LITERATURE Development of clinical guidelines for prone ... · when considering the proning...

LITERATURE REVIEW

© 2004 British Association of Critical Care Nurses, Nursing in Critical Care 2004 • Vol 9 No 250

Development of clinical guidelines for prone positioning in critically ill adultsCatherine Rowe

SUMMARY• Literature reveals evidence that prone positioning can improve the oxygenation of critically ill patients suffering from acute lung injury

or acute respiratory distress syndrome• Multicentre evidence, however, does not support the claim that it improves patients' outcome• The implementation of multiprofessional guidelines by which to direct the manoeuvre will facilitate the safe and effective management of

patients in the prone position. They will thus heighten multiprofessional awareness of the technique and promote its proactive use at such time so as to achieve maximum clinical benefit

Key words: Clinical guidelines • Enhanced oxygenation • Proactive management • Prone positioning

INTRODUCTIONHistorically, within our general intensive care/highdependency units, prone positioning has been used ina relatively ad hoc manner, mainly as a last-ditch attemptto improve patients’ oxygenation when maximumventilatory support has failed. Although it has beenencouraging to note that the pronation of patients hasincreased sporadically, staff remain reluctant to insti-gate the manoeuvre, despite enthusiastically report-ing that it has improved patients’ oxygenation (PaO2),thus allowing the reduction of the fraction of inspiredoxygen (FiO2) and levels of positive-end expiratorypressure (PEEP).

On reflection, our decision to develop and imple-ment comprehensive multiprofessional guidelines todirect the prone maneouvre resulted from a belief thatthey would facilitate the delivery of the safe, effectiveand appropriate use of the technique and would raisemultiprofessional awareness and prompt consistentand proactive utilization.

The following guidelines primarily identify themost significant clinical indications for use of the

prone position before addressing potential exclusioncriteria or reported contraindications. They explore themain manoeuvre detail, address care considerationsprior to and following the maneouvre and identifypotential documented complications before culminatingin a comprehensive bedside algorithm to direct clinicalcare.

LITERATURE REVIEWCritical evaluation of the available literature suggeststhat critically ill adults, who are exposed to either thehypoxic consequence of acute lung injury and acuterespiratory distress syndrome or the iatrogenic com-plications of mechanical ventilation, may benefit frombeing managed in the prone position (Vollman, 1997;Marini and Hotchkiss, 1999).

Extensively, the evidence claims that prone pos-itioning may optimize patients’ oxygenation (Pappertet al., 1994; Fridrich et al., 1996) and minimize the riskof iatrogenic lung injury resulting from mechanicalventilation (Broccard et al., 1997; Gosheron et al., 1998).It can enhance the mobilization of pulmonary secretions,thus optimizing the effectiveness of physiotherapytechniques (Chatte et al., 1997), it improves ventilationto previously atelectic lung regions (Ryan and Pelosi,1996; Mure et al., 1997) and has been shown to minimizethe risk of ventilator-acquired pneumonia (Pappertet al., 1994; Brazzi et al., 1999).

Despite these exhaustive claims, Gattinoni et al.(2001) more recently published the results of a multi-centre, randomized trial that compares the clinical

Author: C Rowe, RGN, ENB 125, Bsc (Hons) Health Studies, Nurse Consultant Critical Care, ICU Derbyshire Royal Infirmary/ITU Derby City General Hospital, Southern Derbyshire Acute Hospitals NHS Trust, Derbyshire Royal Infirmary, Derby

Address for correspondence: Nurse Consultant Critical Care, ICU Derbyshire Royal Infirmary/ITU Derby City General Hospital, Southern Derbyshire Acute Hos-pitals NHS Trust, Derbyshire Royal Infirmary, London Road, Derby DE12QY

E-mail: [email protected]

Clinical guidelines for prone positioning

© 2004 British Association of Critical Care Nurses, Nursing in Critical Care 2004 • Vol 9 No 2 51

outcome of 304 patients with varying degrees ofacute lung injury. Half the eligible patients wererandomly assigned to be conventionally managedwithin the supine position, whilst the other half weremanaged prone for at least 6h a day for a period of10 days.

