Using the prone position for ventilated patients with respiratory failure: a review

Abstract

Aims: This review explored the evidence relating to prone positioning in ventilated patients diagnosed with respiratory failure, including acute lung injury (ALI) or adult respiratory distress syndrome (ARDS). Background: Mortality rates for ventilated patients with ALI or ARDS are high, and there is a growing body of evidence suggesting that the position these patients are nursed in may influence clinical outcomes. However, there are no guidelines to inform nursing practice in positioning these patients. Method: Medline, Scopus, Cinahl and the Cochrane Library databases were searched for original research reports or systematic reviews of evidence between 2000 and 2009. Reference lists of retrieved papers were hand searched and included studies were analysed using the Critical Appraisal and Skills Programme framework. A narrative data synthesis considered the strengths and limitations of studies, and findings were collated and interpreted. Results: Application of the search strategy identified a systematic review, currently underway, which has not yet reported and 14 relevant studies eligible for inclusion in this review. Analysis showed considerable variation in study design, but suggests that PaO 2 /FiO 2 ratio, incidence of VAP and mortality may be positively affected by prone positioning. Conclusions: Evidence of the clinical benefits associated with prone positioning is inconclusive and provides little guidance for nursing practice. There is a need for further research into the clinical outcomes of prone positioning, and greater understanding of the practicalities of prone positioning critically ill patients is required. Relevance to clinical practice: Nurses have a central role to play in the continual assessment and management of this patient group, including the position they are nursed in, not only to ensure the best clinical outcomes but also to provide care and comfort to the patient and their family. It is therefore important that their nursing practice and interventions are informed by the best available evidence.

La terapia decúbito prono desde la perspectiva de la enfermera de UCI: una revisión integrativa

“…Fisiología del SDRA y beneficios del DP: cuando un paciente se sitúa en DP hay mayor movimiento de las densidades pulmonares desde las zonas dorsales a las ventrales mejorando la oxigenación por la movilización de secreciones; de esta forma la fisioterapia respiratoria se incrementa, mejora la ventilación de zonas previamente colapsadas (12,14,17,18,21,24,27) y hay un aumento de la relación ventilación y perfusión (7,15,17,27). Las enfermeras que entienden la base fisiológica y la evidencia de la terapia del DP aseguran que el equipo lleve a cabo el procedimiento adecuadamente y aumentan el uso de la terapia (15).…”

Prone Positioning of Patients With Acute Respiratory Distress Syndrome

“…25,27 Use of the reverse Trendelenburg position while the patient is prone may serve to decrease abdominal pressure and prevent displacement of stomach contents. 2 …”

“…2,17 Prone positioning benefi ts the patient by improving regional ventilation and perfusion, aiding in secretion and redistribution of extravascular lung water, and unweighting the soft tissues. 15,17 Additional physiological benefi ts of prone position include improved lung recruitment and oxygenation.…”

“…12 Use of specialized securement devices may decrease the risk of catheter or airway loss when used in conjunction with careful monitoring. 2 Additionally, having a respiratory therapist in the room for the procedure in the event of airway or ventilator complications may prove useful. Nursing or respiratory staff should securely tie and double tape the endotracheal or tracheostomy tube, as secretions may increase with the patient prone and may loosen adhesive, dislodging the tubes and causing airway compromise.…”

“…In addition, intra-abdominal pressure may be reduced when the patient is prone. 2,25 All measures reduce the compression of the lung and enforce reopening of collapsed alveoli. 25 Decreased ventilation of dependent areas with the patient supine is abolished when the patient is prone, allowing more homogeneous ventilation and perfusion, which reduces the shunt.…”