Acute Respiratory Distress Syndrome and Prone Positioning

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.

Is prone positioning a valid intervention for ARDS in the deployed intensive care unit?

Prone positioning is an intervention used for patients with acute respiratory distress syndrome (ARDS) whose hypoxia is worsening despite conventional treatment. Previously used infrequently, it became an important treatment escalation strategy for hypoxia during the COVID-19 pandemic. Current evidence for prone positioning suggests increased survivability in intubated patients with moderate to severe ARDS who are prone for >12 hours a day. As a relatively low-cost, low-tech intervention with a growing evidence base, the viability of prone positioning in the deployed land environment is considered in this article. The practical technique of prone positioning is easy to teach to healthcare staff experienced in manual handling. However, it requires significant resources, in particular staff numbers, and time to execute and maintain, and necessitates a pressure-minimising mattress. Additionally, staff are placed at increased risk of musculoskeletal injuries and potential exposure to aerosolised microbes if there is a disconnection of the breathing system. We conclude that in the deployed 2/1/2/12 facility (or larger), with access to higher staff numbers and high-specification mattresses, prone positioning is a valid escalation technique for intubated hypoxic patients with ARDS. However, in smaller facilities where resources are constrained, its implementation is unlikely to be achievable.

Perceptions and Perceived Barriers regarding Proning among Nurses of a Tertiary Care Center in India

Current study was conducted to assess the perception and barriers regarding proning among nurses. 385 nurses were conveniently surveyed using pre-tested tools. 3.9% of nurses "felt like running away" while providing care to the patients in prone position. 93.5% believed that prone position for COVID-19 patients is beneficial in reducing morbidity and that teamwork is required to be effective (96.6%). 93% nurses believed that inadequate staff-patient ratio is a significant barrier for prone positioning. Other barriers were fear of dislodgement of tubings (91.5%), difficulty in providing routine care (87.3%) and inadequate institutional protocol (83.9%). 12.5% were trained regarding proning.

Hospital-Acquired Pressure Injuries in Adults With Prone Positioning Using Manual Method Versus Specialty Bed: A Retrospective Comparison Cohort Study

PURPOSE

The purpose of this study was to compare the incidence of hospital-acquired pressure injuries (HAPIs) in patients with acute respiratory distress syndrome (ARDS) and placed in a prone position manually or using a specialty bed designed to facilitate prone positioning. A secondary aim was to compare mortality rates between these groups.

DESIGN

Retrospective review of electronic medical records.

SUBJECTS AND SETTING

The sample comprised 160 patients with ARDS managed by prone positioning. Their mean age was 61.08 years (SD = 12.73); 58% (n = 96) were male. The study setting was a 355-bed community hospital in the Western United States (Stockton, California). Data were collected from July 2019 to January 2021.

METHODS

Data from electronic medical records were retrospectively searched for the development of pressure injuries, mortality, hospital length of stay, oxygenation status when placed in a prone position, and the presence of a COVID-19 infection.

RESULTS

A majority of patients with ARDS were manually placed in a prone position (n = 106; 64.2%), and 54 of these patients (50.1%) were placed using a specialty care bed. Slightly more than half (n = 81; 50.1%) developed HAPIs. Chi-square analyses showed no association with the incidence of HAPIs using manual prone positioning versus the specialty bed (P = .9567). Analysis found no difference in HAPI occurrences between those with COVID-19 and patients without a coronavirus infection (P = .8462). Deep-tissue pressure injuries were the most common type of pressure injury. More patients (n = 85; 80.19%) who were manually placed in a prone position died compared to 58.18% of patients (n = 32) positioned using the specialty bed (P = .003).

CONCLUSIONS

No differences in HAPI rates were found when placing patients manually in a prone position versus positioning using a specialty bed designed for this purpose.

Effect of COVID-19 on the incidence of postintubation laryngeal lesions

Background

Critically ill patients intubated in the intensive care unit experience prolonged intubation leading to increased frequency of laryngeal injuries. This study aimed to demonstrate a suspected increase in vocal fold injury in patients who were intubated with COVID-19 as compared with patients intubated for other reasons.

