Prone Positioning of Patients With Acute Respiratory Distress Syndrome

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.

An Evidence-Based Protocol for Manual Prone Positioning of Patients With ARDS

BACKGROUND

Manual prone positioning has been shown to reduce mortality among patients with moderate to severe acute respiratory distress syndrome, but it is associated with a high incidence of pressure injuries and unplanned extubations. This study investigated the feasibility of safely implementing a manual prone positioning protocol that uses a dedicated device.

REVIEW OF EVIDENCE

A search of CINAHL and Medline identified multiple randomized controlled trials and meta-analyses that demonstrated both the reduction of mortality when prone positioning is used for more than 12 hours per day in patients with acute respiratory distress syndrome and the most common complications of this treatment.

IMPLEMENTATION

An existing safe patient-handling device was modified to enable staff to safely perform manual prone positioning with few complications for patients receiving mechanical ventilation. All staff received training on the protocol and use of the device before implementation.

EVALUATION

This study included 36 consecutive patients who were admitted to the medical intensive care unit at a large academic medical center because of hypoxemic respiratory failure/acute respiratory distress syndrome and received mechanical ventilation and prone positioning. Data were collected on clinical presentation, interventions, and complications.

SUSTAINABILITY

Using the robust protocol and the low-cost device, staff can safely perform a low-volume, high-risk maneuver. This method provides cost savings compared with other prone positioning methods.

CONCLUSIONS

Implementing a prone positioning protocol with a dedicated device is feasible, with fewer complications and lower costs than anticipated.

Development, Implementation, and Impact of a Proning Team During the COVID-19 Intensive Care Unit Surge

BACKGROUND

Prone positioning has been used as an intervention to improve oxygenation in critically ill patients with acute respiratory distress syndrome. During the COVID-19 pandemic, resources were even more limited given a surge in acute respiratory distress syndrome patients, which outstripped intensive care unit (ICU) capacity at many institutions.

LOCAL PROBLEM

The purpose of this article is to describe the development and implementation of a proning team during the surge in ICU patients with COVID-19 and to measure the impact of the program through surveys of staff involved.

METHODS/INTERVENTIONS

A proning protocol and educational plan was developed. A proning team of redeployed staff was created. A survey of ICU registered nurses and proning team members was used to evaluate the benefits and challenges of the proning team.

RESULTS

The proning team was successful in safely performing more than 300 proning and supinating maneuvers for critically ill patients. There is overwhelming support within the institution for a proning team for future COVID-19 surges.

DISCUSSION

The development and implementation of the proning team happened quickly to assist with the surge of patients and off-load work from ICU registered nurses. Despite the success of the proning team, more clearly defined roles and expectations, as well as additional education, are needed to further enhance teamwork and workflow.

CONCLUSIONS

Creation of the proning team was a creative use of resources that helped manage the large and medically complex patient population. This work may serve as a guide to other health care institutions.

Critical Care Considerations in Adult Patients With Influenza-Induced ARDS

TOPIC

Acute respiratory distress syndrome is a complex respiratory disease that can be induced by influenza virus infection. Critical care providers are uniquely positioned to manage this pathological progression in adult patients through evidence-based practice.

CLINICAL RELEVANCE

Influenza and subsequent acute respiratory distress syndrome are associated with extremely high morbidity and mortality in adult patients in the United States. Although evidence-based medical management strategies can alter the clinical trajectory of acute respiratory distress syndrome and improve outcomes, critical care providers do not always implement these measures.

PURPOSE

To provide critical care providers with an overview of the pathological progression of influenza-induced acute respiratory distress syndrome and the current evidence-based strategies for management.

CONTENT COVERED

This article reviews the epidemiology and pathophysiology associated with influenza-induced acute respiratory distress syndrome, the criteria for diagnosis, and the evidence-based medical management.

Placement of a Peripherally Inserted Central Catheter in a Prone Patient With COVID-19: Feasibility and Case Report

The emergence of the coronavirus disease 2019 (COVID-19) virus has increased in patients with acute respiratory distress syndrome (ARDS). The use of prone positioning during COVID-19-associated ARDS has led to improved oxygenation and decreased mortality. Extended hours of proning may delay or prevent traditional approaches to central vascular access, such as jugular, subclavian, or femoral cannulation. A peripherally inserted central catheter (PICC) is a viable option for prone patients. This article presents a PICC placement in a 56-year-old man with COVID-19 ARDS who required 20- to 24-hour prone positioning during his care in the intensive care unit. Insertion of a PICC while the patient is prone expedites lifesaving medications and infusions without waiting for the patient to be stable enough to be turned to the supine position.

