Prone positioning

1. Prone positioning/Prone
ventilation for patients

2. Objectives:
 To discuss the indications of proning
 To increase awareness of the physiological effects
proning has on patients
 To identify the contraindications to proning
 To be aware of the precautions needed to be
undertaken prior to proning
 To discuss the turning procedure
 To identify the complications that can occur with
proning

3. Objectives
 To review the care and management of a patient in
proned position.

4. Prone position
 First studied in 1974 for pediatric group
 Studies in ARDS in late 1990’s

5. Prone position:
 Is a maneuver used to combat hypoxemia in
patients with acute respiratory distress
syndrome.Despite the fact that this is currently
considered an efficient way to improve
oxygenation,the physiological mechanisms that
bring about improvements in respiratory function
are not yet fully understood.

6. ARDS
 Acute Respiratory Distress Syndrome-is a medical
condition occuring in a critically ill patients
characterized by widespread inflammation in the
lungs. It is not a particular disease rather a clinical
phenotype which maybe triggered by various
pathologies such as trauma, pneumonia and sepsis.

7. Prone position
 Evidene base
 1.Taccone P.et al 2009
 2.Gattinoni L.et al 2010
 3.Arbroug F.et al 2011
 4.Robak O. Et al 2011
 5.Guerin C et al 2013

8. Indications:
 Bilateral basal lung collapse/consolidation
 Early acute respiratory distress syndrome
 Acute lung injury
 Pao2 more than 9Kpa despite FIO2 more than 0.6
 PEEP more than 7
 Moderate to severe acute respiratory failure
 Mobilization of secretions
 Bilateral infiltrates on chest x-ray

9. Indications
 No left ventricular failure
 Reduced lung compliance
 Reducing the risk of iatrogenic lung injury due to
prolonged periods of mechanical ventilation

10. Contraindications
 Shock or acute bleeding
 Pregnancy (2nd and 3rd trimester)
 Unstable spinal fractures
 Tracheostomy less than 24 hours old
 Demonstration of previous poor tolerance of prone
positioning
 Chest wall abnormalities,kyphoscoliosis
 Facial trauma and surgery including opthalmic surgery
 Multiple trauma and fractures requiring stabilization
such as pelvic,ribs and sternum.

11. Contraindications:
 Cardiovascular instability/recent cardiac arrest
 Recent cardio thoracic surgery/presence of intra aortic
balloon pump
 Obese patients more than 90kg
 Pain and /or agitation
 Grossly distended abdomen
 Bowel ischemia/recent abdominal surgery
 Burns/open wounds
 Raised ICP and elevated intra abdominal pressure

12. What effects does the prone
position have:
 Increased oxygenation due to:
 1.blood flow redistribution and improved V/Q match
 2.more consistent ventilation and equal distribution of
lung stresses
 3.increase basal expansion and better alveolar
recruitment.
 4.increased functional residual volume

13. What effects does the prone
position have?
 Increased oxygenation due to :
 1.increased surface area for gas exchange
 2.enhanced drainage of pulmonary secretionss
 3.movementof instertitial fluid
 4.increased tidal volumes and reduced work of breathing
due to displacement of abdominal and cardiac structures
 5.decreased in fio2
 6.decrease in PEEP
 Helps to prevent further pulmonary injury caused by high
peep,volutrauma and oxygen toxicity.
 Improvement in survival of ARDS patients.

14. Preparations:
 Inform relatives if they are present
 4-5 nurses must be present,1 respiratory therapist
 Physician
 Ensure patient is well sedated and paralyzed if
necessary
 Ensure slide sheets is in position
 Ensure that ETT is well secured
 Protect the eyes with ointment and eyepads
 Ensure that all equipment and medicine for

15. Preparations:
 Potential resuscitation are within easy reach
 Disconnect and remove all equipment that the patient
can do without, maintaining asepsis
 Adjust the remaining lines and monitor leads to
prevent kinking and disconnection
 Empty ileostomy/colostomy drainage bags
 Repostion ecg leads just before turning