Methods

A retrospective review of medical records was performed to identify patients examined using flexible endoscopic evaluation of swallowing exams. The study included 25 patients with COVID-19 and 27 without COVID-19 at Baylor Scott & White Medical Center in Temple, Texas. Various injuries were evaluated, ranging from granulation tissue to vocal cord paralysis. Severe lesions were those causing clinically significant airway obstruction or requiring operative intervention. The incidence of laryngeal injury in patients intubated for COVID-19 was then compared with that of patients intubated for other reasons.

Results

The increased presence of severe injury in COVID-positive patients appeared clinically significant but was not statistically significant (P = 0.06). Interestingly, patients who received pronation therapy had 4.6 times the odds of more severe injury compared with patients who did not (P = 0.009).

Conclusion

Lower thresholds for performing flexible laryngoscopy on postintubated patients who are proned may allow for earlier intervention and reduce morbidity in an already at-risk population.

Vloga izvajalcev zdravstvene nege pri pronaciji in supinaciji intubiranega pacienta s hudim akutnim respiratornim sindromom koronavirus-2

Uvod: Hud akutni respiratorni sindrom koronavirus-2 je s svojo intenzivnostjo močno vplival na razmere in delo v enotah intenzivne terapije. Pri vse več intubiranih pacientih z akutnim respiratornim distresnim sindromom se je pokazala potreba po pronaciji (obrat na trebuh). Namen raziskave je bil preučiti vlogo izvajalcev zdravstvene nege pri pronaciji in supinaciji (obrat na hrbet) pacienta ter ugotoviti najpogostejše zaplete, ki se ob tem lahko pojavijo.Metode: Uporabljen je bil pregled znanstvene in strokovne literature. Iskanje literature je potekalo v podatkovnih bazah PubMed, Sage in ScienceDirect ter Google Scholar. Vključene so bile raziskave od januarja 2020 do decembra 2021. Izvedena je bila vsebinska analiza raziskav.Rezultati: Skupno je bilo identificiranih 993 člankov. Dodanih je bilo še deset člankov, najdenih s prostoročnim iskanjem v Google Scholar. Izmed 1.003 identificiranih zadetkov je bilo v končno analizo vključenih osem člankov. Izpostavljena so bila tri glavna vsebinska področja: (1) vloga izvajalcev zdravstvene nege pred pronacijo intubiranega pacienta; (2) vloga izvajalcev zdravstvene nege med pronacijo intubiranega pacienta in (3) vloga izvajalcev zdravstvene nege pri supinaciji intubiranega pacienta.Diskusija in zaključek: Pronacija in supinacija intubiranega pacienta predstavljata velik izziv za celoten zdravstveni tim, ki je v času epidemije okrnjen tako številčno kot tudi glede na stopnjo usposobljenosti. Izvajalec zdravstvene nege mora ob teh intervencijah zagotoviti hemodinamsko stabilnost, pravilno pozicioniranje pacienta, preprečiti ekstubacijo in izpade različnih katetrov, zaščititi kožo in vseskozi izvajati potrebne aktivnosti zdravstvene nege.

Short-term prone positioning for severe acute respiratory distress syndrome after cardiopulmonary bypass: A case report and literature review

BACKGROUND

Aortic dissection is a complex and dangerous cardiovascular disease, with many complications in the perioperative period, including severe acute respiratory distress syndrome (ARDS), which affects prognosis and increases mortality. Despite the effect of prone positioning (PP) in improving oxygenation in patients with severe ARDS, reports about PP early after cardiac surgery are few and such an option may be an issue in cardiac surgery patients because of the recent sternotomy.

CASE SUMMARY

A 40-year-old male patient diagnosed with acute type A aortic dissection on October 22, 2021 underwent ascending artery replacement plus total aortic arch replacement plus stent elephant trunk implantation under cardiopulmonary bypass. Unfortunately, he developed ARDS on postoperative day 1. Despite comprehensive treatment with aggressive pulmonary protective ventilation, fluid management with continuous renal replacement therapy, the condition continued to deteriorate and rapidly progressed to severe ARDS with a minimum oxygenation index of 51. We are ready to implement salvage therapy, including PP and extracorporeal membrane oxygenation (ECMO). Due to the large amount of pericardial mediastinal and thoracic drainage after thoracotomy, ECMO may result in massive postoperative bleeding. Prolonged prone ventilation is often inappropriate after thoracotomy. Therefore, we chose short-term PP for < 6 h. Finally, the oxygenation index greatly improved and the diffuse exudation in both lungs of the patient was significantly reduced with short-term prone positioning.

