Prone positioning efficacy

Prone positioning efficacy

Introduction

Prone positioning (PP) is a purposeful placing of patient in a face-down position to improve patient ventilation. This technique has gathered momentous attention as a potential strategy for managing patients with acute respiratory distress/diffuse syndrome (ARDS) and other respiratory issues in intensive care units (ICUs) (Gattinoni et al., 2020). The obvious intended benefit of PP in ARDS is to improve oxygenation (Bamford et al., 2020). The central focus of this paper is to address the following questions: Does prone positioning improve patient outcomes? What factors influence its effectiveness? What are the potential drawbacks and benefits? Are the benefits of PP more significant than the possible risks involved?

Overall, this paper seeks to contribute to the ongoing discourse surrounding prone positioning as an evidence-based intervention for patients with ARDS in the ICU. It also aims to give comprehensive overview of the background of prone positioning, an examination of key factors that influences its effectiveness, possible approaches for effective implementation, recommendations of current evidence based practice (EBP), and a conclusion summarising the key findings and implications for clinical practice.

Background

Prone positioning was first proposed in 1970s and used since (Scholten et al., 2017). However it has become more widely recognized as a therapeutic intervention for patients with ARDS and other respiratory complications in health care setting after PROSEVA' trial. This study was published in 2013. It revealed that prone positioning and higher positive end expiratory pressure (PEEP) significantly reduced mortality rates by 16% at 28 days and 14% at 90 days compared to standard care (Gurin et al., 2013). Since then, it has been extensively investigated and utilised globally, especially during the COVID epidemic. (Gattinoni et al., 2020).The SARS-CoV-2 virus, also known as COVID-19, can cause pneumonia, which can progress to ARDS.

Acute Respiratory Distress Syndrome also knows as Acute Respiratory Diffuse Syndrome (ARDS), is a critical insult to epithelial and endothelial cells of the lung. Which is characterised by extensive diffuse inflammation, worsen by vascular leakiness, leading to apoptosis, necrosis, and an elevated lung weight, ultimately causing the development of alveolar oedema. The loss of aerated lung tissue and alveolar oedema reduces gas exchange, resulting in hypoxemia, diminished ventilation-perfusion (V/Q) matching leading to an increase in physiological dead space, and decrease in lung compliance (Daun et al., 2017).

In the typical supine physiology, the majority of lung tissue, which contains more alveoli than the ventral region, is situated toward the back of the thoracic cavity. This area is generally well perfused but less ventilated. In ARDS, fluid build-up pulls toward the dorsal side of the lung due to gravity further compressing the alveoli affecting gas exchange (Gossman et al., 2019). The prone position serves as a solution by relieving this pressure when unventilated dorsal lung comes on top, and facilitating a more even alveolar ventilation distribution. This ultimately leads to improved V/Q matching, which in turn enhances oxygenation and offers various physiological advantages, such as increased cardiac output. Nonetheless, the use of prone positioning is also associated with elevated risks of pressure sores, blockage of endotracheal tube, and dislocation of chest tube (Bamford et al., 2020).

The prevalence of ARDS in ICUs remains significant, affecting approximately 10% of all ICU admissions and posing a major challenge to patient outcomes, as it is associated with high morbidity and mortality rates (Bellani et al., 2016). During the COVID crisis, there was a 17% surge in the incidence of ARDS (Gattinoni et al., 2020). Consequently, the exploration of effective treatments, such as prone positioning, is crucial to improving patient outcomes and alleviating the burden on healthcare systems.

Key stakeholders in the implementation and evaluation of prone positioning in intensive care includes allied health team, patients, families, nurses, hospitals, and communities. Patients and their families may experience varying degrees of emotional distress due to the critical nature of the illness and the unfamiliarity of the prone positioning intervention. Nurses play a vital role in the recognition and initiation of the PP treatment, as well as safe and effective implementation by monitoring patient (Bamford et al., 2020). The consequences of ARDS extend beyond individual patients, as the condition places considerable strain on healthcare systems and communities. The financial burden is significant, with each ARDS patient admission costing up to $94,000, compared to a general admission cost of around $16000 (Prescott et al., 2015).

