?? Prone Position in ARDS: Elevating Bedside Care ???

Prone positioning has transformed ARDS management, especially for moderate-to-severe cases. With its proven benefits in oxygenation, lung protection, and survival, it’s time to refine its application at the bedside. Let’s dive into the key aspects:

? Why Prone Positioning?

1. Improved Oxygenation ??:

? Promotes uniform lung inflation by redistributing ventilation to dorsal regions while maintaining perfusion.

? Reduces shunt and dead space ventilation.

2. Reduced Ventilator-Induced Lung Injury (VILI) ??:

? Minimizes overdistension in non-dependent lung areas.

? Decreases cyclic opening and closing of dependent regions.

3. Enhanced Hemodynamics ??:

? Unloads the right ventricle, improving cardiac output in patients with acute cor pulmonale.

4. Proven Survival Benefits ??:

? PROSEVA Trial: 90-day mortality dropped from 41% to 23.6% with prone positioning in severe ARDS.

?? Who Benefits and When to Use It?

? For Whom?

? Patients with moderate-to-severe ARDS (PaO?/FiO? < 150 mmHg).

? Spontaneously breathing patients during COVID-19, though evidence remains inconclusive.

? When?

? Early in ARDS (within 36 hours of onset).

? Daily sessions of 16–18 hours are critical, regardless of immediate oxygenation response.

? Contraindications ??:

? Absolute: Unstable spinal fractures.

? Relative: Hemodynamic instability, unstable fractures, open abdominal wounds, or raised intracranial pressure (modifiable with monitoring).

?? How to Implement Prone Positioning?

1. Preparation:

? Assemble a team of 4–6 trained caregivers.

? Ensure secure fixation of the endotracheal tube, lines, and catheters.

2. Positioning:

? Rotate arms between parallel and swimming crawl positions.

? Alternate head positions every 2–4 hours to prevent pressure ulcers.

? Use transverse rolls cautiously to avoid reduced chest wall compliance.

3. Ventilator Settings ???:

? Low Tidal Volumes: 4–6 mL/kg predicted body weight.

? Plateau Pressure: <30 cmH?O.

? PEEP: Adjusted to prevent atelectrauma or hyperinflation.

4. Monitoring:

? Continuous assessment of oxygenation, ventilation, and hemodynamics.

? Observe for complications like facial edema or pressure ulcers.

?? Recognizing and Managing Complications

1. Pressure Ulcers:

? Higher rates initially but equal to supine at ICU discharge. Preventive measures include skin care and cushioning.

2. Device Displacement:

? Ensure meticulous securing of all tubes and lines during proning.

3. Hemodynamic Instability:

? Optimize fluid resuscitation and vasopressors before prone positioning.

4. Ocular Complications:

? Monitor intraocular pressure, especially during prolonged sessions.

?? What’s the Evidence?

1. Mechanistic Benefits:

? Enhances ventilation-perfusion matching.

? Improves gas exchange and reduces dead space ventilation.

? Achieves lung protection by evenly distributing lung stress and strain.

2. Clinical Trials:

? Meta-analyses: Mortality benefit observed in severe ARDS patients with prolonged proning (>12 hours/day).

? COVID-19: Emerging evidence supports use in spontaneously breathing patients, but data on intubation prevention remain limited.

3. Prone in ECMO Patients:

? Feasible and effective when performed by trained teams, with minimal complications.

?? Key Takeaways for Bedside Practice

? Prolonged prone sessions (16–18 hours/day) offer maximum survival benefit.

? Focus on individualizing ventilator settings and managing complications effectively.

? Team training and multidisciplinary collaboration are critical for successful implementation.

?? Questions

1. How do you prioritize ARDS patients for prone positioning in resource-limited settings?

2. What strategies can mitigate complications like device dislodgement or hemodynamic instability during prolonged sessions?

3. How do you optimize PEEP and tidal volume settings to balance lung protection and hemodynamic stability?

Prone positioning isn’t just a maneuver—it’s a lifesaving intervention that requires precision, planning, and persistence. Let’s elevate our bedside care! ???

?? References

1. Guérin C, et al. Prone position in ARDS: Why, when, how, and for whom. Intensive Care Med. 2020;46:2385–96. doi:10.1007/s00134-020-06306-w.

2. PROSEVA Trial Group. Prone positioning in severe ARDS. N Engl J Med. 2013;368:2159–68.