CONCLUSION

Intermittent short-term PP can improve early postoperative severe ARDS after acute aortic dissection.

Nursing Implications of the Updated 2021 Surviving Sepsis Campaign Guidelines

Sepsis is a life-threatening illness that affects millions of people worldwide. Early recognition and timely treatment are essential for decreasing mortality from sepsis. The Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021, the fifth iteration of the guidelines, was released in October 2021 and includes 93 recommendations for the management of sepsis. The evidence-based guidelines include recommendations and rationales for screening and early treatment, initial resuscitation, mean arterial pressure targets, admission to intensive care, management of infection, hemodynamic monitoring, ventilation, and additional therapies. A new section addresses long-term outcomes and goals of care. This article presents several recommendations, changes, and updates in the 2021 guidelines and highlights the important contributions nurses have in delivering timely and evidence-based care to patients with sepsis. Recommendations may be for or against an intervention, according to the evidence. Although many recommendations are unchanged, several new recommendations directly affect nursing care and may require specialized training (eg, venovenous extracorporeal membrane oxygenation). The newest section, long-term outcomes and goals of care, is aimed at using available resources to provide care that is aligned with the patient and the patient's family through goals-of-care discussions and shared decision-making. Interventions aimed at improving recovery across the continuum of care should include attention to long-term outcomes. Nurses are essential in identifying patients with sepsis, administering and assessing response to treatment, supporting the patient and family, and limiting sequelae from sepsis. This article highlights the 2021 recommendations that influence nursing care for patients with sepsis.

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.

Muscle strength and functional outcome after prone positioning in COVID-19 ICU survivors

Objective

To evaluate the muscle strength and functional level of patients discharged from intensive care unit (ICU) in relation to the swimmer position as a nurse intervention during pronation.

Methods

Prospective study conducted in the hub COVID-19 center in Milan (Italy), between March and June 2020. All patients with COVID-19 discharged alive from ICU who received invasive mechanical ventilation were included. Forward continuation ratio model was fitted to explore the statistical association between muscle strength grades and body positioning during ICU stay.

Results

Over the 128 patients admitted to ICU, 87 patients were discharged alive from ICU, with available follow-up measures at hospital discharge. Thirty-four patients (39.1%) were treated with prone positioning as rescue therapy, for a total of 106 pronation cycles with a median duration of 72 (IQR 60–83) hours. Prone positioning did not influence the odds of showing particular level of muscle strength, in any of the evaluated districts, namely shoulder (OR 1.34, 95%CI:0.61–2.97), elbow (OR 1.10, 95%CI:0.45–2.68) and wrist (OR 0.97, 95%CI:0.58–1.63). Only in the shoulder district, age showed evidence of association with strength (OR 1.06, 95%CI:1.02–1.10), affecting people as they get older. No significant sequalae related to swimmer position were reported by physiotherapists or nurses.

Conclusion

Swimmer position adopted during prone ventilation is not associated with worse upper limb strength or poor mobility level in COVID-19 survivors after hospital discharge.

The efficacy and tolerance of prone positioning in non-intubation patients with acute hypoxemic respiratory failure and ARDS: a meta-analysis

Background and aims:

The application of prone positioning with acute hypoxemic respiratory failure (AHRF) or acute respiratory distress syndrome (ARDS) in non-intubation patients is increasing gradually, applying prone positioning for more high-flow nasal oxygen therapy (HFNC) and non-invasive ventilation (NIV) patients. This meta-analysis evaluates the efficacy and tolerance of prone positioning combined with non-invasive respiratory support in patients with AHRF or ARDS.

Methods:

We searched randomized controlled trials (RCTs) (prospective or retrospective cohort studies, RCTs and case series) published in PubMed, EMBASE and the Cochrane Central Register of Controlled Trials from 1 January 2000 to 1 July 2020. We included studies that compared prone and supine positioning with non-invasive respiratory support in awake patients with AHRF or ARDS. The meta-analyses used random effects models. The methodological quality of the RCTs was evaluated using the Newcastle–Ottawa quality assessment scale.

