Clinical guidelines for the use of the prone position in acute respiratory distress syndrome

Establishing a course to train ICU nurses on prone position mechanical ventilation: A Delphi study

AIM

To develop a comprehensive training course for training ICU nurses in prone positioning.

DESIGN

A mixed study combining semi-structured interviews and two rounds of Delphi surveys.

METHODS

We constructed a questionnaire after collecting data through a literature review and semi-structured interviews. We used the Delphi expert correspondence method to conduct two rounds of research among 17 experts in the field of critical illness. Data collection took place between May and August 2022.

RESULTS

The effective questionnaire recovery rate was 88.2%. The expert authority coefficient was 0.876; the Kendall coordination coefficient was 0.402; the average importance score for each index ranged from 4.00 to 4.93; and the coefficient of variation for each index ranged from 0.05 to 0.19. We established 13 second-level indicators and 41 third-level indicators on prone position ventilation training according to three aspects: training contents, training methods and training assessment. The training system of prone mechanical ventilation for ICU nurses established in this study will provide an effective framework for training and evaluating the practical ability of prone mechanical ventilation for ICU nurses.

Cuidados de enfermagem e posição prona: revisão integrativa

Objetivo: explorar, na literatura científica, práticas atuais de cuidado de enfermagem ou intervenções para pacientes com síndrome respiratório agudo grave (SRAG) submetidos à posição prona.     Síntese do conteúdo: revisão integrativa, na qual foram realizadas buscas nas bases de dados PubMed, CINAHL, Scopus, Web of Science e LILACS em setembro de 2020 e janeiro de 2022, sem recorte temporal, por meio da questão deste estudo: “Quais são os cuidados de enfermagem para pacientes com SRAG submetidos à posição prona?”. Foram selecionados 15 artigos, a partir da busca nas bases de dados. Após a leitura, os cuidados encontrados foram categorizados em alinhamento do corpo para a prevenção de lesões neuromusculares, cuidados com equipamentos diversos, cuidados tegumentares e recomendações neurológicas. Conclusões: o enfermeiro deve ter conhecimento sobre as implicações e as complicações de se manter um paciente na posição prona. Tal conhecimento permitirá tomadas de decisões na construção ou no seguimento de protocolos institucionais que contribuam com a prevenção de riscos e resultem em melhores desfechos para o paciente.

Assessment of respiratory drive with esophageal diaphragmatic electromyography in patients with acute respiratory distress syndrome treated with prone position ventilation

BACKGROUND

Prone position ventilation (PPV) is an important strategy for patients with severe acute respiratory distress syndrome (ARDS). This prospective study investigated the use of electromyography of the diaphragm (EMGdi) for monitoring respiratory drive in patients with moderate to severe ARDS during long-term PPV.

METHODS

An integrated nostril-gastric feeding tube containing an esophageal electrode and balloon was placed in 14 patients with severe ARDS prior to PPV. EMGdi and trans-pulmonary pressure (∆P_L) data were collected before PPV (baseline), every 2 h during PPV, and 2 h after the restoration of supine position ventilation (post-2 h SPV).

RESULTS

In ARDS patients, the static compliance of the chest wall was significantly decreased after PPV. EMGdi levels were slightly lower in the early, middle, and late stages of PPV compared with baseline. Patients who received neuromuscular blocker experienced a greater drop in EMGdi from baseline than those who did not.

CONCLUSIONS

For ARDS patients, EMGdi was slightly decreased after prolonged PPV. This is contrary to the change in diaphragm electromyography during normal body position changes. Monitoring EMGdi regularly during PPV in ARDS patients is feasible and can be used as a reference for lung protective ventilation strategies.

Safe prone checklist: construction and implementation of a tool for performing the prone maneuver

OBJECTIVE

To construct and implement an instrument (checklist) to improve safety when performing the prone maneuver.

