Question

1: What are your thoughts on prone positioning as a clinical therapy? How does prone positioning impact ARDS pathophysiology and clinical manifestations? The authors recommend developing an interdisciplinary team specializing in prone positioning. What training would the team need? What are your thoughts about being on the team?

2: What are your thoughts on prone positioning as a clinical therapy? Which patients are candidates for prone positioning? Discuss prone positioning contraindications. What strategies would you implement to support the “proned” patient and their family/loved ones?

Answer 1

PRONE POSITION

In Prone position the client lies on the abdomen with the head turned to one side. As a therapeutic position, prone position improve oxygenation, improves respiratory mechanics, homogenise the pleural pressure gradient, the alveolar inflation and the ventilation distribution, increase lung volume and reduce the amount of atelectatic regions, to facilitate the drainage of secretion and reduce ventillator associated lung injury.

Importance of prone position in ARDS patient

• Improve perfusion to the lungs that leads to better V:Q matching
• The diaphragm drops and the heart shift forward thereby improving compliance
• There will be improved lung recruitment
• Thus it protects the lungs
• In healthy lungs the distribution of perfusion is effected by gravity
• The apex and the middle gets more ventilation than perfusion, V>Q
• At the base, the lungs get more perfusion than ventilation, V<Q
• Atelectasis and inflammation of the lungs leads to worsening V;Q matching
• The improved V:Q matching may improve oxygenation

Perfusion of the anterior and base of the lungs improves in the prone position.

The diaphragm drops and the heart shift forward thus improving compliance, May lower airway pressure, improve VT and MV.

In ARDS, the prone position is given as a rescue therapy.

There is no special guidelines for providing prone position. It is based on the patient condition.

• The bed should be flat.
• Small pillows are placed under the head, abdomen, and lower legs.
• Arms are flexed at the elbows with the hands near the head.
• Alternating cycles of 4 hrs prone with 2 hrs supine position through out the day or a 20 hrs continuous prone position with a 4 hrs supine position.

Being a member of the interdisciplinary team, it is a very critical approach to manage patients with ards. strict evaluation of the patient condition is very important to understand the stage of the patient. Providing care is important since it will be very life threartening unless treated properly. The patient should be managed as per the guidelines and position should be mentioned as per the rules so that it brings effective outcome.

Indications - ARDS <48 hrs, PaO2 / FiO2 <200mmHg

Contraindications - Relative containdications

• Elevated ICP
• Intestinal ischemia
• Obesity
• Recent abdominal surgery

Absolute contraindications

• Spinal cord instability
• unstable facial fractures
• anterior burns, open abdomen
• increased abdominal pressures
• unstable pelvic fractures

Support from the family

• Family members can be asked to support while changing the patient position.
• Family members can help the patient in his or her care while position is maintained
• For continuous prone position the skin should be evaluated and the need should be discussed with the the family
• The patient and the family should be encouraged to do activities they like while in position