is Prone Positioning?
Prone positioning, or
“proning” is a new form of treatment sometimes used to support
mechanically ventilated patients with ARDS who require high
concentrations of inspired oxygen. To initiate prone positioning
medical staff turn an ARDS patient face down from his or her
back (supine position). Thereafter, the patient may be turned from one
position to the other as often as three times a day until the
requirement for a high concentration of inspired oxygen resolves.
Does Prone Positioning Help?
One important goal
for the supportive treatment of patients with ARDS is to maintain
adequate oxygenation of the blood by the injured lungs PO2 greater
than 60 while avoiding a potentially toxic concentration of inspired
oxygen (greater than 60-70% oxygen). Prone positioning often improves
oxygenation in patients who have ARDS by shifting blood flow to
regions of the lung that are less severely injured and thus better
aerated. With the proper
equipment, proning may also allow the abdomen to expand more and
facilitates better movement of the diaphragm.
Proning an Effective Technique?
Researchers have not
reached a consensus as to whether prone positioning improves the
survival rate among ARDS patients.
However, most research has shown that proning does improve
oxygenation, significantly in some cases.
Unfortunately, not all ARDS patients respond favorably to prone
positioning, and the benefit sometimes wanes over time.
Every ARDS Patient Be Proned?
Not all patients are
in a physical condition that permits such movement of the body.
Patients whose heads cannot be supported in a face-down
position, those who have circulation problems, or very large patients
are not recommended for the proning technique.
Some injuries, such as a broken pelvis for example, and other
conditions as determined by the attending physician may also
disqualify a patient from being proned.
Even advocates of the
technique do not typically recommend proning as a “routine”
intervention for ARDS patients. Because there is a small risk of
complications associated with turning critically ill patients, most
researchers and advocates recommend the technique be reserved for
those patients with severe hypoxemia, or low blood oxygen levels.
is Proning Performed?
Proning is performed
by a specific procedure that generally involves several critical care
staff and is usually overseen by the attending physician.
Specific training for critical care staff is available.
Long Should a Patient Be Proned?
research makes no specific recommendations, 6 or more hours a day, for
as long as 10 days, appears typical in clinical studies and reported
are the Risks of Proning?
Even with proper
equipment, physically flipping over a critically ill patient has
risks, particularly since the patient will be hooked up to many wires
and tubes. Possible
problems include unintended extubation (tubes coming out), airway
obstruction, and difficulties coordinating the ventilator. Some
patients may require increased sedation and muscle relaxants, may
experience facial swelling, and may develop “pressure sores” on
the weight-bearing parts of the body, such as the knees and chest.
Though there are
risks, critical care staffs that attempt to prone an ARDS patient are
trained to follow established procedures to ensure safety.
The physical difficulties of proning have been the traditional
barrier to its use. Progress through equipment innovations such as the Vollman
Prone Positioner (www.vollman.com),
a lightweight, cushioned frame that straps to the front of the patient
before turning, has helped to minimize the risks associated with
moving patients and maintaining them in the prone position for several
hours at a time.
Prone Positioning of
Patients With Acute Respiratory Distress Syndrome: A Systematic
Journal of Critical Care, November 1999, Vol 8, No. 6
Effect of Prone
Positioning on the Survival of Patients with Acute Respiratory
Failure, New England Journal of
August 23, 2001, Vol 345:568-573
The Acute Respiratory Distress Syndrome, Mechanical Ventilation, and
the Prone Position, New England Journal of Medicine,
August 23, 2001, Vol 345:568-573
Positioner, Policy and Procedure, http://www.vollman.com
Continuous Axial Rotation Therapy In Prone Position For Complex
Polytrauma Patients With ARDS, Klinikum der Philipps-Universität
Save Life of Expectant Father, Community
Spirit, Community Hospitals Foundation of Indiana.