ARDS + prone position

joeyzstj, LPN · Sep 29, 2008

Yes, we do prone patients and we mostly do it late when all other methods have failed. We have one physician who believes in it strongly and one who does not and says there is not research to back it. He is actually wrong. I have seen it work many times within an hour. Sometimes the patients survive and sometimes they dont. You have too look at the mortality rates of ARDS. A lot of times in combination with sepsis they are automatically put into a 50% mortality rate class with it. The only complications I have ever had was attempting to do it with a large person whom it was very difficult to keep their face and neck area from breaking down. If your patient is dying, you are maxed on peep with a minimal P/F ratio and nothing else to try, I say why not do everything you can? I have actually NEVER seen someone try it and it not work to tell you the truth.

HT3RN · Oct 2, 2008

Prone patients all the time.

Done as last resort...beds are expensive.

Always seems to work (increases oxygenation), more perfusion.

Patient survival rate unknown to me. Haven't seen anyone succumb to resp. complications due to it. But, I am currently on a trauma unit so most of these patients are generally healthy with few or no commorbitities.

Complications not tolerating being supine sometimes requiring 100% FiO2 before and while being rotated supine, facial swelling and breakdown can occur.

It works. Hate the bed, but it works.

PICNICRN, BSN, RN · Oct 5, 2008

YES!! We have been "pron-ing" the pediatric RDS patients for quite some time now. And from my experience, it does improve oxygenation almost instantly! While prone, we are able to decrease their FIO2 and sometimes PEEP. With the smaller kids you might even have to decrease inotropes. We do see better perfusion too. Usually we will flip them Q 12 hours.( Much easier to do with the small kiddos than with your adults I'm sure.)

As for complications, I guess it would be skin break down and periorbital edema.

We ususally do start placing them prone earlier rather than later.

They sometimes do get a little unstable with the repositioning process and for a little while after but seem to settle down with in an hour.

As for mortality rate- I really do not know. Seems like they are pretty sick to start off with anyway.

NoviceToExpert · Oct 5, 2008

I've only seen proning in a very rare circumstance... From what I've read proning can be efficacious... the problem is that patients are proned, often, too late to appreciate the benefit... in other words, the literature that suggests that proning does not correlate with improved outcomes acknowledges that most of the time it is brought on board as a last result... so it should be done earlier to maximize benefit... however, the risks are to be considered... one of our nurses reports the case of a younger woman blinded because of increased pressure on the optic nerves over time... maybe could have been prevented if pt. was not left proned too long... I don't know the details, but remember the warning... and the risk of pulling or displacing lines is significant... so make sure there are PLENTY of hands on deck to safely prone with attention to line security...

Zookeeper3 · Oct 19, 2008

kathleen vollman invented a prone positioner, she gave an inservice and talk at our facility. she herself did several studies. i believe the doc's are wary because quite a bit of literature is from... gasp... nursing !

anyway. google her, there are many articles and research papers out there to help form your opinion. we no longer prone and i regret this, but wasn't my decision. you had to have the tolerence level to not knee-jerk react the the first 15 minutes after the turn.

hi everyone,
i searched the forum, and haven't seen any postings on this since 2002, so i'm bringing this up again: :)
1. do you typically prone ards patients on your unit?
2. if so, do you prone early or late?
3. did you see changes in oxygenation?
4. did the patient survive?
5. did you have complications from the proning?
i'm really curious about ards in general, and haven't seen much research that supports proning, but have heard nurses swear by it.
thanks in advance for any replies! :redpinkhe

JJRBuckeyeRN · Nov 11, 2008

I work in a medical ICU and we get a lot of ARDS pts. I have only been a RN for 2 years. But, it has been my experience that we use proning as a last ditch effort.

We usually try the HFOV (High Frequency Oscillator Vent) and using nitric with the pt before we think about proning.

With the 3-4 pt's that I have seen proned about half of them have survived and the other half have passed away.

Booster · Apr 21, 2010

Hi there,

I was actually a patient, nursed in the prone position during ARDS after getting sepsis. Almost 2 years on now and all is good. However, if you would like any info on ARDS please feel free to contact me..... I am also a member of the ARDS support group.

Kind Regards

canusnurse · Apr 23, 2010

We prone patients on our unit, and it seems to work well. I have to say with many others, though, it is often used as a last ditch effort.

The last patient we proned was a very large patient, and it took many hands to keep vent tubes, TLCs and A-lines and all other lines straight, but we rested her face on a large piece of foam that we cut to fit her face and ETT. We would prone her for 4-6 hours a shift, Q 12 hr. Before we shipped her to a long term vent unit in the south of the state, she was trached, but able to communicate and respond appropriately..many of the nurses on the unit had not thought she would survive..

ForrestGump · May 1, 2010

hey all,

my first post here - how exciting!!

firstly to answer the original questions;

1. do you typically prone ards patients on your unit?

no, especially now the doctors have a brand new ecmo machine they are keen to get some mileage out of.

2. if so, do you prone early or late?

of the times i have seen it done it has always been late. usually after considerable time on high fio2 and following failure of prostacyclin. usually used as a last ditch effort.

3. did you see changes in oxygenation?

often see early and marked improvement in oxygenation however have noted that this improvement is not sustained past two hours.

4. did the patient survive?

i would say the vast majority of pts i have seen proned died.

5. did you have complications from the proning?

yes. dislodgement of central line, development of pressure sore on the pts forehead and severe peri-orbital swelling.

anecdote aside, the evidence on this topic provides no real consensus on whether prone ventilation is beneficial. seminal studies indicated that whilst oxygenation was improved in the short term this did not extrapolate to improved mortality. criticism regarding these original studies centered around the "late" timing of prone positioning in ards pts. as a result subsequent studies have aimed to prone pts "earlier" which has demonstrated some improvement in mortality. despite these studies there still remains no widely accepted standard on when, how or even if to use prone ventilation. so until then we will continue to wallow in anecdote and speculation on whether we should be flipping our pts like the eggs i am just about to cook myself for breakfast.

kind regards,

forrest :monkeydance:

RescueNinja · May 2, 2010

Here are two good articles...

Fernandez, R... (2008). Prone positioning in acute respiratory distress syndrome: a multicenter randomized clinical trial. Intensive Care Medicine, 34(8), 1487-1491.

Vieillard-Baron, A... (2005). Prone position improves mechanics and alveolar ventilation in acute respiratory distress syndrome. Intensive Care Medicine, 31(2), 220-226.

http://scholar.google.ca/scholar?hl=en&q=ards+prone+position&as_sdt=2000&as_ylo=2000&as_vis=0

sunnycalifRN · May 3, 2010

this was discussed in the MICU forum also:

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