Pronation Therapy - CE/NCPD

The content in Clinical Skills is evidence based and intended to be a guide to clinical practice. Always follow your organization’s practice.

ALERT

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

OVERVIEW

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:

• Increased intracranial pressure
• Hemodynamic instability
• Massive bleeding or hemoptysis
• Maxillofacial injuries
• Rib fractures
• Recent abdominal surgery
• Bronchopleural fistula, unstable airway, or recent tracheal surgery
• Second or third trimester pregnancy or extremely distended abdomen²
• Burns of the ventral body surface
• Advanced arthritis

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.

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Explain the patient’s oxygenation issues and the reason for the use of pronation therapy, the perceived benefit, the frequency of assessments, the expected response, and the parameters for discontinuation.
• Explain the equipment and the procedure.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient.
3. Verify the correct patient using two identifiers.
4. Assess the patient’s respiratory status.
5. Assess the patient’s hemodynamic status to determine the patient’s ability to tolerate a position change.
6. Obtain the patient’s height and weight to determine the possibility of turning the patient within the confines of the bed frame and the risk of injury to the health care team members. Ensure that the height and weight do not exceed the manufacturer’s recommended limits for commercial positioning systems or beds.
7. Assess the patient’s level of sedation and level of pain.
8. Assess the patient's level of neuromuscular blockade, if indicated.

Preparation

1. Ensure that an adequate number of experienced, knowledgeable health care team members are available to perform the procedure. The recommended number is five.⁶
   1. Place one team member (i.e., a respiratory therapist or RT) at the head of the bed managing the airway and two team members (i.e., nurses, patient care assistants) on each side of the patient to assist with moving the patient.
   2. Consider having more staff members present to help secure catheters and tubes or support additional patient body weight to guarantee safety and minimize potential risks to patient and team members.
   3. Consider using lift assist devices when the patient weighs more than 159 kg.⁶
2. Administer sedatives, analgesics, and neuromuscular blockade agents as prescribed. Reassess the patient’s pain and sedation status, allowing for sufficient onset of action per the medication, route, and the patient’s condition.
3. Perform eye care, including lubricating the eyes and horizontal taping of the closed eyelids.
4. Apply a soft silicone multilayer foam dressing to the face and all bony prominence areas (e.g., shoulders, chest, iliac crest, elbows, tibial areas) (Figure 1).⁷
5. Apply thin foam dressings under all medical devices.⁷
6. Ensure that the patient’s tongue is inside the mouth. If the tongue is swollen or protruding, insert a bite block or an oropharyngeal airway.
7. If a commercial endotracheal (ET) tube securement device is in use, consider switching to tape or ties.⁶

   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.

8. Ensure that all lines, tubes, and drains are secure. Consider using two sutureless securement devices for central lines.⁴
   1. Reposition all lines, tubes, and drains that are located above the patient’s waist up toward the head of the bed.
   2. Reposition all lines, tubes, and drains that are located below the waist down toward the foot of the bed.
9. Change dressings that are due to be changed during pronation therapy.
10. Empty ileostomy or colostomy bags before positioning. Place a pad around the stoma to prevent direct pressure on it.
11. Consider an indwelling urinary drainage catheter for accurate intake and output.
12. Consider a fecal containment device for patients with increased stool to minimize moisture-related skin concerns.
13. Suspend orogastric or nasogastric enteral feeding 1 hour⁶ before pronation therapy to allow for gastric emptying, then resume enteral feeding once the patient is placed in the prone position.
14. If the patient is on a low air-loss surface, inflate it to the maximum level to make turning easier.
15. Remove the headboard and reposition the bed to ensure access to the ET tube and the ventilator tubing.
16. Suction the patient’s artificial airway and oral cavity.

