Running head: PRONE POSITION TO IMPROVE RESPIRATORY STATUS

Prone Position to Improve Respiratory Status in Acute Respiratory Distress Syndrome

Rachel M. Wood

School of Nursing, James Madison University

NSG 464: Introduction to Nursing Research

Dr. Nena Powell

April 20, 2022

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Abstract

Acute Respiratory Distress Syndrome is a type of hypoxemic respiratory failure that usually

requires mechanical ventilation. The proposed research question is whether the prone position is

more beneficial than the supine position for these patients. The intervention of the prone position

involves positioning the patient on their stomach. The studies gathered information about these

patients, measuring their PaO2:FiO2 and other data to evaluate whether it was beneficial, safe,

and feasible. After analyzing the studies, it supports that the prone position may increase

oxygenation, promote better clinical outcomes, and that it’s linked to lower mortality rates, with

good safety outcomes and low adverse effects. The prone position is recognized as a safe and

simple intervention that may significantly benefit patients. The prone position should be

considered for every patient admitted with ARDS to the ICU.

Keywords: Acute Respiratory Distress Syndrome, ARDS, mechanical ventilation,

positioning, supine, prone, prone position, oxygenation, respiratory status.

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Introduction

Acute Respiratory Distress Syndrome (ARDS) is a progressive illness characterized by

shortness of breath, the initiation of advanced support measures such as mechanical ventilation

and is often fatal. In adult patients with ARDS, the current standard of care is to position the

patient supine with scheduled turns. This is the standard of care across most patient populations.

However, the prone position is evidenced to be one of the best noninvasive strategies for

improving oxygenation and perfusion distribution for patients with ARDS (Gleissman et al.,

2019). This review is aimed at analyzing the evidence of the prone position versus the current

standard of care and determining if the prone position is more beneficial. The research question

is, “In adult patients with ARDS, what is the effect of proning on complications, mortality, and

quality of ventilation, compared with the supine position.”

Analysis

In order to answer the research question, several studies were analyzed to support a

conclusion. The studies were performed on adult patients with ARDS in the ICU at various

hospitals in the United States. They sought out to evaluate the effectiveness of the prone position

as an intervention to promote oxygenation and better clinical outcomes. Of the six studies

reviewed to answer this question, some main methods were noted to measure the effectiveness of

the prone position. Changes in oxygenation were measured most commonly by the PaO2:FiO2

ratio, which is used to indicate oxygenation status. One study also measured static respiratory

compliance, which is a measurement of the lungs ability to expand. Another measurement used

was the patient’s arterial blood gasses. Some studies had additional criteria to determine safety

and outcomes, which had measurements not related to oxygenation, such as the rate of adverse
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events and pressure wounds. Rather than the efficiency and the respiratory effects, these studies

were focusing more on the feasibility and practicality of proning, an important aspect to

determine before implementing a new standard of care.

The results of these studies supported the prone position as an effective intervention and

a superior treatment option to the supine position. It was found that regardless of the underlying

cause of the patient’s declining respiratory status, whether they were intubated and mechanically

ventilated, or awake and able to be self-prone, that the intervention of prone positioning resulted

in minimal complications, decreased mortality, and improved respiratory status. The prone

position was found to be effective, safe, and linked to positive clinical outcomes.

Pertinent Findings

To analyze the prone position as an intervention, some findings were evaluated and

measured in a variety of ways. The effectiveness of the prone position on improved oxygenation

and respiratory status was measured by a notable increase in the PaO2;FiO2 during and after

prone positioning (Gleissman et al., 2019). This is a significant indication of improving ARDS,

supporting that the prone position could increase oxygenation. These improved values were seen

across the studies and were evidenced again by Park, Lee, Lee, & Lee (2021), where they found

that patients with ARDS secondarily related to COVID-19 had marked improvement in their

PaO2:FiO2 after the first session.

The duration of stay, survival rates, and outcomes were analyzed to evaluate the effect of

the prone position on mortality. COVID-19 patients who were positioned prone also had shorter

duration of stay in the ICU; as well as a reduced rate of advancement of respiratory support

measures to mechanical ventilation (Taboada et al., 2021). This finding ties into the reduced
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mortality and subsequent better survival rates found as a result of early initiation of prone

positioning (Mathews et al., 2021). Additionally, the patient’s response to the first session of

prone positioning was indicative of their future clinical outcomes (Park, Lee, Lee, & Lee, 2021).

With better outcomes and lower rates of mechanical ventilation, the survival rate for these

patients has increased through the prone position.

For an intervention to be implemented, it needs to be reasonably feasible and have

guidelines. The study by Jayakumar et al., (2021), was conducted during the peak COVID-19

months of the pandemic, and despite their research being multicentered during a time of severe

short staffing; strong positive evidence was still found. This supports that the prone position is

feasible even when resources are limited and will not be impractical to implement. However, the

study found that the guidelines for implementing this intervention are not well understood. It

was noted that the prone respiratory improvements returned to baseline after the patient resumed

the supine position. The study questions if this reverting back to baseline meant that the patient

had not been prone for an optimal amount of time. Without evidence to support an answer, this

calls for further investigation to be conducted to evaluate the optimal duration and schedule for

proning to be effective.