Results:

A total of 16 studies fulfilled selection criteria and included 243 patients. The aggregated intubation rate and mortality rate were 33% [95% confidence interval (CI): 0.26–0.42, I² = 25%], 4% (95% CI: 0.01–0.07, I² = 0%), respectively, and the intolerance rate was 7% (95% CI: 0.01–0.12, I² = 5%). Prone positioning increased PaO₂/FiO₂ [mean difference (MD) = 47.89, 95% CI: 28.12–67.66; p < 0.00001, I² = 67%] and SpO₂ (MD = 4.58, 95% CI: 1.35–7.80, p = 0.005, I² = 97%), whereas it reduced respiratory rate (MD = −5.01, 95% CI: −8.49 to −1.52, p = 0.005, I² = 85%). Subgroup analyses demonstrated that the intubation rate of shorter duration prone (⩽5 h/day) and longer duration prone (>5 h/day) were 34% and 21%, respectively; and the mortality rate of shorter duration prone (⩽5 h/day) and longer duration prone (>5 h/day) were 6% and 0%, respectively. PaO₂/FiO₂ and SpO₂ were significantly improved in COVID-19 patients and non-COVID-19 patients.

Conclusion:

Prone positioning could improve the oxygenation and reduce respiratory rate in both COVID-19 patients and non-COVID-19 patients with non-intubated AHRF or ARDS.

The reviews of this paper are available via the supplemental material section.

Prone Team: A Large-Scale Prone Position Initiative During COVID-19 Pandemic

AIM

To identify strategies to improve time to prone in ICUs during the coronavirus disease 2019 (COVID-19) pandemic for patients meeting the criteria for prone position ventilation.

BACKGROUND

Healthcare systems worldwide experienced an influx of COVID-19 patients, especially in critical care. COVID-19 patients are at risk of acute respiratory distress syndrome (ARDS). Prone position ventilation is the standard of care for mechanically ventilated patients with moderate to severe ARDS. Prone maneuvers in and of itself are time-consuming and labor-intensive, posing additional risks to patients.

APPROACH

Our academic medical center developed a travel proning team to address the rapid increase in COVID-19 patients with ARDS necessitating prone positioning.

EVALUATION

Over a period of 30 days, 420 ICU patients were intubated, 131 had moderate to severe ARDS and underwent prone positioning. Patients were placed in prone position or returned to supine position more than 834 times over 38 days. At the highest point, 37 procedures were done in 24 hours.

CONCLUSION

This quality initiative demonstrated that utilization of a traveling proning team provides efficiency in time to prone. Developing a travel prone team allowed for efficiency in time to prone, supported the ICU clinical teams, and enhanced interdisciplinary collaboration, which is essential during times of crisis.

The Fundamentals of Respiratory Physiology to Manage the COVID-19 Pandemic: An Overview

The growing coronavirus disease (COVID-19) crisis has stressed worldwide healthcare systems probably as never before, requiring a tremendous increase of the capacity of intensive care units to handle the sharp rise of patients in critical situation. Since the dominant respiratory feature of COVID-19 is worsening arterial hypoxemia, eventually leading to acute respiratory distress syndrome (ARDS) promptly needing mechanical ventilation, a systematic recourse to intubation of every hypoxemic patient may be difficult to sustain in such peculiar context and may not be deemed appropriate for all patients. Then, it is essential that caregivers have a solid knowledge of physiological principles to properly interpret arterial oxygenation, to intubate at the satisfactory moment, to adequately manage mechanical ventilation, and, finally, to initiate ventilator weaning, as safely and as expeditiously as possible, in order to make it available for the next patient. Through the expected mechanisms of COVID-19-induced hypoxemia, as well as the notion of silent hypoxemia often evoked in COVID-19 lung injury and its potential parallelism with high altitude pulmonary edema, from the description of hemoglobin oxygen affinity in patients with severe COVID-19 to the interest of the prone positioning in order to treat severe ARDS patients, this review aims to help caregivers from any specialty to handle respiratory support following recent knowledge in the pathophysiology of respiratory SARS-CoV-2 infection.

