days.
Once all staff has passed the
written exam, there will be a
patient simulation on the unit
scheduled. The staff will be
observed by experts on the
protocoland graded.
Siimulation Grading Criteria
-Acknowledges indiciations and
contraindiciations for prone positioning
-Performs procedure without error OR self
identifies errors
-Recognizes adverse reactions promptly
-Performs appropriate Interventions
-Patient safety is never compromised
If the simulation is unsuccessful
there will be immediate
remediation and theteam will be
allowed another simulation. If
unsuccessful again, there will be
another simulation scheduled.
For safety theproject will not
move forward until this is
successful.
Once the simulation is deemed
successful there will be a set
implementation date. The
protocolwill be in effect after
this date.
Once implemented the following
will be monitored
- Vital Signs
- Length of intubation
- Length of stay
- ARDS Mortality rate
After 90 days the data will be
reviewed and alterations will be
made to the protocolas needed.