METHODS

This was an applied, qualitative and descriptive study. The instrument was developed based on a broad review of the literature pertaining to the construction of a care protocol using the main electronic databases (MEDLINE, LILACS and Cochrane).

RESULTS

We describe the construction of a patient safety tool with numerous modifications and adaptations based on the observations of the multidisciplinary team regarding its use in daily practice.

CONCLUSION

The use of the checklist when performing the prone maneuver increased the safety and reliability of the procedure. The team's understanding of the tool's importance to patient safety and training in its use are necessary for its success.

Good practices for prone positioning at the bedside: Construction of a care protocol

Last year, interest in prone positioning to treat acute respiratory distress syndrome (ARDS) resurfaced with the demonstration of a reduction in mortality by a large randomized clinical trial. Reports in the literature suggest that the incidence of adverse events is significantly reduced with a team trained and experienced in the process. The objective of this review is to revisit the current evidence in the literature, discuss and propose the construction of a protocol of care for these patients. A search was performed on the main electronic databases: Medline, Lilacs and Cochrane Library. Prone positioning is increasingly used in daily practice, with properly trained staff and a well established care protocol are essencial.

S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders : Revision 2015: S2e guideline of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioneda revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientificrelevance the guidelines were extended to include the issue of "early mobilization"and the following main topics are therefore included: use of positioning therapy and earlymobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

Physiological rationale and current evidence for therapeutic positioning of critically ill patients

Prolonged bed rest is common in critically ill patients, and therapeutic positioning is important to prevent further complications and to improve patient outcomes. Nurses use therapeutic positioning to prevent complications of immobility. This article reviews therapeutic positions including stationary positions (supine, semirecumbent with head of bed elevation, lateral, and prone) and active repositioning (manual, continuous lateral rotation, and kinetic therapy). The physiological rationale and current evidence for each position are described. Applicable evidence-based practice guidelines are summarized. Special considerations for therapeutic positioning of critically ill obese and elderly patients are also discussed.

Adult respiratory distress syndrome

ARDS or acute respiratory distress syndrome continues to be a considerable critical care challenge. Mortality has not decreased significantly over the last more than 30 years. This article presents an overview of origin, evaluation, and treatment of ARDS. Recent findings relative to onset and precipitators of ARDS have led to changes in evaluation and treatment plans. Clinical and radiologic descriptors in assessment of the patient with ARDS are discussed. Ventilatory modes and nursing interventions to optimize patient outcomes are identified. The challenges of outcomes issues presented offer opportunities for further study.

Reviewing evidence

This paper summarises how evidence based practice is defined, and what can be considered to constitute evidence. It describes the steps which should be undertaken in a systematic review of evidence and some of the issues involved in implementing the findings from such reviews in practice. This includes identifying the types of evidence which should inform decisions about practice and how these should be integrated with clinical expertise and client choice in order to achieve best practice.

Nursing the ARDS patient in the prone position: the experience of qualified ICU nurses

The revival of the use of the prone position as a treatment for acute respiratory distress syndrome (ARDS) has been well documented in the medical literature, but there is little information regarding the difficulties of nursing patients in this position. The purpose of this study was to increase the body of knowledge by exploring the experiences of nurses who had cared for a patient in the prone position. A questionnaire was sent to all registered nurses in four large intensive care units (ICUs) to determine the main areas of concern when nursing patients in the prone position. There was a 62% response rate. Following this, a sample of 12 nurses volunteered to participate in three focus group interviews to further explore the issues. The main difficulties experienced related to the manoeuvre, including the timing of the move, the number of personnel and the co-ordination required. Problems experienced in providing nursing care related to pressure areas, suctioning, accidental injuries and management of emergencies. Deficits in knowledge of ARDS and skills in handling communication with relatives were also identified. As a result of this exploration, guidelines have been developed, focusing mainly on the manoeuvre, organizational and nursing issues, to provide guidance in caring for a patient when being nursed in the prone position.