ARDS: Should we be prone to prone?

by juan de la cruz 5,972 Views | 15 Comments Guide

This author's goal is to present the results of a large randomized study on the beneficial effects of prone positioning in preventing mortality in ARDS recently published in the New England Journal of Medicine. The author hopes to elicit a discussion of these results especially in terms of it's significance to current nursing practice in the ICU.

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    ARDS: Should we be prone to prone?

    The buzz in critical care circles these days is the recent publication of the results of the PROSEVA Study Group in the New England Journal of Medicine. This European study begs to answer the question long-debated by critical care professionals over the years – is there a benefit to prone positioning in Acute Respiratory Distress Syndrome (ARDS)? Prior to the release of the PROSEVA results, trials that tested this hypothesis have failed to show a beneficial effect on patient outcomes.

    Before going further on the topic, allow me to refresh our memories and establish an understanding of what happens in ARDS, a life-threatening condition many of us critical care professionals have encountered in our practice. In normal individuals, oxygen enters our respiratory tract into air filled sacs in our lungs called alveoli. Capillaries run through the walls of each alveoli exchanging carbon dioxide with oxygen which is then carried into our bloodstream to supply our organs with this life-sustaining gas.

    ARDS develops in the lungs of patients for multiple reasons, infection and trauma being common. The lungs become injured by fluid accumulating in the patient’s alveoli thus preventing them from filling with air. The capillaries that run through the alveolar walls are not able to exchange carbon dioxide for oxygen to be delivered into the bloodstream. As we all know, our organs such as the brain, heart, and kidneys are hungry for oxygen and the effect of prolonged absence of oxygen-rich blood affects their function.

    In Medicine, a diagnosis of ARDS is made when the following criteria are met: (1) acute onset, (2) bilateral infiltrates on chest x-ray, (3) PAWP < 18 or if this data is unavailable, a lack of clinical evidence of left atrial hypertension, (4) ABG results that shows a PaO2:FiO2 ratio of < 200. Patients with ARDS are intubated and placed on mechanical ventilation in order to improve gas exchange. It is a common diagnosis for ICU admission. While there are numerous modalities now being used in the treatment of ARDS, prone positioning has come in and out favor through the years.

    Mechanically ventilated lungs suffer from further injury because of the artificial nature of positive pressure ventilation which forces a volume of air into alveolar sacs causing undue strain. Recumbent positioning creates dependent areas of fluid-filled alveoli centered in the posterior segments of the lungs. Forced air follows the path of least resistance so that a set volume of oxygen delivered by the ventilator can potentially over-distend the remaining healthy alveoli. This causes a vicious cycle of further lung injury. Prone positioning, in theory, allows for a homogenous distribution of stress and strain within all the alveoli.

    The investigators in the PROSEVA study had astounding results. 466 Adult ICU patients in France and Spain were enrolled in the study and randomized to Supine Group (n-229) and Prone Group (n-237). At 28 days, patients who were placed in prone position for 16 hours daily had 16% mortality compared to 32.8% in the patients who remained in semi-recumbent position. At 90 days, mortality for the patients who were placed in the prone position was 23.6% vs 41% in the group who remained supine. Successful extubation was higher in the prone group at 80.5% at 90 days compared to 65% in the supine group. Length of stay and let me gasp for a minute…incidence of complications such as accidental extubations and cardiac arrests were insignificant between the two groups. Results were adjusted based on severity of symptoms and organ failure.

    It should be mentioned that the centers who participated in the study all have experience with prone positioning at a minimum of 5 years and that no specialized beds or contraptions were used in all the ICU’s that participated. All patients were laid on standard ICU beds and the technique of prone positioning was standardized across all the participating centers. Anyone interested in the technique should log into their hospital’s free access to the New England Journal of Medicine articles to see a video depicting the technique used. I guarantee that you will get a kick out of hearing a male voice speaking in a French accent explaining the steps while three young women dressed in white who look like nurses perform the prone positioning on a patient.

    The PROSEVA study has its share of criticisms just like any other new piece of evidence. Foremost among them is the fact that the centers enrolled in the study have all been shining stars in terms of mastering prone positioning as a modality in ARDS. Not every center in Europe, much less the US, could say the same thus making reproducibility of results precarious to say the least in centers with very little experience on the technique. For obvious reasons, the study is not blinded. Fluid volume status, an essential consideration in ARDS outcomes was not mentioned in the results. Body mass index in both groups averaged at 29, a number not quite consistent with a svelte figure but the mere thought of morbidly obese American patients with higher BMI’s being proned truthfully makes my heart skip a beat…and I'm not judging here!

