ARDS, COVID-19 and Pronation Therapy

We are proning ventilated patients and encouraging non ventilated patients to self prone. Proning patients without proning beds is labor intensive, an ... d takes 4 people. So usually it is done twice a shift without a proning bed, due to the labor requirements. I think Covid 19 is changing the way doctors consider intubating patients, because intubation does not always mean a life is saved, but it can mean high costs and the promise of false hope for families. If the prognosis and outcome is clinically poor in the ED should patients be intubated with Covid? Read More

With a few hours of scanning through my resources affiliated with my institution sadly as I sense urgency with many of these requests about prone posi ... tioning, I want to answer your question quickly. I scanned about 50 abstracts and read a few articles. There isn't much research out there that fits your patient population and I'll echo the above "anecdotal" phrase (search phrases include: "prone"/"proning" as well as "non-intubated"/"non intubated"). A couple small studies report yes, prone position therapy looks to have positive results in non-intubated patients in studies, n=15 ("Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: A retrospective study", Scaravilli, V, et. al., doi: 10.1016/j.jcrc.2015.07.008), n=7 ("Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study", Ding, L, et. al., doi: 10.1186/s13054-020-2738-5). Read More

Hello Wendy, We are implementing the prone therapy in my unit and it works fantastic in most of the patients. We prone the patients for a minimum of ... 14 hours. Read More

I am looking for specific guidance on posterior CPR for proned COVID 19 ventilated patients. Has anyone found a good video for critical care staff to ... watch that demonstrates proper hand positioning to begin posterior CPR until additional members of the team arrive in PPE? Read More

Hi Robin - American Heart has published interim guidelance for basic and advanced life support for adults, pediatrics and neonates with suspected or c ... onfirmed COVID-19 that can be found here: https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.120.047463. They address doing CPR with patient in prone position on page 7. This is their statement: While the effectiveness of CPR in the prone position is not completely known, for those patients who are in the prone position with an advanced airway, avoid turning the patient to the supine position unless able to do so without risk of equipment disconnections and aerosolization. Instead, consider placing defibrillator pads in the anterior-posterior position and provide CPR with the patient remaining prone with hands in the standard position over the T7/10 vertebral bodies. Read More

We prone our covid pts who present to ER/ICU c/o SOB and requiring oxygen from nasal prong to highflow. We ask them to stay prone as long as they can ... over night then alternate supine/prone as tolerated during day time. I don’t have exact statistics but i have seen drastic improvement from O2sat 85% on 100% highflow oxygen to less then 50% O2 requirements and o2 sat above 94% within 30min to 2 hours. We often see O2 requirements increasing again when supine and pts requesting to be proned again. We have been able to avoid intubation in a lot of cases. Since we have been doing this we have less intubated covid pts in our icu. Read More

Thank you Linda, this is very helpful. Do you have any information or found any research on proning NON intubated patients? Lyne, your post is very ... interesting! What challenges have you seen in proning your patients who are non vented? Thank you for sharing! Read More

To John Powell, thank you for the articles you have posted. The research included parameters and steps to help reduce the RATE of intubating patients ... and therefore prevent negative outcomes (focus on progressive mobility goals). The patient population were of pneumonia and flu. Parameters used were PF ratio and oxygen requirement in the decision tree. If we are able to sift through these research, it can help with nursing load and ratio. I am definitely looking at these articles to meet patients goals, promote good outcomes, and get them back to their families! We have success stories in our facility. Anything helps! Read More