Results revealed that there was no significant differ-ence in the mortality rates of either group at the end ofthe 10-day study period, at the time of discharge fromintensive care or after 6 months. However, it is import-ant to note here that the study results sustain the claimthat prone positioning undoubtedly improved oxy-genation in more than 70% of patients, thereby render-ing it a useful option in the management of patientswith severe hypoxaemia.

The study also expounds that the incidence ofposition-related complications was similar in both thegroups and that the most significant in relation to pro-nation was the need to increase sedation, facialoedema and the immediate need for airway clearance.Accidental extubation only occurred in four of the 721manoeuvres undertaken.

Interestingly enough, the authors reveal that pro-nation of the sickest patients resulted in a transientsurvival advantage during the 10-day study periodand has led them to recommend a further trial toclarify the role of pronation in those patients sufferingfrom severe acute respiratory distress syndrome.

Despite medical and therapeutic advancements,there is still no definitive treatment for acute respir-atory distress syndrome. Although they have declinedover the past decade, the mortality figures associatedwith the disease are estimated at between 32 and 45%(Udobi et al., 2003). For patients who present with theclinical injustice of increased dyspnoea, advancinghypoxaemia, deterioration in lung compliance anddiffuse bilateral infiltrates on chest radiography, wecan merely offer supportive management and funda-mental care to minimize the associated iatrogenicevents. However, given the evidence available, thismanagement should, I suggest, include the proactiveuse of prone positioning.

For clarity, the following dialogue will reflect thecontents of the clinical guidelines, which we havedeveloped and adopted for use within our clinicalarea in order to encourage the proactive use of themanoeuvre.

INDICATIONS FOR USE OF THE PRONE POSITIONFor prone positioning to be effective, the literaturesuggests that it should be undertaken early in thepatients’ disease pathway (Vollman, 1997), as it hasbeen shown to preferentially re-expand dorsal alveoli

and is particularly effective in the early oedematousphase of acute lung injury and acute respiratorydistress syndrome (Table1) (Blanch et al., 1997). How-ever, as the disease progresses, it has been reportedthat the subsequent development of associated pulmon-ary fibrosis may interfere with alveolar re-recruitmentand the potential for the patient to benefit from themanoeuvre will be greatly reduced (Pappert et al.,1994).

In addition, prone positioning has been shown toenhance the mobilization of chest secretions, maximizethe effects of physiotherapy and enhance ventilationto previously atelectic lung regions, thus reducing therisk of ventilator acquired pneumonia (Chatte et al.,1997; Mure et al., 1997; Brazzi et al., 1999).

Exposure to high levels of both oxygen and PEEPreportedly contribute to progressive lung damage inmechanically ventilated patients and may result in thedevelopment of pulmonary atelectasis and alveolarand interstitial oedema, which will further contributeto the impairment of gaseous exchange. The literaturesuggests therefore that the pronation of mechanicallyventilated patients will minimize the development ofthe iatrogenic events associated with prolonged expos-ure to mechanical ventilation, where those ventilatorymechanisms involved have been shown to cause orpropagate lung injury (Broccard et al., 1997; Chatte et al.,1997; Mure et al., 1997; Gosheron et al., 1998; Brazziet al., 1999; Marini and Hotchkiss, 1999).

POTENTIAL EXCLUSION CRITERIAFrom the evidence presented, Table2 summarizesconditions or clinical scenarios, which have been citedas potential exclusion criteria and which should pre-cipitate a risk/benefits analysis to be undertakenwhen considering the proning positioning of patients.

