Teaming up for prone positioning
However, despite its known benefits, the use of prone positioning has often been limited by the physical challenges and risks associated with it. Risks such as inadvertent endotracheal extubation, airway obstruction, hemodynamic instability, transient oxygen desaturation, pressure injuries, enteral feeding intolerance, and arterial and central venous access catheter dislodgement (AACN, 2017a).
Patients with severe COVID-19 have been developing ARDS that differs somewhat from typical ARDS. They develop severe hypoxemia yet maintain lung compliance, which usually decreases in typical ARDS. Despite this differentiating factor, prone positioning has been effective for patients with COVID-19-associated ARDS. The American Thoracic Society-led International Task Force recently included a recommendation for prone positioning in their published guide, “COVID-19: Interim Guidance on Management Pending Empirical Evidence.” The task force recommends that patients with refractory hypoxemia caused by COVID-19 pneumonia (ARDS) receive prone ventilation for more than 12 hours per day (Wilson, 2020).
So, how do you provide prone positioning for at least 12 hours a day for these patients and overcome the associated risks? Some facilities have found success by using a dedicated interprofessional team for prone positioning. The team, which may consist of a respiratory therapist, anesthesia practitioner, physical therapist, and nurse, train together to develop a systematic approach to proning.
Using this approach, one designated team member secures the endotracheal tube and coordinates the procedure, while the others position themselves on either side of the bed to facilitate repositioning (NEJMvideo, 2013). Before proning the patient, staff gathers the necessary equipment and takes measures to protect the patient’s skin and eyes. They limit the number of cables to prevent catheter dislodgement, preoxygenate the patient, and suction the endotracheal tube and oral cavity, as needed. Next, they remove anterior chest wall electrocardiogram (ECG) monitoring leads, while ensuring the ability to monitor the cardiac rate and rhythm, and then reattach leads to the patient’s back. After the patient assumes the prone position, staff reattaches the cables and zero the hemodynamic transducers (AACN, 2017a).
Compensating for decompensation
It isn’t uncommon for patients to decompensate initially after transitioning into a prone position because the body’s oxygen demand increases during repositioning. If the patient desaturates in response, hyperoxygenation may be necessary until the patient’s body has time to adjust. If the patient develops cardiovascular instability, vasopressors may be titrated upward temporarily, and then titrated downward when appropriate. Staff monitors the patient for 10 to 15 minutes before they consider repositioning the patient back to a supine position. If a life-threatening arrhythmia occurs, staff immediately return the patient to a supine position (AACN, 2017b).
Overcoming the challenges
As you can see, prone positioning has its benefits in improving oxygenation in patients with severe COVID-19-associated ARDS, but it presents challenges. Challenges that can be overcome by using a specialized team approach.
Lippincott Solutions note: for the latest coverage on COVID-19 by the Lippincott Nursing team, please visit nursingcenter.com/coronavirus.
Kallet, R. H. (2015). A Comprehensive Review of Prone Position in ARDS, Respiratory Care, 60, 1660-1687.
Wilson, K.C., et al. (2020). COVID-19: Interim Guidance on Management Pending Empirical Evidence.
NEJMvideo. (2013). Prone Positioning in Severe Acute Respiratory Distress Syndrome.
American Association of Critical-Care Nurses. (2017). AACN Critical Care Webinar Series: Why Prone, Why Now? Improving Outcomes for ARDS Patients.
About the author
Collette Bishop Hendler, RN, MS, MA, CIC, Editor-in-Chief, Lippincott Solutions, Point-of-Care, is certified by the Certification Board of Infection Control and Epidemiology, Inc. as an Infection Preventionist. She has more than 15 years of experience in critical care nursing and maintains Alumnus Status as a Critical-Care Registered Nurse.