Given the significant impact ARDS has on all stakeholders, understanding the potential benefits and risk of prone positioning in intensive care nursing is of paramount importance.

This will help to determine if implementation is beneficial compare to its expenses.

Key Factors

The efficacy of prone positioning in intensive care nursing is influenced by a variety of factors, including patient characteristics, degree of hypoxemia, duration of positioning, and staff expertise. This section will delve into these factors to provide a comprehensive understanding of the key variables that impact the effectiveness of prone positioning in the management of patients with ARDS and other respiratory complications.

Patient characteristics: The demographics and clinical characteristics of patients can significantly influence the efficacy of prone positioning. Factors such as age, body mass index (BMI), severity of lung injury, and presence of comorbidities can all impact the response to prone positioning (Gattinoni et al., 2020). For example, patients with higher BMIs may require special bed and additional support to maintain proper positioning and minimize the risk of pressure injuries.

A descriptive ambispective study conducted across multiple ICUs in Spain involving 44 patients, it showed that the most common adverse events (AEs) were facial oedema (80.3%) and facial pressure ulcers (60.6%). A significant correlation was found between time spent in PP and facial pressure ulcer development (RodrguezHuerta et al., 2021). Extended prone positioning can be beneficial for improved alveolar ventilation. However for obese patients, it comes with the possibility of various issues, including pressure ulcers, pain, nerve damage, infections, as well as an increased risk of endotracheal tube and chest displacement (De Jong et al., 2013).

Implementation and duration of positioning: Initiating prone-positioning treatment early within 12 to 24 hours intubation and, prolonging the PP duration can substantially improve patient outcomes (Gurin et al., 2013). A RCT study showed, early and prolonged prone positioning significantly reduced mortality in severe ARDS (Gurin et al., 2013). Nonetheless, if prone positioning is introduced too late during the ARDS trajectory, it may not effectively improve respiratory condition (Bloomfield et al., 2015).

The duration of prone positioning plays a crucial role in its effectiveness. Analysis of eight randomised control trial showed that prone positioning for 12+ hours reduce mortality in severe ARDS patients and improved PaO2/FiO2 ratios, while shorter durations of prone positioning did not provide the same benefits (Munshi et al., 2017). This underscores the importance of maintaining prone positioning for an extended period of time and initiating the treatment early will help to achieve desirable V/Q matching and alveolar ventilation.

Degree of hypoxemia: The degree of hypoxemia, or low blood oxygen levels in sever ARDS is a critical factor in determining the potential benefits of prone positioning. This is usually determined by the percentage of oxygen inspired compare to the amount of oxygen dissolved in the arterial blood (PaO2/FiO2 ratio). According to (Gurin et al., 2020) the main indication to commence PP in sever ARDS is refractory hypoxemia with PaO2:FiO2 ratio below 150 mm Hg, FiO2 at or above 0.6, PEEP at or above 10 cm of water. Proning is more beneficial for patients with severe hypoxemia, where the potential benefits of the intervention outweigh the risks and discomfort associated with the procedure. If a patient's P/F ratio is higher and their hypoxemia is less severe, the risks and discomfort associated with proning may not be justified.

Prone positioning has been extensively researched and found to be particularly effective in cases of severe ARDS, as opposed to mild or moderate cases. A prevalence study of 735 patients with ARDS in 141 ICUs from 20 countries, where PP was used in 101 cases, highlighted that PP was more commonly used in severe ARDS (80.2%) than mild ARDS (32.9%). The study showed, the benefits of PP outweighs the risk in sever ARDS with significant improved patient outcome, these including low complications, better oxygenation, and reduced driving pressure (Gurin et al., 2017).