PROCEDURE

Turning the Patient Prone Manually Using Sheets—Burrito Method

1. Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Explain the procedure and ensure that the patient agrees to treatment.
4. Verify that an adequate number of health care team members are available to assist with the procedure. The team members stationed on each side of the bed should maintain body contact with the bed at all times, serving as side rails to ensure a safe environment.
5. Start with the patient in the supine position on a clean, flat sheet.
6. Remove the patient’s gown and electrocardiogram (ECG) leads and replace to the posterior chest with wires toward the head:
   1. Place the RA and LA leads on the upper posterior shoulders.
   2. Place the RL and LL leads on the right and left lower back positions.
   3. Place the V1 lead once patient is in the prone position.
7. Place absorbent pads over the perineal area (Figure 3A).
8. Place pillows or positioning foam in the chest area, pelvic area, and shins.
9. Tuck the patient’s arms and hands under the buttocks on either side.
10. Cover the patient and all positioning supports fully with a second flat sheet.
11. The two health care team members on either side will roll the top and bottom sheets together (Figure 3B).
    1. Team members on the side of the ventilator (receiving team) will roll sheets under (down) and tuck.
    2. Team members on the side of the patient away from the ventilator (delivering team) will roll sheets over (up), getting as close to the patient as possible.
12. On the count of the RT, or health care team member at the head of the bed holding the patient’s head and ET tube, move the patient laterally away from the ventilator.
13. Turn the patient onto a full side-lying position facing the ventilator, allowing the receiving team to position hands on the patient and positioning sheets (Figure 3C).
14. The team furthest away from the ventilator (delivering team) will pull the positioning sheets under the patient while the receiving team on the other side lowers the patient into the complete prone position.
15. Ensure the ECG electrodes are properly positioned on the patient’s back (Figure 4).
16. Straighten all lines and tubes.
17. Place extremities in swimmer’s position if not contraindicated (Figure 3D). Avoid overextension, overabduction, or overrotation of the neck and arms.
18. Position the head to prevent pressure areas. Place the patient’s head on a facial positioning device (Figure 3E).⁷ Follow the manufacturer’s instructions for application.

    Rationale: The facial positioning device should offload pressure to the patient’s forehead, nose, cheeks, and chin.⁷

19. Elevate the feet and protect the toes from pressure by placing pillows under the shins.
20. Place the patient in the reverse Trendelenburg position between 15 and 25 degrees if not contraindicated.⁶

    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.

21. If the patient is on a low air-loss, pressure-redistribution, or continuous lateral rotation surface, adjust the inflation as appropriate.
22. Resume the enteral feeding.
23. Discard supplies, remove PPE, and perform hand hygiene.
24. Document the procedure in the patient’s record.

Turning the Patient Supine Manually Using Sheets—Burrito Method

1. Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Explain the procedure and ensure that the patient agrees to treatment.
4. Complete any required preparation steps.
5. Verify that an adequate number of health care team members are available to assist with the procedure. The team members stationed on each side of the bed should maintain body contact with the bed at all times, serving as side rails to ensure a safe environment.
6. Start with the patient in the prone position on a positioning sheet.
   1. Return both arms to the patient’s sides.
   2. Remove additional bedding and positioning aids around the patient.
7. Remove the patient’s gown. Remove ECG leads and pads and replace to the anterior chest with wires toward the head:
   1. Place the RA and LA leads on the upper chest.
   2. Place the RL and LL leads on the right and left lower abdomen.
   3. Place the V1 lead once patient is in the supine position.
8. Place the absorbent pad over buttocks.
9. Tuck the patient’s arms and hands under the anterior thighs on either side.
10. Cover the patient fully with the second sheet.
11. The two health care team members on both sides will roll the top and bottom positioning sheets together:
    1. Team members on the side of the ventilator (delivering team) will roll sheets over (up).
    2. Team members on the side of the patient away from the ventilator (receiving team) will roll sheets under (down), getting as close to the patient as possible.
12. On the count of the RT, or health care team member at the head of the bed holding the patient’s head and ET tube, move the patient horizontally toward the ventilator.
13. Turn the patient onto the full side-lying position facing the ventilator, allowing the receiving team to position the hands on the patient and positioning sheets.
14. The team closest to the vent (delivering team) will pull sheets under the patient, while the receiving team lowers the patient into the complete supine position.
15. Ensure the ECG electrodes are properly positioned on the patient’s chest.
16. Straighten all lines and tubes.
17. Position the patient’s head on the pillow to prevent pressure areas if not contraindicated.
18. Elevate the legs and feet to float the heels using a heel suspension device.
19. Elevate the head of the bed 30 degrees unless contraindicated.
20. If the patient is on a low air-loss, pressure redistribution, or continuous lateral rotation surface, adjust the inflation as appropriate.
21. Resume the enteral feeding.
22. Discard supplies, remove PPE, and perform hand hygiene.
23. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Assess the patient’s hemodynamic and oxygenation status after moving the patient from supine to prone or prone to supine position.

   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

2. Assess the skin of the body frequently and with each repositioning of the head for areas of nonblanchable redness or breakdown.