Table1 Indications for use of the prone position

• Patients diagnosed with acute lung injury (Bernard and Artigas, 1994), with an acute lung injury score ≥2 (see Appendix 1)

• Patients diagnosed with acute respiratory distress syndrome (Bernard and Artigas, 1994), with an acute lung injury score ≥2·5 (see Appendix 1)

• Patients diagnosed with bilateral basal consolidation/collapse (Mure et al., 1997)

• Patients requiring postural drainage of pulmonary secretions (Chatte et al. 1997)

• Patients in whom their oxygen index ≤300 or who are requiring progressively increased concentrations of oxygen and/or levels of PEEP in order to maintain individually accepted oxygenation values (Gosheron et al., 1998; Brazzi et al., 1999)

• Patients who are expected to require prolonged periods of mechanical ventilation (Broccard et al., 1997; Brazzi et al., 1999)



Manoeuvre techniquePreparation of patient and the environmentThe patients’ suitability for proning must be assessedfrom a multiprofessional perspective prior to the eventin order to aid communication and encourage a multi-disciplinary approach to patient care.

Preparation of the patient and their immediateenvironment then becomes of primary importance, asthorough consideration and planning of the manoeuvrewill minimize the occurrence of its associated risks, forexample, accidental displacement of the patients’airway and/or invasive monitoring or lines.

Consideration should also be given to the timing ofthe turns and to all the necessary assessments andclinical interventions required. Only by means ofeffective and coordinated care can the patients safetybe guaranteed and unnecessary repositioning beavoided.

The patient should be nursed on an appropriatepressure-relieving mattress, with a sliding-sheet in situ

to aid repositioning. Their pressure areas must beassessed in advance of the turn and areas of concernhighlighted, documented and appropriately alleviatedin accordance with Trust tissue viability recommenda-tions. An individual care régime should then be devel-oped in order to minimize the risk of pressure areadevelopment, whilst the patient is maintained withinthe prone position.

Prior to commencement, the manoeuvre should beexplained to both the patient and their relatives, thushighlighting the potential clinical benefits and sideeffects, in order to promote effective communication,to gain cooperation and to reduce resultant anxietiesor concerns.

An arterial blood gas analysis must be performedprior to commencement of the turn and the oxygenindex calculated by dividing the patients’ PaO2 bytheir FiO2, as expressed as a decimal. This should thenbe documented accordingly in order to facilitate theaccurate establishment of the Responder–Non-responderpatient status and to prospectively evaluate the effect-iveness of the manoeuvre on individual patient’soxygenation.

Electrocardiogram electrodes should be removedfrom the patients’ anterior chest wall, and all non-essential monitoring and invasive lines disconnected.That deemed essential by its continued presence mustbe adequately secured and flexible enough to accom-modate all aspects of the turn, thus minimizing therisk of accidental displacement or removal and tomaintain patient safety throughout (Canter, 1989;Stocker et al., 1997).

Pulse oximetry with an effective pulsatile traceshould remain in situ and be visible or audible at alltimes to provide effective monitoring during themanoeuvre and to alert staff to potential deterioration.If at any time, the patient develops an unacceptabledeterioration in physiological status, the turn shouldbe abandoned to re-establish stability, and should acardiac arrest situation arise, the patient must bereturned to the supine position for resuscitation to beeffective (Gosheron et al., 1998).

The patients’ enteral feed should be temporarilyhalted prior to the turn and their nasogastric tubeaspirated to reduce risk of regurgitation of the feed,which may predispose to aspiration of gastric contentsand the development of aspiration pneumonitis(Gosheron, 1998).