Althea: The AACN Procedure Manual suggests you stop feedings one hour prior to pronation and then restart once the patient is proned. This response is ... from Sharon Dickinson: Critically ill patients with severe hypoxemia receiving mechanical ventilation can be safely feed in the prone position. Enteral nutrition is feasible and is generally well tolerated when delivered via a continuous nasogastric/orogastric feeding. Nutritional delivery in prone position is comparable with that of supine position. Sources: Savio, RD, Parasuraman, R., Lovesly, D, et al., Feasibility, tolerance and effectiveness of enteral feeding in critically ill patients in prone position, Journal of Intensive Care Society, January 14, 2020. https://doi.org/10.1177/1751143719900100 Saez de la Fuente I, Saez de la Fuente J, Estelles MDQ et al. Enteral nutrition in patients receiving mechanical ventilation in a prone position. JPEN J Parenter Enteral Nutr.2016;40(2):250-255. Read More

Marfil: As John noted, the research on proning non-ventilated patients is scarce and the 2 studies he cited are very small and the same ones I would ... give you. At this time there is not enough evidence to either endorse or refute the procedure, however, we know that it is being done as part of efforts to not intubate COVID-19 patients. It would make a good study . . . Read More

Hi Linda, Thank you very much for the information. Very helpful. I was skeptic that stomach upset & vomiting would more likely happen when pt's are p ... rone. Read More

Hi Maria. The recommendations say that you should stop feedings for 1 hour prior to proning if possible and then restart once the patient is proned. T ... he rate will be determined by patient tolerance and your nutritional plan determined by the team. Read More

Hi Rita: The goal is always to only use medication that the patient needs. If they are tolerating the procedure with only sedation, it would be a disc ... ussion with the team about the value and/or utility of using NMBs if the patient's clinical condition does not warrant use. Read More

Hi Caitlin: This response is from Sharon Dickinson: Critically ill patients with severe hypoxemia receiving mechanical ventilation can be safely feed ... in the prone position. Enteral nutrition is feasible and is generally well tolerated when delivered via a continuous nasogastric/orogastric feeding. Nutritional delivery in prone position is comparable with that of supine position. Sources: Savio, RD, Parasuraman, R., Lovesly, D, et al., Feasibility, tolerance and effectiveness of enteral feeding in critically ill patients in prone position, Journal of Intensive Care Society, January 14, 2020. https://doi.org/10.1177/1751143719900100 Saez de la Fuente I, Saez de la Fuente J, Estelles MDQ et al. Enteral nutrition in patients receiving mechanical ventilation in a prone position. JPEN J Parenter Enteral Nutr.2016;40(2):250- Read More

Our ratio remains the same: ( 2:1 ) 2 patients/RN; because we have on overhead lift, at times when everybody's busy we are able to prone the patient w ... / 2 RN's and an RT Read More

Hi Patricia - thanks for your question and thanks to Sheila for her response. We are seeing variability around the country depending on availability o ... f staff and what level of the emergency response they are working in. I'd love to be able to tell you that all patients are being managed in the same way, but that is not possible universally. Read More

Hi Catherine - The recommendations from ASPEN regarding enteral nutrition for patients proned and on mechanical ventilation suggest that there is no d ... ifference between feeding a proned vs. supine patient on mechanical ventilation. The concern is for patients who are hemodynamically unstable on multiple vasopressors as well as narcotics and/or paralytics. You would still include assessing for feeding tolerance, such as vomiting or gastric ileus especially while receiving narcotics and/or paralytics. Should this occur you may have to consider using trophic feeds or holding feedings. Here's a short video from ASPEN that may help: https://www.youtube.com/watch?v=rUUK3lSpkqw&feature=youtu.be Read More

Hi Shannon - I would suggest you put this question to one of the AACN Practice discussion groups as anecdotally it seems that practice varies. This pa ... ge will give you the options: https://www.aacn.org/clinical-resources/online-nursing-community-forums Read More

Hi Amanda - We have been noting questions on the various listservs and discussion groups about the issue of increased CAUTI rates in COVID-19 patients ... , however, no one has specifically directed their questions r/t proned patients. I would suggest you put this question to one of the AACN Community discussion groups for their responses. You can access them through this page on the AACN website: https://www.aacn.org/clinical-resources/online-nursing-community-forums Read More