   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

3. Ensure that the health care team members are aware that the patient should be repositioned every 2 hours.^6,7
   1. Set expectations with clear communication to the team members as a reminder that it is necessary to turn the patient every 2 hours to protect the patient from pressure areas, minimize nerve injuries, and decrease strain to the neck and shoulders.⁶
   2. Shift the patient’s head every 2 hours.⁷ Reposition the patient’s head side to side every 4 hours.⁷ While one health care team member lifts the patient’s head, the second health care team member moves the head positioning device to provide support in a different position.

      Rationale: Shifting and repositioning the patients head helps prevent facial pressure injuries.

      Reportable condition: Skin breakdown

4. Place all patients at risk for pressure injuries and critically ill patients on a pressure-redistribution surface.

   The most appropriate type of pressure-redistribution surface is not currently known.⁶

5. Provide frequent oral care and suction the airway as needed.

   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

6. Maintain enteral feedings as tolerated.

   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

7. Check whether the patient is able to sustain improvements in PaO₂ made while in the prone position.

   Reportable condition: Decreases in oxygenation saturation

8. If the patient experiences a cardiopulmonary arrest and cannot be turned supine, perform cardiopulmonary resuscitation (CPR) over the thoracic spine with the patient in the prone position.
   1. Place the defibrillator pads in the anterior-posterior position.³
   2. Position hands in the standard position over the T7 to T10 vertebral bodies (Figure 5).³
   3. Perform CPR at the same depth and rate as if the patient were supine.
9. Assess, treat, and reassess pain, sedation, and level of neuromuscular blockade.

EXPECTED OUTCOMES

• Increased oxygenation
• Improved secretion clearance
• Improved lung compliance

UNEXPECTED OUTCOMES

• Agitation
• Disconnection or dislodgment of tubes and lines
• Peripheral arm nerve injury
• Periorbital and conjunctival edema
• Skin injuries or pressure injuries
• Eye pressure or injury
• Aspiration of enteral feeding

DOCUMENTATION

• Education
• Patient’s tolerance of the procedure
• Length of time in the prone position
• Maximal oxygenation response while in the prone position
• Oxygenation response when returned to the supine position
• Positioning schedule
• Complications noted during and after the procedure
• Amount and type of secretions
• Unexpected outcomes and related interventions
• Pain assessment and management
• Sedation assessment and management

REFERENCES

1. Evans, L. and others. (2021). Surviving sepsis campaign: International guidelines for management of sepsis and septic shock 2021. Critical Care Medicine, 49(11), e1063-e1143. doi:10.1097/CCM.0000000000005337 (Level VII)
2. Guérin, C. and others. (2020). Prone position in ARDS patients: Why, when, how and for whom. Intensive Care Medicine, 46(12), 2385-2396. doi:10.1007/s00134-020-06306-w (Level V)
3. Hsu, A. and others. (2021). 2021 Interim Guidance to Health Care Providers for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19. Circulation: Cardiovascular Quality and Outcomes, 14(10), e008396. doi:10.1161/CIRCOUTCOMES.121.008396 (Level VI)
4. Lucchini, A. and others. (2020). Prone position in acute respiratory distress syndrome patients: A retrospective analysis of complications. Dimensions of Critical Care Nursing, 39(1), 39-46. doi:10.1097/DCC.0000000000000393 (Level V)
5. Morata, L. and others. (2021). Manual vs automatic prone positioning and patient outcomes in acute respiratory distress syndrome. American Journal of Critical Care, 30(2), 104-112. doi:10.4037/ajcc2021674 (Level V)
6. Morata, L. and others. (2023). Manual prone positioning in adults: Reducing the risk of harm through evidence-based practices. Critical Care Nurse, 43(1), 59-66. doi:10.4037/ccn2023174 (Level VII)
7. National Pressure Injury Advisory Panel (NPIAP). (2020). Pressure injury prevention: PIP tips for prone positioning. Retrieved December 18, 2023, from https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/posters/npiap_pip_tips_-_proning_202.pdf (Level VII)
8. Shearer, S.C. and others. (2021). Facial pressure injuries from prone positioning in the COVID-19 era. The Laryngoscope, 131(7), E2139-E2142. doi:10.1002/lary.29374 (Level V)

ADDITIONAL READINGS

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.

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports

Clinical Review: Genevieve L. Hackney, MSN, RN

Published: February 2024