The Three P’s of Proning for ICU Nurses

Flipping a patient onto their belly while attached to various life-saving things can seem incredibly overwhelming. Proper preparation is the biggest way to ensure the safety of the patient, and the healthcare team who is positioning them. Before getting into the Three P’s of Proning, let’s review who is appropriate for this therapy and how it helps.

Who is appropriate for prone therapy?

Prone positioning is used for patients with moderate-to-severe acute respiratory distress syndrome (ARDS) who do not meet any contraindications. It is a strategy used for patients with a P/F ratio of < 150 to improve oxygenation and decrease mortality.

In the past, prone therapy was used as a Hail Mary. However, studies have shown prone therapy is best when used early in the course of severe ARDS. This is something to take into consideration as a critical care nurse as it is still underutilized. If we begin to recognize ARDS in our patients, we can suggest early implementation of prone positioning to improve our patient’s oxygenation and chances of survival.

How does prone positioning help?

Prone positioning improves alveoli recruitment, oxygenation, V/Q mismatching, and secretion drainage.

When patients are supine position, the abdominal and mediastinal structures increase the pressure on the dorsal lung fields. This can lead to overdistention of the ventral alveoli and alveoli collapse in the dorsal lung fields. Overdistension of the ventral alveoli can lead to additional lung injury. Additionally, fluid builds up in the dependent structures leading to poor oxygenation. V/Q mismatching is worse in the supine position due to blood flow and alveolar collapse being the greatest in the dependent lung fields.

When patients are moved to the prone position, the pressure within the thorax changes. The abdominal and mediastinal structures no longer compress the dorsal lung fields which can lead to reduced overdistention of the ventral alveoli and recruitment of the previously collapsed alveoli. Blood flow will continue to be the greatest in the previously dependent lung fields and those alveoli will begin to reopen. All of these things will ultimately lead to improved oxygenation, increased alveoli recruitment, and improved V/Q mismatching while reducing ventilator associated lung injury.

Now the big question is: How do we do this? It all comes down to proper preparation. Some facilities will have special beds to help prone patients, but many use manual proning. It is important to become familiar with your facility’s process and any equipment that may be used.

The Three P’s of Proning:

• PREPARE:
  • Ensure patient is adequately sedated & paralyzed (if using NMBA).
  • Check that all safety equipment is in the room in case accidental extubation occurs. 
  • Gather at least four people to assist, including one respiratory therapist. 
  • Communicate with the team and review proning steps to ensure seamless transition. 
  • Place silicone dressings on body prominences (i.e. Mepilex). 
  • Change commercial ET tube holders to tape. 
  • Disconnect anything that can be disconnected temporarily (i.e. tube feeds, temperature sensing foley probe, BP cuff, SCDs, ect..)
  • Remove ECG leads and gown front the patient. 
  • Extra: Wash the anterior portion of your patient. They will typically be in this position for at least 16 hours. 

• POSITION:
  • Respiratory will be at the head of the bed. Move on their count! Turn towards the ventilator. 
  • Indwelling catheter should be positioned between patients legs with securement device removed. 
  • IV infusion pumps should either at the head of the bed (if IJ or SC CVC sites) or at the foot of the bed (if femoral access).
  • Safety check halfway through the proning. 
  • Position ECG leads on the patient’s back.
• POST:
  • Ensure everything is still in place 
  • Reconnect anything disconnected. 
  • Assess vital signs. Don’t be alarmed if your patient has a drop in their SpO₂ at first and takes time to recover.
  • “Swimmers” position and Q2H head turns. 
  • Place patient in reverse Trendelenburg. 

How long will patients stay like this?

Patients should remain in the prone position for at least 16 hours. Patients are then placed back into the supine position for about eight hours. During this time, patients will be assessed for improved compliance, oxygenation, and level of lung injury. This is also a great time to perform any necessary nursing care. Do not be alarmed if your patient’s face is quite swollen. I usually try to have some cold compresses ready and elevated the head of the bed to help.

If the patients P/F ratio remains <150 then re-proning is usually performed. On some occasions, prone therapy will be ineffective. If this happens, or if the patient worsens hemodynamically or from a gas exchange perspective, then the patient will be returned back to the supine position.

Overall, proning a patient is labor-intensive. Having a proper plan in place is essential to the safety of everyone involved.

Resources:

Scholten, E. L., Beitler, J. R., Prisk, G. K., & Malhotra, A. (2017). Treatment of ARDS With Prone Positioning. Chest, 151(1), 215–224. https://doi.org/10.1016/j.chest.2016.06.032

Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013; 368:2159.

Hadaya J, Benharash P. Prone Positioning for Acute Respiratory Distress Syndrome (ARDS). JAMA. 2020;324(13):1361. doi:10.1001/jama.2020.14901

Koulouras, V., Papathanakos, G., Papathanasiou, A., & Nakos, G. (2016). Efficacy of prone position in acute respiratory distress syndrome patients: A pathophysiology-based review. World journal of critical care medicine, 5(2), 121–136. https://doi.org/10.5492/wjccm.v5.i2.121

UpToDate: Prone ventilation for adult patients with acute respiratory distress syndrome

Yuan, X., Zhao, Z., Chao, Y. et al. Effects of early versus delayed application of prone position on ventilation–perfusion mismatch in patients with acute respiratory distress syndrome: a prospective observational study. Crit Care 27, 462 (2023). https://doi.org/10.1186/s13054-023-04749-3