    Nevertheless, the results of the PROSEVA study will undoubtedly cause a jolt of excitement within the critical care community and many an intensivists will want to replicate the results in their practice. As a nursing professional with years of practice at the bedside in the ICU, my hope is that any plan to introduce such a practice change in our respective ICU’s be met with heavy input from nurses at the bedside. The huge burden of manpower required for implementing such modality calls for adequate staffing levels and involvement of a dedicated team of respiratory therapists. Let me know your thoughts, are you now prone to prone?
    Last edit by Joe V on Jun 13, '13
    sapphire18, BVFD 333, flexiseal, and 4 others like this.
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  3. About juan de la cruz

    Juan De La Cruz, RN, NP, CCRN-CSC is a board-certified Acute Care Nurse Practitioner working with a multidisciplinary team of intensivists in a number of multi-specialty Adult Critical Care Units at a university-affiliated tertiary medical center in the West Coast.

    juan de la cruz joined Nov '06 - from 'California'. Age: 45 juan de la cruz has '20+' year(s) of experience and specializes in 'APRN, Adult Critical Care'. Posts: 2,841 Likes: 2,668; Learn more about juan de la cruz by visiting their allnursesPage


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    15 Comments so far...

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    Started with this "modern" vent:



    My colleagues were positioning our long term vented patients in prone position in early 80's in Resp step down unit. We also did 3 person lift OOB to our highback chair and when obtunted would tape their heads to back of chair using cloth double backed tape, place tray table in front chair piled high with pillows to rest their arms on to get them OOB on days and middles...... 85% were extubated and went home.

    Prone is my best sleep position too.
  5. 1
    Thank you Juan, very interesting! Thanks Karen too for your input!
    juan de la cruz likes this.
  6. 3
    Juan, thank you for this really down to earth article that I really enjoyed for many reasons. Karen, that trip down memory lane with a look at the Bird was almost like a silent scream for me. We used to call Birds "the kiss of death" and worked really hard to keep away that kiss when all we had were those Birds. That was back in the early 70's. We thought we had reached a new century in vents when the MA-1 came in.

    When DH was on vent he was barely moved off back. His turns by staff were only a few degrees. That was one of the few things I saw where he was that I did not agree with but had not been involved in ICU for too many years to argue the point. I know it would not have made any difference in outcome but I am glad to see that the discussion continues about positioning.

    Thanks again.
  7. 3
    Quote from NRSKarenRN
    Started with this "modern" vent:



    My colleagues were positioning our long term vented patients in prone position in early 80's in Resp step down unit. We also did 3 person lift OOB to our highback chair and when obtunted would tape their heads to back of chair using cloth double backed tape, place tray table in front chair piled high with pillows to rest their arms on to get them OOB on days and middles...... 85% were extubated and went home.

    Prone is my best sleep position too.
    OMG!!!!!!!!! A BIRD!!!! I haven't seen one of those in forever!!! we did prone as well and got them up in the chair...everyday.

    Juan great article!
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    NRSKarenRN, I did catch the tail end of the Bird Ventilator...I remember being amazed at its little size yet annoyed at the loud piston-like hissing sound it made with each breath, lol. Pretty soon they were left in the corner unused and collecting dust. The vents that took over were bulky and had bellows! another lol moment.
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    It has been standard practice to prone position ARDS patients, and a few other kinds too, in our ICU since at least 2005. I thought this was a settled question?
  10. 1
    I have never seen a vented patient prone in our hospital. Great article, thanks for the source. Not having read much into the study, it sounds like best practice.
    aknottedyarn likes this.
  11. 2
    Quote from PMFB-RN
    It has been standard practice to prone position ARDS patients, and a few other kinds too, in our ICU since at least 2005. I thought this was a settled question?
    Previous studies showed benefits of prone positioning with oxygenation. Due to associated risks, many centers were not quick to adopt the practice and there are centers right now that do not prone patients. There are other modalities that have gained favor over proning (i.e., ECMO based on the CESAR trial, fluid restrictive strategies, ARDSnet).
    Last edit by juan de la cruz on Jun 13, '13
    Esme12 and Altra like this.
  12. 1
    My MICU uses rotaprone beds pretty frequently with ARDS patients. Our intensivists do not use ECMO and I think the literature at this point favors proning. Good article.
    juan de la cruz likes this.


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