It is essential that particular attention be given to thesecurity of the patients’ endotracheal/tracheostomytube to reduce the risk of accidental tube displacementor extubation. In addition, tube size, length at lips andgrade of intubation should be noted. All appropriateintubation equipment should be immediately available

Table2 Potential exclusion criteria for prone positioning of patients

• Acute haemodynamic instability or acute shock (Fridrich et al., 1996; Vollman, 1997)

• Recent cardiac arrest, cardiac surgery or sternotomy (Chatte et al., 1997; Ball, 1999)

• Weight >90kg and girth >50 inches (Vollman, 1997). Note: For patients who exceed the weight and girth parameters identified, additional considerations must be employed, including the use of hoists to aid repositioning or the use of available rotational beds

• Pain and/or agitation (Mims, 1989)• Formation of a tracheostomy within 24h (Ball, 1999)• Bronchopleural fistula (Pappert et al., 1994)• Grossly distended abdomen, ischaemic bowel, recent abdominal surgery

or abdominal stoma (Pappert et al., 1994; Stocker et al., 1997; Ball, 1999)

• Pregnancy (second/third trimester.) (Gosheron et al., 1998; Ball, 1999)• Acute head injury raised intracranial pressure/frequent seizures (Fridrich

et al., 1996; Blanch et al., 1997; Vollman, 1997; Gosheron et al., 1998)• Raised intraocular pressure/recent ophthalmic surgery (Ball, 1999)• Unstable cervical spinal injury, spinal instability, evidence of osteoporo-

sis (Fridrich et al., 1996; Ryan et al., 1996; Stocker et al., 1997)• Multiple trauma, acute pelvic fracture, external pelvic fixation, rib or

sternal fractures, and traction (Ryan et al., 1996; Chatte et al., 1997; Ball, 1999)

• Acute asthma, chronic obstructive pulmonary disease or pulmonary abscess (Blanch et al., 1997; Jolliet et al., 1998)

• Acute haemoptysis or acute alveolar haemorrhage (Jolliet et al., 1998)• Chest wall abnormalities/kyphoscoliosis or advanced arthritis (Blanch,

1997; Ball, 1999)• Extensive inguinal/abdominal soft-tissue injury (Stocker et al., 1997;

Jolliet et al., 1998)• Facial trauma or following oral maxillary facial surgery (Fridrich et al.,

1996; Blanch et al., 1997)



so as to facilitate effective repositioning/re-intubation,should the need arise (Canter, 1989; Gosheron et al.,1998; Ball, 1999).

Endotracheal/tracheal suctioning should be under-taken prior to turning and a closed suction systemplaced in line to accommodate ease of access tothe patients’ airway, as pronation may precipitate themobilization of copious pulmonary secretions, whichrequire immediate and ongoing removal (Ball, 1999).

An individual eye assessment should be undertakenprior to commencement of the manoeuvre, as thepatients’ eyes are particularly vulnerable both duringand after the turn.

Care must be taken to ensure that the eyelidsremain closed at all times and appropriate lubricationinstilled to reduce the risk of corneal drying, abrasionor infection (Canter, 1989).

There must be five team members available beforeinitiation of the turn, one of which must be an experi-enced anaesthetist or possess competent intubationskills. In addition to coordination of the turn, thisperson should remain responsible for the patients’head and airway management and be immediatelyavailable to re-intubate the patient, should accidentaldisplacement of the airway occur (Blanch et al., 1997;Gosheron et al., 1998; Pelosi et al., 1998; Ball, 1999).

At this stage, the patients’ pain/sedation statusshould be assessed, and where required, prescribedanalgesia/sedation is accordingly administered tooptimize sedation, prevent pain, minimize discomfortand avoid agitation during the turn (Canter, 1989;Jolliet et al., 1998). Should interference with mechanicalventilation become problematic in the presence ofoptimal sedation, the administration of pharmacologicalmuscle relaxants may be considered and adminis-tered, in order to prevent ventilatory interference andoptimize oxygenation and stability (Jolliet et al., 1998).