16. Procedures:
 The direction of the first turn should be towards the
ventilator,where possible ,to minimize the risk of
disconnection or extubation.
 Place the pillows over the patient’s chest and pelvis to
avoid abdominal pressure from the mattress
 Place a pillow over the shins to flex the knees and
reduce stretching of the achilles tendon.
 Place a sheet over the patient
 Pull the patient to the edge of the bed and slowly turn
him over onto the pillows

17. Potential complications:
 Ett and trachy tube displacement
 Difficulty in assessing the patients airway
 Increased oral and tracheal secretions
 Facial and periorbital edema, increased intraocular
pressure, corneal injury
 Difficulty performing eye, oral and facial care
 Displacement ,compression or difficulty accessing iv
line ,enteral feed line or invasive monitoring devices.
 Breakdown of pressure areas or vulnerable areas

18. Potential complications:
 Such as face,cheeks,breasts,genitalia,knees,pelvic area
 Gastric regurgitation, intolerance of enteral feeding
 Joint stiffness or damage ,nerve compression
 Cardiovascular instability
 Inadequate sedation or analgesia

19. Nursing care:
 Any specific care intervention,clinical procedure or
sheet change should be completed prior to proning
 Eyelids should be closed using eyepads to prevent
corneal abrasions
 Place absorbent material under the dependent side of
the face to absorb excess saliva
 Perform regular oral suctioning
 Monitor for evidence of gastric regurgitation
 Place in reverse t-burg position to minimize gastric
regurgitation and facial edema

20. Nursing care:
 Used closed suction system to facilitate suction of
ett/trachy tube
 Use pressure relieving mattress and appropriated head
support
 Laterally rotate the head 2-3 hours ,placing it away
from the elevated arm(if possible) and avoiding neck
extension
 Avoid pressure on the knees and stretching of the
achilles tendon by pillow placement under the shins
 Abduct the hips

21. Nursing care:
 Reposition the upper limbs 2-3 hours using the
swimmer’s position
 Avoid stretching of the brachial plexus and over
distention of the shoulder
 Nurse allocation should ensure an appropriate
experienced nurse is available to care of prone patient
 In case of emergency situation such as cardiac arrest,
loss of airway ,return the patient in supine position as

22. Summary
 Discussed the indications for proning.
 Increased awareness of the physiological effects
proning has on patients,to be benificial prone early.
 Identified the contraindications to proning
 Increased awarenss of the precautions needed to be
undertaken prior to proning,
 Discussed the practicalities involved in the turning
procedure.
 Identified the complications that can occur with
proning.

23. Summary
 Reviewed the care and management of a patient in the
proned position.

24. References
 ARDS,ECMO,NO which works,Dr.Fadi S.
Aljamaan,Critical care consultant,King Khalid
University
 Ball C,Adams J,Boyce S and Robinson P.(2001)Clinical
guidelines for the use of prone position in acute
respiratory distress .Intensive and critical care nursing
vol 17 pp94=104
 Chantler J and Soanes C (2014) AICU/CICU Guidelines
for Prone ventilation in Severe Hypoxic ARDS Oxford
University Hospital.NHS Trust

25. Thank you!

26. Answer me!
 1.Prone positioning has been proven to improve
mortality of what condition?
 A.Skin breakdown
 B.Acute respiratory distress illness
 C.Bronchitis
 D.COPD

27. Answer me!
 2.How long should a patient with ARDS be in the
prone position.
 A.1-2 hours a day
 B.Any amount of time is as effective as another
 C.16 hours +
 D.Continuosly

28. Answer me!
 3.What effects does the prone position have on cardiac
function?
 A.Decreased stroke volume
 B.Decreased heart rate
 C.Decreased vascular tone

29. Answer me!
 4.How should the patient’s feet and toes be protected
from pressure damage?
 A.Padding
 B.Padding and Elevation
 C.Only through positioning
 D.All of the above

30. Answer me!
 5.Give atleast 3 nursing care in a proned vented
patient.