Prone positioning in patients with acute respiratory distress syndrome, translating research and implementing practice change from bench to bedside in the era of coronavirus disease 2019

Background

Acute respiratory distress syndrome (ARDS) is a relatively common condition of varied aetiology associated with high morbidity and mortality. A range of therapies have been proven to be useful for patients with ARDS, including ventilatory and nonventilatory strategies. Prone positioning is one of the nonventilatory strategies and has been proven to be safe and is associated with significant mortality benefit in patients with moderate to severe ARDS. It is now included in several international guidelines as the standard of care for these cases.

Objectives

The aim of the study was to develop, implement, and evaluate a prone positioning program in two nonmetropolitan, nontertiary intensive care units in South East Queensland.

Methods

A Plan–Do–Study–Act quality improvement model was used to implement changes in clinical practice in relation to prone positioning of patients.

Results

A description of the methods used to promote a complex change strategy is provided in this article.

Conclusions

In this article, we demonstrate the feasibility of introducing a nonventilatory intervention of prone positioning in the management of patients with moderate to severe ARDS in regional intensive care in South East Queensland. This implementation strategy could be replicated and adopted in other similar intensive care units that do not have the ability to provide tertiary services such as extracorporeal life support.

Prone positioning as an emerging tool in the care provided to patients infected with COVID-19: a scoping review

Objective:

to describe scientific evidence regarding the use of prone positioning in the care provided to patients with acute respiratory failure caused by COVID-19.

Method:

this is a scoping review. PRISMA Extension for Scoping Reviews was used to support the writing of this study. The search was conducted in seven databases and resulted in 2,441 studies, 12 of which compose the sample. Descriptive statistics, such as relative and absolute frequencies, was used to analyze data.

Results:

prone positioning was mainly adopted in Intensive Care Units, lasted from a minimum of 12 up to 16 hours, and its prescription was based on specific criteria, such as PaO₂/FiO₂ ratio, oxygen saturation, and respiratory rate. The most prevalent complications were: accidental extubation, pressure ulcer, and facial edema. Decreased hypoxemia and mortality rates were the main outcomes reported.

Conclusion:

positive outcomes outweighed complications. Various cycles of prone positioning are needed, which may cause potential work overload for the health staff. Therefore, an appropriate number of trained workers is necessary, in addition to specific institutional protocols to ensure patient safety in this context.

Prone Positioning in Patients With Acute Respiratory Distress Syndrome and Other Respiratory Conditions: Challenges, Complications, and Solutions

Acute respiratory distress syndrome (ARDS) and respiratory failure are characterized by hypoxemia, i.e., low levels of blood oxygen. Infections such as influenza and COVID-19 can lead to ARDS or respiratory failure. Treatment is through supportive measures. In severe cases, patients receive oxygen through a ventilator and, when appropriate, are placed in a prone position for an extended period. A retrospective review of events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) identified 98 prone position–related events in patients with ARDS, respiratory failure, distress, and pneumonia from January 1, 2010, through June 30, 2020; 30 events were associated with COVID-19. Skin integrity injuries accounted for 83.7% (82 of 98) of the events. The remaining events, 16.3% (16 of 98), involved unplanned extubations, cardiac arrests, displaced lines, enteral feedings, medication errors, a dental issue, and posterior ischemic optic neuropathy.

Proning Patients With COVID-19: A Review of Equipment and Methods

OBJECTIVE

To identify and critically evaluate methods for proning patients with COVID-19 in the intensive care unit (ICU).

BACKGROUND

Acute respiratory distress syndrome (ARDS) is common in hospitalized patients with COVID-19. Proning improves blood oxygenation and survival rates in these patients but is not commonly performed due to the difficulty of the procedure.

METHODS

An academic literature review, internet video search, and consultation with five subject-matter experts was performed to identify known methods for proning. Evaluation of each method considered the number of healthcare workers required, physical stresses on staff, risk of adverse events to patients, and equipment cost and availability.

RESULTS

Several variations of manual techniques and-lift assisted techniques were identified in addition to a specialized proning bed. Manual methods require more healthcare workers, higher physical stresses, and greater risk of adverse events than lift-assisted methods or the proning bed.

CONCLUSION

Both the specialized proning bed and a lift-assisted method using straps largely eliminated manual forces required for proning while allowing for a controlled lowering and positioning of the patient.

APPLICATION

This review will guide practitioners to the most suitable methods for proning patients in the ICU.