Turning the patient pronePrior to commencement of the turn, it is essential toensure that the patients’ arms are positioned close totheir sides, with the palms facing inwards (Figure1).Pillows should then be carefully placed across theirchest, pelvis and knees (Pelosi et al., 1998). Ensuringall essential lines are safely secured and directedtowards the patients’ head, the coordinator should bepositioned likewise, with two additional staff mem-bers on either side. The bottom sheet must be pulledstraight and taut and a second sheet laid across thepatient, ensuring that all corners are matching. Thepatients’ head and face are then uncovered, and thestaff either side should proceed to roll the matchingedges of the sheets together tightly, effectively cocoon-ing the patient inside.

Once the patient has been secured, and it is safe toproceed the patient should be glided across the bed,away from the ventilator, to as near the opposite edgeof the bed as is safely possible. Whilst maintainingsheet integrity and affording all personnel the oppor-tunity to swap over supporting hands, the patientshould then be primarily manoeuvred into the lateralposition and then lowered carefully onto the support-ing pillows and into the prone position. Finally, thepatient can be glided into a more central position inthe bed, for more detailed consideration to be given tothe supporting pillows (Figure2).

The upper pillow must support the patients’ upperchest, allowing their shoulders to fall forwards slightlyand reducing the risk of overdistension of the anteriorcapsule of the shoulder joint and injury to the brachialplexus (Figure3). The middle pillow should be posi-tioned under the patients’ pelvis, thus maintainingthem in an abdomen-free position to promote

Figure1 Sheet preparation prior to turn.

Figure2 Patient is initially placed in lateral position.



diaphragmatic excursion and to optimize functionalresidual capacity and basal lung expansion (Vollman,1997). In addition, the abdomen-free approach isreported to minimize the risk of bacterial translocationof the gut, which may predispose to sepsis (Ball, 1999),the risk of caval compression and its potential haemo-dynamic consequences and will promote the toleranceof enteral feeding.

Finally, the lower pillow should be positioned suchthat the patients’ knees are allowed to remain in a flexedposition with the ankles slightly forwards. This will pre-vent overstretching of the soft tissues surrounding theankles joints, avoid shortening of the Achilles’ tendonand reduce the pressure exerted over the head of thefibula, which may injure the common peroneal nerve.

Stringent attention to detail must then be given tothe positioning of the patients’ head and limbs. Theyshould be maintained within the swimmers position,ensuring that their face looks towards the prominentarm, the opposite one being positioned carefullydown by their side.

It is essential that the shoulder position of theprominent arm be maintained at 80° abduction, whilstthe elbow is flexed to 90° to minimize the risk of injuryof the neural tissue and prevent overextension ordevelopment of limb contractures (Gosheron et al.,1998; Ball, 1999). In addition, a small-rolled pillowcaseshould be placed in the palm of the prominent hand toextend the wrist and allow flexion of the fingers.

Care must be taken with any subsequent reposition-ing of the patients’ arms, and carers must at all timesavoid pulling on the patients’ wrist to elicit a response(Canter, 1989) (Figure4). Once established in the proneposition, the bed should be placed in a reverseTrendelenburg’s position, i.e. tilted foot down 30–45°(Gosheron et al., 1998), to reduce the severity of facialand periorbital oedema. Immediate attention must be

given to the patients’ individual eye care regime, withthe initial assessment maintaining that they remainclosed and free from direct pressure, thus minimizingthe risk of iatrogenic ophthalmic complications andto avoid corneal drying, abrasion or ulceration(Gosheron et al., 1998; Ball, 1999).

It is essential to continue to mobilize the patientwhilst in the prone position, thus avoiding pressurearea development, soft-issue injury and muscle deterior-ation and to optimize effective sputum drainage,clearance and removal. An individual repositioningrégime must be negotiated (Figure5), as directed bythe patients’ tolerance level and physiological require-ments. However, it should at least incorporate a modi-fied repositioning approach, whereby the patients’swimmers position is alternated every 2–4h and theposition of their supporting pillows changed, thusrendering them three-quarter prone.

All non-essential monitoring equipment removedprior to the proning maneouvre must be re-attached at

Figure3 Patient is prone in swimmers position. Figure4 Patient in reverse Trendelenburg's position.