The primary focus in managing patient with ARDS is to maximize tissue oxygenation while ensuring lung-protective ventilation to minimize adverse effects of mechanical ventilation such as barotrauma and volume trauma (Duan et al., 2017). Protective lung ventilation are the standard care as the lung becomes fibrotic, the compliance reduces. Employing low tidal volume ventilation (4-8 mL/kg) and allowing higher than normal level of carbon dioxide also known as permissive hypercapnia minimizes the risk for ventilator-associated lung injury (VALI). Additionally, applying high PEEP prevents alveolar collapse and enhances arterial oxygenation (Chikhani et al., 2016).

Staff expertise: The expertise of the ICU team, particularly nurses, is a critical factor in the successful implementation of prone positioning. Experienced and well-trained staff are better equipped to assess patient suitability for prone positioning, manage potential complications, and ensure patient safety (Bamford et al., 2020). Adequate training and ongoing education for nursing staff are essential for optimizing the benefits of prone positioning in intensive care settings.

The insufficient expertise and understanding of the prone positioning procedure can lead to delays in treatment. A study conducted 2020 in 30 ICUs in the United States. It showed that PP initiation ICU was delayed by more than 48 hours due limited staff expertise,and limited resources (Klaiman et al., 2020). For instance, repositioning procedure can be daunting it requires a minimum of five trained people as well as comprehensive checklist to follow (Kallet, 2015). PP also need to be completed during working hours as the other multidiscipline team will not be available otherwise. Ultimately, all these factors contribute to less adherence and intervention delays resulting in with poor patient outcome (Koulouras et al., 2016).

Strategies and Limitations

Several approaches and strategies can be adopted to optimise the efficacy of PP and improve patient outcome. This section will evaluate three possible approaches, outlining their strength and weakness.

Approach 1: Standardized protocols for prone positioning

A recenceny EBP sudied by Elpern et al. (2021) proved that a dedicated multidisciplinary team including; physiotherapist, occupational therapist, nurses, doctors, family and ward support used multiple approaches including standardizing PP protocol and achieved remarkable effect. The research highlighted the importance of considering the suggestions and apprehensions of the multidisciplinary team engaged in PP for establishing a functional protocol and a collaborative team environment.This input contributed to the development of a protocol that fostered a team-oriented atmosphere and feelings of appreciation within the group. Engaging this team in the formulation of a standardized protocol will facilitate the customization of crucial aspects and practical measures for a particular clinical environment.

Implementing standardized protocols for prone positioning in intensive care settings can help ensure consistency in patient care, give confidence to staff and improve patient outcomes (Bamford et al., 2020). These protocols can provide clear guidelines on patient selection, timing, duration, and monitoring of prone positioning, as well as recommendations for managing potential complications (Elpern et al., 2021). Additionally, having a step by step instruction, details of equipment required, staffing roles, indications for adjunct therapy (such as sedations and neuromuscular blocking agent), contraindications, safety checklist will give a clear guidance to the staff. This will potentially avoid intimidation by the prospect of PP and lack of knowledge in the area (Klaiman et al., 2020).

Strengths: Standardized protocols will help to improve patient care by setting clear instructions based on evidence-based practice (EBP) and reducing variations in care (Bamford et al., 2020). It also plays a crucial role in providing efficient, secure, and cost-effective therapy by implementing uniform care protocols. Uniform care helps to monitor outcomes, reduces unexpected events, increases patient safety, minimizes wastage, thorough documentation and improves care quality (Menk et al., 2020).

They can be easily accessible to all staff when published. They can also expedite and streamline the prone positioning process as early recognition and initiation is essential for improving oxygenation. These protocols also make it easier for staff to implement the intervention and monitor patient progress.

Weaknesses: The limitation for Standardized protocols is generalisation as it might not work for individualised circumstances and clinical characteristics. Additionally, implementing standardized protocols requires regular evaluation for effectiveness, requires further research to find current EBP, staff training and ongoing education to ensure adherence and understanding of the guidelines, which can be time-consuming and resource-intensive.

