Prone Positioning in Patients with ARDS

Jean Harken

Ferris State University

PRONE POSITIONING IN PATIENTS WITH ARDS1

Nurses analyze data and research everyday as part of their jobs. Much of the information that is gathered is evidence-based and used to improve the way we care for our patients. The purpose of this assignment to take the evidence based research, reflect on it and hopefully implement it in our daily practices (Ursuy, 2014).

Clinical Question

When talking about data research and analysis, a clinical question or problem must be identified. This question should come from daily practices and should be something that should be able to be improved upon, therefore making the care of the patient better. The question that is being analyzed in this paper is: Does changing the patient to a prone position for at least 12 hours a day reduce the damage done to the lungs and promote faster recovery as opposed to keeping the patient in a supine position in a patient with adult respiratory distress syndrome(ARDS) that is ventilator dependent? By experimenting with this method and then analyzing the research, we will be able to establish a conclusion as to whether or not changing positions to the prone position is beneficial to a patient with severe ARDS (adult respiratory distress syndrome).

While developing a question for data research and analysis the PICOT acronym is often used to help direct the question tospecific areas to analyze. The first letter in the acronym “P” is the problem/patient/population(Lansing Community College Library, 2014). This depends on what type of question you are asking. Are you dealing with a specific patient such as age, gender, health status? Are you dealing with an entire population or are you dealing with a specific problem? You can have more than one of these questions as part of the “P”. Next comes the “I” which stands for intervention. This would cover what you plan to change or do differently for the patient. Is there a specific test that needs to be done? Is there lab work that needs to be completed? Does the patient need to change something or have something changed for them? This part of the question is trying to figure out what needs to be done to improve care of the patient. The “C” stands for comparison. This would be to show if your interventions are working or not. In the particular question being addressed in this paper, the comparison is whether to leave the patient supine at all times or whether proning the patient for several hours a day will help improve lung function and reduce damage. Next brings us to the “O” of the PICOT acronym, which is outcome. What do you expect to see, or what is wanted to be seen or what is actually seen after the first three letters are completed and analyzed. Finally we have the “T” which is for time. This is not always utilized in each question, but in this question be do use time. We want to know how many hours a day must a person be in each the prone position and supine position to have a benefit to the lungs.

Once the PICOT question research is done and analyzed, it can then be determined the effect that it will have on your patient. By placing a patient in the prone position for at least 16 hours each day and then changing the patient to a supine position, oxygenation has been shown to improve in 70% of patients (White, 2005). There is also a great deal of evidence that shows there is less damage to the baroreceptors, that also allow better oxygenation, ultimately improving patient outcomes (White, 2005). By improving the oxygenation and decreasing the damage done to the lungs, you ultimately improve the quality of care for the patient. Although you need several staff members to make this happen, if trained to do so, this is very safe for patients and they do much better in the long run.

Methodology

When searching for research article on this topic, initially a database was searched in the Cumulative Index for Nursing and Allied Health Literature (CINAHL) website. The search words were proning, ARDS and ventilator dependent. It was noted that only using key words was going to yield some articles, but not as many as when other search terms were entered. Another search was done on PUBMED utilizing the same search as on the CINHAL website. While articles were found and most of them were relevant to the topic, this was also not found to be the best words that could be searched. When the search words ARDS positioning was entered, there were several more research articles that were found. There was much more pertinent articles that were found and the majority of them dealt with prone positioning.

It was difficult to find articles that only dealt with nursing research at ones current level of nursing rather than advanced practice research. Many of the articles that were found were done by nurse practitioners, certified registered nurse anesthetists or even physicians. Nursing research at the registered nurse level is extremely important because those nurses are the ones that are hands on with the patients and taking care of them. This type of research with the same nurses taking care of the patients will provide much more accurate evidence based practice, than utilizing the data of advance practice nurses or physicans that only observe and inperpert the data done by the nurses. There is a larger margin of error, the more the information gets passed from person to person.

There are seven levels of evidence that are evaluated when breaking down the articles for review (Melnyk & Fineout-Overholt, 2011). These levels start with level one which is based on actual trials, with guidelines or a systematic review of randomized controlled trials (Melnyk & Fineout-Overholt, 2011). Levels two and three are based on trails, where level two is randomized and level three is controlled. Levels four thru six all involved studies that are cased controlled or dealing with qualitative studies. Level seven has no studies, trials, guidelines or reviews, it is merely an expert opinion.

Discussion of Literature

Article One

The first article is a nursing research article from The American Journal of Respiratory Care and Critical Medicine. This article involved patients that were in a critical care unit. These patients were taken to a CT scanner and a scan was done while the patient was in a prone position to see the effects of a high amount of positive end-expiratory pressure (PEEP) on lung recruitment. The results noted that patients in the prone position did enhance lung recruitment (Rodrigo et al., 2013). This was a level five study because it was a review of a qualitative study.