Figure5 Patient is in modified three-quarter prone position.



this stage and the patients’ previous enteral feedingrégime resumed.

As previously stated, pronation of the patient mayresult in the mobilization of copious pulmonary andoral secretions, which will require immediate andongoing removal (Wayne et al., 1994; Chatte et al.,1997). In addition, it may be essential to provide add-itional protection under the patients’ head and faceusing absorbent material and to ensure that soiled orwet linen there is changed promptly to avoid excori-ation or breakdown of skin in this area.

The patients’ response to prone positioning shouldbe assessed after 30min, assuming no immediate andunnacceptable physiological deterioration has occurred.An arterial blood gas analysis should be undertakenand the oxygen index calculated compared to supineand documented accordingly.

If the patients’ PaO2 has increased by 1·3kPa(10mmHg) or more, or their oxygen index hasincreased by 20mmHg or more, they can be classed asa Responder (Chatte et al., 1997; Gattinoni et al., 1997;Jolliet et al., 1998). Although most patients respondvery quickly, there are those who will benefit fromproning but show a more gradual positive response.In the absence of an immediate improvement inoxygenation and assuming there is no prolonged orunacceptable deterioration in the patients’ condition,the prone position should be maintained for anadditional 3–6h in order to afford the patient theopportunity to gain Responder status (Canter, 1989;Gattinoni et al., 1997). Conversely, there are patientswhose oxygenation will not improve or may deterio-rate to an unacceptable level. These patients areclassed Non-responders. If the patient therefore doesnot respond after pronation of 6h or if an unacceptabledeterioration occurs, they should be returned to thesupine position. However, it is important to note herethat this initial lack of response does not automaticallymean the patient will never respond in a positivemanner. It should not therefore preclude subsequentproning attempts, if considered necessary (Jolliet et al.,1998; Trottier, 1998).

The evidence suggests that patients can be main-tained prone for as long as they continue to demon-strate a positive response (Stocker et al., 1997; Webster,1997; Jolliet et al., 1998). However, it is essential thatthey undergo modifications to their position, every2–4h, as previously directed, unless extreme circum-stances dictate. If the patient has indeed demonstratedan unacceptable deterioration when being returnedsupine, it may be necessary to maintain them in theprone position for longer than the 12-h maximumperiod routinely recommended within our clinicalarea.

POTENTIAL CLINICAL CONSEQUENCES OF NURSING A PATIENT PRONETable3 summarizes potential side effects associatedwith pronation. However, with adequate preparationand compliance to our guidelines, these should bereduced but will be subject to ongoing clinical scrutiny.

Although our guidelines offer a comprehensiveguide to all aspects of prone positioning, they con-stitute quite an extensive document; therefore the fol-lowing bedside algorithm is used to direct the clinicalprocess (Figure6).

CONCLUSIONDespite being labour intensive when undertaken by aconfident and competent multiprofessional team, thepronation of patients has been shown to be relativelystraightforward and safe, with the incidence of poten-tial side effects minimal (Gattinoni et al., 2001).

Although there is lack of statistical evidence to sup-port the claim that it improves patients’ survival, thereis overwhelming evidence to say that pronation has apositive impact on oxygenation in responder patients(Blanch et al., 1997; Vollman. 1997; Gattinoni et al., 2001).

Although mortality from acute lung injury andacute respiratory distress syndrome is not directlyattributable to hypoxaemia, its proactive managementwill facilitate the reduction of ventilatory support; thusthe risk of iatrogenic complications associated withmechanical ventilation may be avoided or minimized.

The development and introduction of our guide-lines will help direct, safe and effective care for thosepatients who may clinically benefit from being man-aged prone and reduce the clinical risks associatedwith the manoeuvre. Moreover, they will help usachieve our initial clinical quest, which was to initiatethe use of prone positioning early within the patients’care pathway as a proactive management strategy soas to maximize clinical effect rather than to use it indesperation, when conventional management hasfailed.