Approach 2: Individualized prone positioning based on patient needs

An alternative approach to standardized protocols is individualized prone positioning, which involves tailoring the intervention to each patient's specific needs and clinical characteristics (Gattinoni et al., 2020). This approach may include customizing the duration of prone positioning, adjusting patient positioning to address unique anatomical factors or comorbidities, and using specialized equipment such as RotoProne to support individual needs. Obesity is a specific population that has been extensively studied to understand its correlation with the effects of prone positioning. A study find out patients with a higher body mass index had lower optimal PEEP in the prone position, improved oxygenation, and more uniform ventilation.

Strengths: Individualized prone positioning has the potential to lead to better patient outcomes, as it takes into account each patient's unique circumstances and needs such as body type, underlying medical conditions, and severity of respiratory distress (Gattinoni et al., 2020). By tailoring the intervention to each patient needs, the ICU can optimize the oxygenation and respiratory function of prone positioning and minimize the risk of complications.

Weaknesses: Individualized prone positioning places greater demands on staff, as it requires a more in-depth assessment of each patient's needs and close monitoring of their progress. It may also necessitate the use of specialized equipment, which can be expensive and difficult to procure. Furthermore, individualized prone positioning may be more challenging to implement in high-volume settings, where standardized protocols may be more feasible.

Approach 3: Enhanced education and team-work

Investing in staff education and running simulation with the multidisciplinary team is essential to ensure collaborative, safe and effective implementation of prone positioning in intensive care nursing (Bamford et al., 2020). Enhanced education and training can include ongoing professional development opportunities, workshops, and simulation exercises to build staff confidence and competence in prone positioning techniques.

A study conducted by Klaiman et al., (2020) looked at team work in PP in 14 ICUs over seven-week period, it found that interdisciplinary team safely performed prone positioning for 100+ patients.The study showed having a standerdized protocol and implementation of multidisciplinary team can reduce reluctance, helps with nursing staff workload (Klaiman et al., 2020). This demonstrates that a highly cooperative team in PP plays a crucial role in initiating therapy promptly. Additionally, establishing a communication platform (like 'Microsoft Teams') enables seamless interaction among team members, ensuring they stay informed and up-to-date.

Strengths: Improved staff education and group simulations can aid with familiarizing with the procedures ultimately can lead to patient care. The team will be more knowledgeable about the nuances of prone positioning and better equipped to manage potential complications (Bamford et al., 2020). Enhanced education and training can also increase staff confidence in implementing prone positioning, fostering a culture of evidence-based practice and continuous improvement.

Weaknesses: Enhancing staff education and training can be time-consuming and resource-intensive, as it requires the allocation of resources for professional development and the organization of training sessions. Additionally, staff may face challenges in maintaining their skill level if they do not have regular opportunities to practice prone positioning techniques.

In conclusion, each of the three approaches discussed has its strengths and weaknesses in optimizing the efficacy of prone positioning in intensive care nursing. A combination of standardized protocols, individualized prone positioning, and enhanced staff education and training may offer the most comprehensive and effective solution to improve patient outcomes and promote evidence-based practice in this critical area of patient care.

Ultimately, the selection and implementation of these approaches will depend on the specific context, resources, and patient population of each intensive care unit. Healthcare providers should continuously evaluate and adapt their prone positioning practices to ensure that they are meeting the unique needs of their patients and providing the highest quality care possible. By combining the strengths of standardized protocols, individualized prone positioning, and enhanced staff education and training, intensive care nursing teams can optimize the efficacy of prone positioning and contribute to improved patient outcomes in the management of acute respiratory distress syndrome (ARDS) and other respiratory complications.

Recommendation

To optimize the efficacy of prone positioning in intensive care nursing, it is essential to prioritize approaches based on the clinical setting, available resources, and staff expertise. This section provides recommendations for implementing prone positioning practices that promote improved patient outcomes and enhance the quality of care in intensive care unit.

