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Prone patients are at high risk for pressure injuries (Figure 1). Continual monitoring and preventive measures are needed to avoid this complication. There are a number of different positioning devices available to facilitate offloading pressure to the various parts of the patient’s body. Follow the manufacturer’s instructions when using these devices.undefined#ref7">7 Prone patients are particularly vulnerable to facial injuries.8
Pronation therapy, or prone positioning, is a short-term therapeutic modality used to improve oxygenation in patients with acute respiratory distress syndrome (ARDS). It involves turning the patient onto the abdomen in the face-down position.
ARDS is not a diffuse, homogenous disease that affects all areas of the lungs equally; instead, the dependent lung areas are more heavily damaged than the nondependent lung areas. The improvement in oxygenation is likely the result of three physiological effects: a decreased transpulmonary pressure gradient, reduced lung compression, and improved lung perfusion matching (or an increase in recruited alveoli available to match) with perfusion (Figure 2). Pronation therapy also improves perfusion to less damaged areas of the lungs, which improves ventilation–perfusion matching.4
Pronation therapy is indicated in patients with ARDS who have a partial pressure of arterial oxygen/fraction of inspired oxygen (PaO2/FIO2 or P/F) ratio less than or equal to 150 mm Hg.1 This therapy can be used to facilitate the mobilization of secretions and it improves oxygenation and mortality in patients with ARDS.2
Absolute contraindications for pronation therapy include patients with unstable cervical, thoracic, or lumbar fractures. Relative contraindications include:
No standard has been established for the length of time a patient should remain in the prone position. The benefits increase the longer a patient is prone.2 The positioning schedule (length of time in the prone position and frequency of turning) is usually based on the patient’s tolerance of the procedure, the success of the procedure in improving the patient’s PaO2, and the patient’s ability to sustain improvements in PaO2 when turned back to the supine position.
The most significant limitation to pronation therapy is the actual mechanics of turning the patient. A number of methods are discussed in the literature, including manually turning the patient with the use of bed sheets, a turning system, or an automatic system that turns the patient with the use of a bed such as the RotoProne® Therapy System. Thus far, research indicates that manual prone positioning has outcomes similar to those of automatic prone positioning with less risk of interruptions in therapy, fewer complications, and lower expense.5
Complications of the procedure include dislodgment or obstruction of tubes and drains, cardiac arrhythmias, hemodynamic instability, massive facial edema, pressure injuries (Figure 1), aspiration, and corneal ulcerations.
Prone ventilation may require an increase in pain and sedation medications. The use of neuromuscular blocking agents is warranted if ventilator asynchrony continues after maximum pain and sedative medications are used.
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Rationale: Commercial ET tube securement devices are not recommended for use during prone positioning because of the potential for increased skin breakdown and breakdown of adhesive due to increased saliva.
Rationale: The facial positioning device should offload pressure to the patient’s forehead, nose, cheeks, and chin.7
Rationale: Reverse Trendelenburg position is recommended to keep the head of the bed up to decrease overall edema, including eye conjunctival edema, and to prevent complications associated with enteral feeding and aspiration.
Rationale: Some patients immediately respond to pronation therapy; others may take several hours to show maximal response.
Reportable conditions: Decreasing peripheral oxygen saturation, hemodynamic instability
Rationale: Patients requiring pronation therapy are at risk for skin breakdown, particularly to facial areas and bony prominences. Frequent, patient-specific assessment is needed to prevent pressure injury.
Reportable conditions: Nonblanchable redness, shearing and friction injuries
Rationale: Shifting and repositioning the patients head helps prevent facial pressure injuries.
Reportable condition: Skin breakdown
The most appropriate type of pressure-redistribution surface is not currently known.6
Rationale: The prone position promotes postural drainage. Drainage from the nares may be a sign of an undetected sinus infection.
Reportable conditions: Drainage from the nares, change in the amount or character of secretions
Rationale: Enteral feedings should continue even during pronation therapy. Recommend the use of prokinetic agents only if signs and symptoms of gastrointestinal (GI) intolerance are observed. If GI intolerance persists, placement of a postpyloric tube for enteral feeding may be indicated.6
Reportable condition: Evidence of tube-feeding material when suctioning
Reportable condition: Decreases in oxygenation saturation
Bhatia, N., Yaddanapudi, S., Aditya, A.S. (2022). Prone cardiopulmonary resuscitation: Relevance in current times. Journal of Anaesthesiology, Clinical Pharmacology, 38(Suppl. 1), S8-S12. doi:10.4103/joacp.joacp_421_21
Adapted from Johnson, K.L. (Ed.). (2024). AACN procedure manual for progressive and critical care (8th ed.). St. Louis: Elsevier.
Clinical Review: Genevieve L. Hackney, MSN, RN
Published: February 2024
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