Article Two

This article was a study to see if placing a patient in a prone position for several hours during the time a patient in severe ARDS was on a ventilator decreased the mortality rate. In this trial, ICU patients were studied and a number of patients were placed in prone position for sixteen hours per day. A second set of patients was placed in a prone position for less than sixteen hours per day. This study found that the patients that were placed in a prone position for sixteen hours each twenty-four hour period has a better chance of survival as well as greater lung protection (Sud et al., 2014). This was a level one study due to having randomized controlled trials, which had systematic reviews.

Article Three

The last article reviewed was also a level one study. There was review of randomized studies, including the studies with a cross over design along with a meta-analysis of the effects of prone position on mortality. This article used nine controlled trials with two thousand two hundred and forty two patients (Hu et al., 2014). These studies were reviewed by investigators and it was decided whether or not the patient or the trials met the exclusion criteria. This article showed that the duration that the patient is in the prone position is definitely relevant. This article also showed that if the patient was prone long enough there was improvement in mortality as well as decrease damage to the lungs.

Significance to Nursing

In nursing, and healthcare in general, there is constant change. In nursing, we are always finding ways to improve the care our patients receive and to improve the outcomes of our patients. Evidence based practice is extremely important to improve just those things. Through evidence based trial and error, we can improve the lives of the people we care for. It would be very beneficial for hospitals to have a protocol for proning patients in severe ARDS. Especially in the younger populations. With the research that has been presented, there is significant data to show that proning patients improves many things. One recent case in a local hospital was on a thirty two year old female. This patient presented with “the flu” which rapidly progressed into respiratory distress and ARDS that progressively became worse. Physicians were trying anything they could think of to assist this patient. She was near arrest and unstable at least three times during her stay. Calls were made to get her inextracorporeal membrane oxygenation(ECMO) and she was not a candidate. The decision was made to place her prone for sixteen hours a day and then place her supine. Changes were seen within twenty four hours and continued to improve. This patient made a full recovery. It is remarkable to actually see the effects of proning a patient.

With safety and quality obviously being the most important things while caring for patients, Quality and Safety Education for Nurses(QSEN) would play a role as well. Training is required before proning a patient and several people (at least five) are needed to properly and effectively prone a patient. With this type of patient positioning, good communication, teamwork and safety are required (QSEN, 2014). The practice of proning patients should be something that is implemented in hospitals across the world. It would be beneficial to have videos that hospitals could present to their staff to show the art of teamwork and communication during this process and how important it is to utilize these skills.

The American Nurses Association (ANA) describes the who, what, when, where, how and why of nursing (American Nurses Association, 2014). With that in mind, proning patients should be done in all patients with severe ARDS that are requiring artificial ventilation. This needs to take place for at least sixteen hours per day and continue until drastic improvements are noted. The number of lives and lung tissue that is saved could be large. With this practice we are giving patients the greatest chance of not only survival, but also decreasing the negative long term effects. The ANA also recognizes that many practices require many other specialties to participate in the care of the patient (American Nurses Association, 2014). In the case of proning patients, the care of anesthesia, critical care and respiratory care are all needed to work together for the greater good of the patient. Implementing this procedure as a standard of practice across the United States would be a huge step in the care for patients. The amount of time that patients are on the ventilator is reduced and well as the amount of damage to the lungs. This will then reduce the amount of time in the hospital and the resources needed for rehab and continued care.

Conclusion

As the data shows, proning patients is a great way to manage a patient in severe ARDS that is on a ventilator. Although there needs to be a great deal of teamwork and communication not only among the nurses, but also among other disciplines. This would improve the quality of care and improve the safety of our patients. Although this is only in the first staged of being added into the protocols of larger hospitals, hopefully in the very near future it will be added to local hospitals across the United States.

References

American Nurses Association (2014). Scope and Standards of Practice. Retrieved from

Hu, S., He, H., Pan, C., Liu, A., Huang, Y., Guo, F., ... Oiu, H. (2014, May 28). The effect of prone positioning on mortality in patients with acute respiratory distress syndrome: A meta-analysis of randomized controlled trials. Critical Care, 18, 109.

Lansing Community College Library (2014). What is PICOT? Retrieved from

Melnyk, B.M. & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia: Lippincott, Williams & Wilkins.

QSEN (2014). QSEN Initiatives. Retrieved from

Rodrigo, A., Cornejo, J. C., Diaz, E. R., Tobar, A. R., Bruhn, C. A., Ramos, R. A., ... Diaz, A. J. (2013). Effects of Prone Positioning on Lung Protection in Patients with Acute Respiratory Distress Syndrome. American Journal of Respiratory and Critical Care Medicine, 188, 440-448.

Sud, S., Friedrich, J., Adhikari, N., Taccone, P., Mancebo, J., Polli, F., ... Sud, M. (2014, July 8). Prone Positioning on Mortality Among Patients with ARDS. CMAJ, 10, 381-390.

Ursuy, P. (2014). NURS 350 Research in Nursing. In Couse Syllabus (pp. 1-10). Retrieved from Ferris State University MyFSU

White, M. (2005, April). Proning for ARDS makes a comeback. Critical Care Nursing, 35, 32cc1-32cc2. Retrieved from