Factors Influencing Prone Positioning in Treating Acute Respiratory Distress Syndrome and the Effect on Mortality Rate

Acute respiratory distress syndrome (ARDS) is often associated with severe hypoxemia and a high mortality rate. Prone positioning is a well-established intervention for ARDS. It has been shown to improve oxygenation and prevent ventilator-induced lung injury due to the more uniform distribution of lung stress and strain. This narrative review aims to compare the various factors that may influence how prone positioning affects mortality rates. We will examine the duration of time a patient is in the prone position, severity of ARDS, use of lung-protective ventilation, and the time elapsed between ARDS diagnosis and placing a patient in the prone position. A literature review on prone positioning in ARDS was performed and searched data from PubMed and Google Scholar for articles published from 2010 to 2020. Although no single variable used during prone positioning reduces mortality rates in ARDS patients, combining several optimal conditions may yield increased survival benefits. Early initiation of extended prone positioning sessions combined with low tidal volumes shows encouraging results in severe ARDS patients. Future research on this subject should focus on further examining these variables in a study enrolling a larger number of subjects in a setting with adequately trained staff familiar with proper prone positioning techniques.

Prone Positioning of Patients With Acute Respiratory Distress Syndrome Related to COVID-19: A Rehabilitation-Based Prone Team

OBJECTIVE

Prone positioning is an effective intervention for acute respiratory distress syndrome (ARDS). An increasing number of patients with ARDS related to coronavirus disease 2019 require prone positioning, which poses a challenge to the intensive care unit staff at Brigham and Women's Hospital.

METHODS

A prone team service of physical therapists and occupational therapists with critical care experience was established to assist with increasing demands for prone positioning of patients who were mechanically ventilated. The goals of the rehabilitation-based prone team were to provide support to nursing and respiratory therapy; create a consistent, efficient process; and ensure patient and staff safety.

RESULTS

The service evolved over 7 weeks, expanding to 24-hour coverage and adding responsibilities to support the staff as patient volume grew. The volume of requests to the rehabilitation-based prone team generally increased to week 4 and has, since then, declined. Key points for successful implementation included identification of rehabilitation therapists with intensive care unit experience and leadership qualities, multidisciplinary collaboration, availability of needed positioning devices and supplies to protect the integument, and well-defined roles of all disciplines participating in position change process.

CONCLUSION

The description of the development, operations, evolution, and utilization of a rehabilitation therapist prone team acts as a guide for future development and implementation.

IMPACT

This case report is one of the first reports of a rehabilitation-based prone team established to assist with positioning patients in prone as an intervention for ARDS related to coronavirus disease 2019 and will help guide other institutions.

Community Experience With Acute Respiratory Distress Syndrome in the Prone Position

Mechanical ventilation in the prone position has been shown to improve outcomes in randomized trials of patients with moderate to severe acute respiratory distress syndrome and is recommended in clinical practice guidelines. However, data is lacking on the results of attempts to implement this practice in the community outside of clinical trials. To describe our early outcomes implementing mechanical ventilation in the prone position.

DESIGN

Retrospective cohort study.

SETTING

Medical intensive care unit of a large community-based teaching hospital.

PARTICIPANTS

All patients ventilated in the prone position between June 2013 and October 2016.

MEASUREMENTS AND MAIN RESULTS

We describe patient characteristics, mortality, and frequency of complications (such as skin breakdown and accidental extubation) at our center. Eighty-one patients with a mean age of 55 years underwent mechanical ventilation in the prone position during the study period. Most patients also received vasopressors, neuromuscular blockade, and steroids. Overall mortality was 43%. The duration of the first proning session ranged from 1.5 to 40.5 hours. Mortality was lower (34%) in those ventilated in the prone position for more than 16 hours during the first session. In the 50 patients without treatment limitations, only 14% expired. There were no accidental extubations during prone positioning. Most of those who died had limitations placed on treatment prior to death.

CONCLUSIONS

Overall mortality was higher in our cohort than in the randomized trial. However, differences such as lack of stabilization period, different cultures impacting end-of-life decisions, and timing of enrollment in the course of illness limit interpretation of this comparison. This exercise allows identification of areas for future quality improvement efforts such as increasing the duration of some proning sessions. Complications of prone positioning were uncommon.