Nursing Management of Prone Positioning in Patients With COVID-19

BACKGROUND

At the height of the coronavirus disease 2019 (COVID-19) pandemic, Italy had the highest number of deaths in Europe; most occurred in the Lombardy region. Up to 4% of patients with COVID-19 required admission to an intensive care unit because they developed a critical illness (eg, acute respiratory distress syndrome). Numerous patients with acute respiratory distress syndrome who had been admitted to the intensive care unit required rescue therapy like prone positioning.

OBJECTIVE

To describe the respiratory management of and the extensive use of prone positioning in patients with COVID-19 at the intensive care unit hub in Lombardy, Italy.

METHODS

A total of 89 patients (67% male; median age, 59 years [range, 23-80 years]) with confirmed COVID-19 who were admitted between February 23 and March 31, 2020, were enrolled in this quality improvement project.

RESULTS

Endotracheal intubation was required in 86 patients (97%). Prone positioning was used as rescue therapy in 43 (48%) patients. Significantly more younger patients (age ≤ 59 years) were discharged alive (43 of 48 [90%]) than were older patients (age ≥ 60 years; 26 of 41 [63%]; P < .005). Among the 43 patients treated with prone ventilation, 15 (35% [95% CI, 21%-51%]) died in the intensive care unit, of which 10 (67%; P < .001) were older patients.

CONCLUSIONS

Prone positioning is one strategy available for treating acute respiratory distress syndrome in patients with COVID-19. During this pandemic, prone positioning can be used extensively as rescue therapy, per a specific protocol, in intensive care units.

Implementing Prone Positioning for COVID-19 Patients Outside the Intensive Care Unit

BACKGROUND

Proning intubated intensive care unit patients for the management of acute respiratory distress syndrome is an accepted standard of practice. We examined the nursing climate in 4 units and its impact on implementing a novel self-proning protocol to treat COVID-19 patients outside the intensive care unit.

LOCAL PROBLEM

Nursing units previously designated for medical/surgical populations had to adjust quickly to provide evidence-based care for COVID-19 patients attempting self-proning.

METHODS

Nurses from 4 nursing units were surveyed about the implementation process on the self-proning protocol. Their perception of unit implementation was assessed via the Implementation Climate Scale.

INTERVENTIONS

A new self-proning nursing protocol was implemented outside the intensive care unit.

RESULTS

Consistent education on the protocol, belief in the effectiveness of the intervention, and a strong unit-based climate of evidence-based practice contributed to greater implementation of the protocol.

CONCLUSIONS

Implementation of a new nursing protocol is possible with strong unit-based support, even during a pandemic.

Plan de cuidados de enfermería para la prevención de úlceras por presión secundarias a la posición prono en pacientes COVID-19

Introducción: La posición prono (PP) es una alternativa terapéutica ampliamente recomendada e implementada en los pacientes con COVID-19. Sin embargo, aunque es un procedimiento no invasivo, es complejo y se asocia con eventos adversos como las úlceras por presión (UPP). Nuestro objetivo es proponer un plan de cuidados de enfermería basado en el lenguaje estandarizado NANDA-I, NIC, NOC para la prevención de las UPP secundarias a la PP en la enfermedad de COVID-19. Síntesis del contenido: En los pacientes con COVID-19, además de factores de riesgo propios del paciente como la edad avanzada y la presencia de comorbilidades, la PP contribuye a la presencia de los diagnósticos de enfermería de riesgo de úlcera por presión [00249], de deterioro de la integridad cutánea [00047] y tisular [00248]. Por su parte, la intervención de enfermería prevención de úlceras por presión [3540], es clave para minimizar el desarrollo de esta complicación, mejorar la calidad de la atención y el pronóstico en este tipo de pacientes. Finalmente, para determinar la efectividad del cuidado de enfermería se proponen los resultados NOC consecuencias de la inmovilidad: fisiológicas [0204] e integridad tisular: piel y membranas mucosas [1101]. Conclusión: La PP es una terapia coadyuvante recomendada para el manejo de los pacientes con COVID-19 críticamente enfermos, debido a que optimiza la función pulmonar, sin embargo está asociada a eventos adversos como las UPP. Este artículo presenta recomendaciones basadas en una revisión narrativa para facilitar la implementación de cuidados de enfermería preventivos que reduzcan su frecuencia en esta población.

