Prone Position in Acute Respiratory Distress Syndrome Patients

Abstract

Background Early application of prolonged prone positioning has been shown to improve patient survival in moderate to severe adult respiratory distress syndrome (ARDS) patients. Prone position is a key component of lung protective mechanical ventilation in association with low tidal volume and neuromuscular blocking agents in patients with severe ARDS. Pressure sores are the major prone position complication. The rate of complication is lowering with the increase in center expertise. Aims The aim of this study was to examine the onset of pressure sores and other complications caused by the use of prone position in patients having ARDS. Design This is a single-center, retrospective, observational study. Results One hundred seventy patients were enrolled, with a median age of 49 years (interquartile range [IQR], 38-63). Of all participants, 58% (n = 98) survived the intensive care unit recovery. The total prone position maneuvers were 526, with a median of 2 prone position sessions for each patient (IQR, 1-3). The median length of the prone position session was 9 hours (IQR, 7-12). Twenty-three patients developed pressure sores after prone position (14%). The anatomical positions of pressure sores were as follows: face/chin, 5% (n = 8); face/cheekbones, 6% (n = 11); thorax, 2% (n = 3); trochanter, 1% (n = 1); and other sites, 5% (n = 8). Complications were observed in 1% (n = 6) of all pronation maneuvers (vomit, 2%; respiratory device removal, 0.4%). No removal of intravascular catheter was observed. Conclusions The onset rate of complications given by the use of prone position in ARDS patients is similar to data reported by previous literature. The implementation of a dedicated protocol in specialized centers and the involvement of 5 trained and skilled professionals while moving the patient in the prone position are recommended to prevent the occurrence of similar adverse events.

Prone position in ARDS patients: why, when, how and for whom

“…Priority must be given to the safety in order to maximize benefits and minimize harm. Continuous education and training should be provided to the caregivers [59].…”

Facial pressure ulcers in COVID-19 patients undergoing prone positioning: How to prevent an underestimated epidemic?

“…3). Head position should be changed 2 or 3 times during a prone position session and the position of the breathing tube should be changed between each prone position session [5]. The circumferential fixation should be protected with gauzes or replaced by a specific endotracheal tube holder endowed with a silicon shield in contact with the cheek and the labial commissure [9].…”

“…As the prone position must be maintained for 10 to 12 h to be effective [3], it may result in prolonged pressure points on the face leading to potential ischemic lesions [4]. Facial pressure ulcers resulting from prone positioning have already been described for treatment of ARDS of various origins before the COVID-19 pandemic [5]. These facial ulcers occur mostly at the level of the bony structures including: the forehead, the cheekbone and the chin [4].…”

Prone position pressure sores in the COVID-19 pandemic: The Madrid experience

“…They include unplanned extubation, removal of central or arterial lines, bronchoaspiration, transient desaturation, hypotension, facial edema, corneal abrasions, brachial plexus injury and pressure ulcers. Among them, pressure ulcers are the most frequent 6 . Pressure injuries are localized damage to the skin and underlying soft tissue usually over a bony prominence or in relation to a medical device.…”