Table3 Potential side effects of pronation

• Accidental displacement or removal of the patients' artificial airway• Difficulty in performing eye care, oral toilet and facial care due to

reduced access• Displacement, compression of, or difficulty in accessing or re-siting

intravenous lines, enteral feeding lines or invasive monitoring devices• Pressure on the cheeks, breasts, genitalia, knees and pelvic area• Gastric regurgitation, intolerance of enteral feed and translocation of

abdominal bacteria• Joint stiffness, overextension, nerve compression or the development of

contractures



REFERENCESBall C. (1999). Use of the prone position in the management of

acute respiratory distress syndrome. Intensive and Critical CareNursing; 15: 192–203.

Blanch L, Mancebo J, Perez M et al. (1997). Short-term effects ofprone position in critically ill patients with acute respiratorydistress syndrome. Intensive Care Medicine; 23: 1033–1039.

Bernard G, Artigas A. (1994). The American–European consensusconference on ARDS: definitions, mechanisms, relevantoutcomes, and clinical trial coordination. American Journal ofRespiratory Critical Care Medicine; 149: 818–824.

Brazzi L, Ravagnan I, Pelosi P et al. (1999). Prone position inanaesthesia and intensive care. Care of the Critically Ill; 15: 5–9.

Broccard A, Shapiro R, Schmitz L. (1997). Influence of the proneposition on the extent and distribution of lung injury in hightidal volume oleic acid model of acute RDS. Critical CareMedicine; 25: 16–27.

Canter C. (1989). Nursing mechanically ventilated patients in theprone position. Care of the Critically Ill; 3: 3.

Chatte G, Sab J, Dubois J et al. (1997). Prone position in mechanic-ally ventilated patients with severe acute respiratory failure.American Journal of Respiratory and Critical Care Medicine; 155:473–478.

Fridrich P, Krafft P, Hochleuthner H et al. (1996). The effects oflong-term prone positioning in patients with Trauma inducedadult respiratory distress syndrome. Anaesthesia and Analgesia;83: 1206–1211.

Gattinoni L, Tognoni G, Brazzi L et al. (1997). Ventilation in theprone position. Lancet; 350: 815.

Gattinoni L, Togoni G, Pesenti A et al. (2001). Effect of pronepositioning on the survival of patients with acute respiratoryfailure. New England Journal of Medicine; 345: 568–573.

Gosheron M, Leaver G, Forester A et al. (1998). Prone lying – anursing perspective. Care of Critically; 14: 89–92.

Figure6 Care algorithm for prone positioning of patients.

No

No

Assess pain / sedation scoreIs it adequate?

Would patient benefit from proneposition?

Do contraindications apply?

No

Are there four staff and ananaesthetist available?

• Ensure all clinical assessments / interventions have been undertaken• Explain the manoeuvre to patient & relatives• Perform arterial blood gases• Calculate oxygen index• Disconnect all non-essential lines & monitoring• Check flexibility of remaining monitoring & lines• Discontinue enteral feed & aspirate nasogastric tube• Check security of endotracheal / tracheal tube• Check grade of intubation & tube size & length• Perform eye assessment and required eye care• Perform endotracheal / tracheal suction

Does patientrequire muscle

relaxant?Administerprescribedanalgesia /sedation·

Place bed in reverse Trendelenburg’s position

Re - attach all monitoring

Re - establish enteral feed

Perform oral & endotracheal / tracheal suction

Unacceptable deterioration

Yes

Administer musclerelaxant asprescribed

Yes

Yes

Return supine

Non-responder status

Establish individual repositioning regime / pressure area care

Establish individual eye assessment / care regime

• Perform ABG’s after 30 min and calculate oxygen index

• In absence of positive response but assuming unacceptable deterioration has not occurred, maintain position & repeat calculation after 3 h

• In absence of positive response after 3 h but assuming unacceptable deterioration has not occurred, maintain position & repeat calculation after a further 3h

Performmanoeuvre

Responderstatus.