Using In Situ Simulation to Develop a Prone Positioning Protocol for Patients With ARDS

BACKGROUND

Acute respiratory distress syndrome carries a 40% mortality rate. Prone positioning remains underused owing to clinicians' low degree of confidence, concern about the risk of adverse outcomes, and lack of staff competency training.

LOCAL PROBLEM AND PURPOSE

A prone positioning protocol and educational program were needed in an intensive care unit to achieve compliance with best practices for treating acute respiratory distress syndrome patients.

METHODS

An initial survey was conducted to measure staff confidence and competency in prone positioning. A literature review was performed, and a plan-do-study-act approach was used to develop a protocol through in situ simulation involving mock patients. A training video and a simulation scenario using a high-fidelity manikin were developed to facilitate staff education. Staff were surveyed again after training.

INTERVENTIONS

During the simulation scenario, interdisciplinary clinicians learned to apply the protocol and resupinate the patient during a simulated emergency. The training video was later used for "just in time" education minutes before actual prone positioning events.

RESULTS

A total of 25 critical care nurses, 11 respiratory therapists, and 10 physicians completed the initial survey and simulation training. The survey showed that staff lacked confidence and competency in prone positioning. Staff demonstrated competence during the simulation sessions, and posttraining surveys indicated increased confidence. After the educational program, prone positioning was successfully used for 6 critically ill acute respiratory distress syndrome patients.

CONCLUSIONS

In situ simulation and interdisciplinary collaboration increase standardization of high-risk, underused procedures, improving staff confidence and competence as well as patient safety.

Utilization of a Visit-Based Sepsis Assessment to Prevent Hospital Readmissions

Sepsis results in 270,000 deaths annually in the United States. Despite the current healthcare focus on sepsis, there exist few postacute best-practice standards to rapidly identify health changes in home healthcare patients to prevent and reduce hospital readmissions due to sepsis. We systematically examined whether an evidence-based process and intervention triggering home healthcare clinicians to activate a Positive Sepsis Assessment would reduce the likelihood that the patient would be readmitted to the acute care hospital. Over 24 months, we tracked the rate of sepsis readmissions to acute care hospitals through the initial phase of early recognition education; assessment, review, and revision of best-practice algorithms; standardized documentation; and proactive care management, in conjunction with the patient's primary care provider. During our review of the last 12 months of data on home care patients triggering the Positive Sepsis Assessment 130 patients were identified to have potential signs of sepsis. Ninety-seven of these patients received early medical intervention in place and were not readmitted to the hospital. Our findings suggest that a multidisciplinary home healthcare team utilizing standard sepsis education and sepsis algorithm on every patient during every visit can reduce and prevent readmissions.

Acute Respiratory Distress Syndrome and Prone Positioning

Acute respiratory distress syndrome continues to have high morbidity and mortality despite more than 50 years of research. The Berlin definition in 2012 established risk stratification based on degree of hypoxemia and the use of positive end-expiratory pressure. The use of prone positioning as a treatment modality has been studied for more than 40 years, with recent studies showing an improvement in oxygenation and decreased mortality. The studies also provide evidence to support the methodology and length of treatment time. Recent guidelines include several ventilator strategies for acute respiratory distress syndrome, including prone positioning. Protocols and procedures discussed in this article ensure successful prone repositioning and prevention of complications related to the procedure itself.

Why is prone positioning so unpopular?

Recent studies have shown acute respiratory distress syndrome (ARDS) to be underdiagnosed and inadequately treated, as evidenced by underutilization of low-tidal volume ventilation. Despite a proven survival benefit in patients with severe ARDS, studies have also shown underutilization of prone positioning. Many questions persist as to the reasons for prone positioning's unpopularity. Additional studies are required to uncover the causes of this prone positioning underutilization phenomenon.

Optimizing Oxygenation in the Mechanically Ventilated Patient: Nursing Practice Implications

Critical care nurses constitute front-line care provision for patients in the intensive care unit (ICU). Hypoxemic respiratory compromise/failure is a primary reason that patients require ICU admission and mechanical ventilation. Critical care nurses must possess advanced knowledge, skill, and judgment when caring for these patients to ensure that interventions aimed at optimizing oxygenation are both effective and safe. This article discusses fundamental aspects of respiratory physiology and clinical indices used to describe oxygenation status. Key nursing interventions including patient assessment, positioning, pharmacology, and managing hemodynamic parameters are discussed, emphasizing their effects toward mitigating ventilation-perfusion mismatch and optimizing oxygenation.