Adapt and adopt evidence-based protocols: Healthcare providers should consider adopting standardized protocols for prone positioning, such as those provided by the Intensive Care Society (Bamford et al., 2020), while adapting them to the specific context and needs of their ICU. This approach ensures consistency in patient care while allowing for necessary flexibility in implementation.

Collaborate with interdisciplinary teams and dedicate team: Involving interdisciplinary teams, including physicians, respiratory therapists, physiotherapists, and nursing staff, in the planning and implementation of prone positioning can promote a comprehensive approach to patient care and enhance clinical decision-making (Bamford et al., 2020).

Individualize care: When possible, healthcare providers should prioritize individualized prone positioning based on patient needs and clinical characteristics (Gattinoni et al., 2020). This approach may require additional resources and staff expertise, but it can lead to better patient outcomes by addressing each patient's unique needs.

Invest in staff education and training: Enhanced staff education and training are essential for the safe and effective implementation of prone positioning in intensive care nursing (Bamford et al., 2020). Healthcare organizations should allocate resources for ongoing professional development opportunities and hands-on training in prone positioning techniques. Arming staff with current evidence-based trainings and running simulation a periodic manner help to best prepare implement PP therapy. Additionally, developing a checklist and notification system integrated with Cerner which triggers when a patient is potentially eligible for the PP, help to initiate the process.

Continuously evaluate and improve practices: Healthcare providers should consistently evaluate the efficacy of prone positioning practices in their ICUs, using patient outcomes and feedback from key stakeholders to inform improvements in care.

By prioritizing the above recommendations, clinicians can optimize the benefits of prone positioning for patients with ARDS and other respiratory complications, while addressing the limitations and challenges associated with each approach. Further studies and long-term data are needed to better understand PP's effects in managing hypoxemic respiratory failure. According to Gurin et al. (2017) prone positioning is often implemented as a last resort in most clinical settings, these is due to limited clinicians' experience and limited knowledge in the area which led to reluctance in initiation. However, adopting these recommendations can result in better patient outcomes and elevate the quality of care for crucial stakeholders, such as patients, families, and healthcare professionals, based on the best available study at present.

Conclusion

This paper has explored the efficacy of prone positioning in intensive care nursing, focusing on the question of whether prone positioning improves patient outcomes and the factors that influence its effectiveness. Through a review of the literature and examination of various approaches, it is evident that prone positioning can indeed help with ARDS treatment by improving V/Q matching and alveolar ventilation when implemented appropriately (Gattinoni et al., 2020; Guerin et al., 2013).

Prone positioning has been shown to most effective when tailored to individual patient needs and supported by standardized protocols, staff education, and training (Bamford et al., 2020; Gattinoni et al., 2020). By employing this comprehensive and evidence-based approach to prone positioning, the intensive care unit can optimize the benefits of this intervention and contribute to reduction of mortality rate caused by ARDS.

Reference List

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References

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Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK436002/Gurin, C., Albert, R. K., Beitler, J., Gattinoni, L., Jaber, S., Marini, J. J., Munshi, L., Papazian, L., Pesenti, A., Vieillard-Baron, A., & Mancebo, J. (2020). Prone position in ARDS patients: why, when, how and for whom. Intensive Care Medicine, 46(12). https://doi.org/10.1007/s00134-020-06306-wGurin, C., Beuret, P., Constantin, J. M., Bellani, G., Garcia-Olivares, P., Roca, O., Meertens, J. H., Maia, P. A., Becher, T., Peterson, J., Larsson, A., Gurjar, M., Hajjej, Z., Kovari, F., Assiri, A. H., Mainas, E., Hasan, M. S., Morocho-Tutillo, D. R., Baboi, L., & Chrtien, J. M. (2017). A prospective international observational prevalence study on prone positioning of ARDS patients: the APRONET (ARDS Prone Position Network) study. 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