PaO2 increased ≥1.3 kPa(10 mmHg)or oxygen index increased≥20 mmHg.

Yes

No

No

Yes

Yes



Jolliet P, Bulpe P, Chevrolet J. (1998). Effects of the prone positionon gas exchange and haemodynamics in severe acute respir-atory distress syndrome. Critical Care Medicine; 26: 1977–1985.

Marini J, Hotchkiss J. (1999). PEEP in the prone position:Reversing the perfusion imbalance. Critical Care Medicine; 27:1–2.

Mims B. (1989). Physiological rationale of SvO2 monitoring. Crit-ical Care Nursing Clinics of North America; 3: 619–628.

Mure M, Martling C, Lindahl S. (1997). Dramatic effect on oxy-genation in patients with severe acute lung insufficiencytreated in the prone position. Critical Care Medicine; 25:1539–1544.

Murray J, Matthay M, Luce J et al. (1988). An expanded definitionof the adult respiratory distress syndrome. American Review ofRespiratory Disease; 138: 720–723.

Pappert D, Rossaint R, Slama K et al. (1994). Influence of position-ing on ventilation – perfusion relationships in severe adultrespiratory distress syndrome. Chest; 106: 1511–1516.

Pelosi P, Masheroni Tubiolo D et al. (1998). Effects of the proneposition on respiratory mechanics and gas exchange during

acute lung injury. American Journal of Respiratory Critical CareMedicine; 157: 387–393.

Ryan D, Pelosi P. (1996). The prone position in acute respiratorydistress syndrome. British Medical Journal; 312: 860–861.

Stocker R, Stein S, Ecknauer E et al. (1997). Prone positioning andlow volume pressure limited ventilation improve survival inpatients with severe ARDS. Clinical Investigations in CriticalCare; 1008–1017.

Trottier. S. (1998). Prone position in acute respiratory distresssyndrome: Turning over an old idea. Critical Care Medicine; 26:1934–1935.

Udobi K, Childs E, Touijer K. (2003). Acute respiratory distresssyndrome. American Family Physician; 15: 315–322.

Vollman K. (1997). Prone positioning for the ARDS patient.Dimensions of Critical Care Nursing ; 16: 184–193.

Wayne J, Lamm. M, Richard A. (1994). Mechanism by which theprone position improves oxygenation in acute lung injury. Ameri-can Journal of Respiratory Critical Care Medicine; 150: 184–193.

Webster N. (1997). Ventilation in the prone position. Lancet; 349:1638–1639.

APPENDIX 1The acute lung injury score (Murray et al., 1988).

Value Score

Chest radiograph scoreNo alveolar consolidation 0Alveolar consolidation in one quadrant 1Alveolar consolidation in two quadrants 2Alveolar consolidation in three quadrants 3Alveolar consolidation in all four quadrants 4

Hypoxaemia scorePaO2/FiO2 ≥300 0PaO2/FiO2 225–299 1PaO2/FiO2 175–224 2PaO2/FiO2 100–175 3PaO2/FiO2 <100 4

Respiratory system compliance score (if mechanically ventilated)Compliance

≥80ml/cm H2O0

Compliance60–79ml/cm H2O

1


2


3

Compliance≤19ml/cm H2O

4

Positive-end expiratory pressure (PEEP) scorePEEP ≤5cm H2O 0PEEP 6–8cm H2O 1PEEP 9–11cm H2O 2PEEP 12–14cm H2O 3PEEP ≥15cm H2O 4

The final value is obtained by dividing the aggregate sum by the number of components that were used.

No lung injury 0Mild to moderate lung injury 0·1–2·5Severe lung injury >2·5

FiO2, fraction of inspired oxygen; PaO2, patients' oxygenation.

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