“Prone positioning may also cause potentially severe complications which should be

weighed against the potential benefits of the procedure.” (Gleissman et al., 2019) (p.362). Some

mild complications were found, such as minor ventral pressure wounds, and a rare but slightly

higher rate of infection (Douglas et al., 2021). However, it was deemed that the benefits of the

prone position could outweigh those adverse effects. The main complication associated with the

prone position was a high incidence of facial edema (Gleissman et al., 2019). Because this

complication can lead to an obstructed airway and fatality, it must be closely monitored for and
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signs of developing angioedema or facial edema would indicate that the prone positioning must

be discontinued.

Nursing Practice Implications

The main implication on nursing practice found is that a prone positioning schedule

should be considered for patients with ARDS. Jayakumar et al., (2021), notes that the prone

positioned patients had a significant improvement in oxygenation compared with the supine

patients. While this study directly addresses the prone position compared with the supine

position, each of the six studies reviewed addresses the comparison. When a marked

improvement is noted, it is compared to the baseline the patient was at previously, when the

patient was supine. With the evidence being compared to baseline, it supports that the prone

position is more desirable for this patient population. Nursing practice is affected by proposing

that the prone position must be included in the nurse’s arsenal of interventions for patients with

ARDS.

The reviewed studies found evidence that supports that prone positioning is associated

with improved oxygenation status, linked to better clinical outcomes and lower mortality rates.

Age, sex, and BMI did not affect those benefits of the intervention, meaning the prone position

might improve any patient’s status regardless of comorbidites (Gleissman et al., 2019).

Implicating a change to nursing practice that all patients should be considered for prone

positioning regardless of the underlying cause. As evidenced by Douglas et al., (2021), “The

findings have implications for adoption of the technique both for the care of critically ill

COVID-19 patients and for ARDS patients of other etiologies.” (p.500)

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Early prone position initiation was associated with lower mortality rates (Mathews et al.,

2021), which calls for the consideration of prone positioning to be a high priority assessment on

new ICU admissions. Taboada et al., (2021), noted that it was a simple and effective intervention

that is recommended for any patient without respiratory fatigue and who is hemodynamically

stable. Therefore, in addition to considering prone positioning for every patient with ARDS, this

intervention should also be considered early on in their admission to maximize the potential

benefits.

Conclusion

In conclusion, the prone position was widely accepted as an effective, safe, feasible,

intervention with minor severity and low rate of adverse effects. The studies all point toward

initiating a new standard of care, where patients with ARDs are normally considered for and

positioned in the prone position. The prone position was superior in improving the patient's

PaO2;FiO2 ratios and without major adverse events. The main implication for nursing practice is

that ICU patients should be assessed and considered as a candidate for the prone position early

on in their admission. This implication must be followed by the nursing consideration of

monitoring for facial edema during the patient’s prone hours. The nurse has a role of being an

advocate, and this information should affect nursing practice due to that role. Turn schedules,

positions, and the like are often overlooked, despite being a major factor in patient outcomes.

However, with the avoidable complications, decreased mortality, and improved quality of

ventilation and oxygenation associated with the prone position, nurses must consider each patient

with ARDS as a candidate to be positioned towards a successful recovery.

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References

Douglas, I. S., Rosenthal, C. A., Swanson, D. D., et al. (2021). Safety and outcomes of

prolonged usual care prone position mechanical ventilation to treat acute coronavirus

disease 2019 hypoxemic respiratory failure*. Critical Care Medicine, 49(3), 490–502.

https://doi.org/10.1097/CCM.0000000000004818

Gleissman, H, Forsgren, A, Andersson, E, et al. Prone positioning in mechanically

ventilated patients with severe acute respiratory distress syndrome and coronavirus

disease 2019. Acta Anaesthesiol Scand. 2021; 65: 360– 363.

https://doi.org/10.1111/aas.13741

Jayakumar, D., Ramachandran, DNB, P., Rabindrarajan, DNB, E., et al. (2021). Standard

care versus awake prone position in adult nonintubated patients with acute hypoxemic

respiratory failure secondary to covid-19 infection—A multicenter feasibility randomized

controlled trial. Journal of Intensive Care Medicine, 36(8), 918–924.

https://doi.org/10.1177/08850666211014480

Mathews, K. S., Soh, H., Shaefi, S., et al. (2021). Prone positioning and survival in

mechanically ventilated patients with coronavirus disease 2019–related respiratory

failure. Critical Care Medicine, Publish Ahead of Print.

https://doi.org/10.1097/CCM.0000000000004938

Park, J., Lee, H. Y., Lee, J., & Lee, S.-M. (2021). Effect of prone positioning on

oxygenation and static respiratory system compliance in COVID-19 ARDS vs. non-

COVID ARDS. Respiratory Research, 22(1), 220.

https://doi.org/10.1186/s12931-021-01819-4
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Taboada, M., González, M., Álvarez, A., et al. (2021). Effectiveness of prone positioning

in nonintubated intensive care unit patients with moderate to severe acute respiratory

distress syndrome by coronavirus disease 2019. Anesthesia & Analgesia, 132(1), 25–30.

https://doi.org/10.1213/ANE.0000000000005239