Prone Position in ARDS: Nursing Implications

This report provides an overview of the prone position in ARDS and its nursing implications. It discusses the benefits, procedure, and indications for prone positioning. ARDS or Acute Respiratory Distress Syndrome is a severe condition that involves respiratory failure. Prone positioning can improve outcomes for ARDS patients.

Prone Position in ARDS-
Nursing Implications

Table of Contents
PREAMBLE....................................................................................................................................3
Abstract............................................................................................................................................4
Background......................................................................................................................................5
ARDS Pathophysiology Review............................................................................................5
Patients with ARDS................................................................................................................6
Prone Positioning of Patients With ARDS.............................................................................6
Procedure for achieving Prone Position.................................................................................7
Indications and Nursing Implications.....................................................................................7
Feedback..........................................................................................................................................8
Discussion........................................................................................................................................8
CONCLUSION................................................................................................................................9
REFERENCES..............................................................................................................................10

PREAMBLE
Objective
ARDS or Acute Respiratory Distress Syndrome is a disease which involves the failure of
the respiratory system of a person. This is a result of inflammatory processes in the body which
can be derived from a variety of pathological factors. This report provides an overview of the
prone position of ARDS as well as nursing implications.
Setting
Australian Health Services
Primary Argument
It is essential to ensure that health care practitioners are aware of the implications of
ARDS and how can it be treated in the most efficient way. This ensures that effective health care
services are delivered to the patients by implementing suitable strategies.
Conclusion
Since nurses are primarily responsible for delivering the best health care services to the
patients, they should be aware of the strategies that can be implemented in order to ensure that
the patients receive best treatment for their condition. There are a variety of techniques as well as
devices available to ensure fast recovery among patients.

Abstract
Acute respiratory distress syndrome or ARDS is a severe condition wherein there is a
respiratory failure among the patents. People who suffer from this condition are at a high risk of
death and do not survive most of the times. Prone position is a type of body position that is
beneficial for such patients and can improve the overall outcomes for them.

INTRODUCTION
Nurses that work in critical care are committed to managing patients that are intensely ill
and are in an unstable condition. ARDS or acute respiratory distress syndrome is a type of
respiratory failure that is mainly characterized by a rapid onset wherein there is a widespread
inflammation in the lungs1. There can be various factors that can trigger the condition of ARDS,
but one of the most common causes of this is an infection or sepsis in the blood. Besides this, if a
person gets a serious injury in their head or chest, and there is severe bleeding, they can also
develop ARDS. There is no cure for acute respiratory distress syndrome, but the treatment
involves supporting the patients while their lungs heal. The condition becomes evident acutely,
but progresses in a rapid manner.
Background
ARDS Pathophysiology Review
In context to nursing, ARDS is a lung condition that is life threatening for people who
suffer from it. In simple words, it can be referred to as a breathing failure that occurs in people
who are either very ill or injured severely. ARDS basically develops due to an injury in the
lungs, which can either be direct or indirect2. Indirect or extrapulmonary lung injury is the injury
of the alveolar epithelium as well as pulmonary vasculature leads to an increased permeability of
the alveolar capillary. Pathological specimens from patients with ARDS reveal an alveolar
damage. On the other hand, there are different laboratory studies which show that both alveolar
epithelial as well as lung endothelial injuries. These result in the accumulation of an
inflammatory fluid that is protein rich. The treatment of acute respiratory distress syndrome
focuses lung protective ventilation. Besides this, long-term outcomes of patients who are
suffering from ARDS are being identified as research targets. Also, any impairment of the
oxygenation ensues is seen on radiographs of the chest. Prone positioning benefits the patients by
improving the ventilation as well as perfusion.
1 Engström J and et. al., Physiological changes associated with routine nursing procedures
in critically ill are common: an observational pilot study. Acta Anaesthesiologica
Scandinavica. 2017 Jan;61(1):62-72.
2 Falkenstein B A and et. al., The economic and clinical impact of an early mobility
program in the trauma intensive care unit: a quality improvement project. Journal of
Trauma Nursing| JTN. 2020 Jan 1;27(1):29-36.

Patients with ARDS
ARDS is a condition that cannot be cured, but the patient is provided with utmost care in
order to make sure that they are stable. In simple words, patients who deal with acute respiratory
distress syndrome occurs when fluid builds up in the lungs of the patients. This fluid acts as a
barrier for the lungs to function properly, which means that enough blood is not able to reach the
bloodstream. As a result, the organs are deprived of the oxygen and are not able to function in an
effective manner3. Most of the people, who deal with this condition do not survive and
otherwise, there is a high risk of death which increases with age. Patients who deal with the
condition face symptoms such as severe shortness of breath, a low blood pressure, confusion as
well as extreme tiredness (ARDS, 2020). Patients with ARDS have to be hospitalized for their
treatment so that a stable condition can be maintained. There are several causes of ARDS and
some of them can include severe pneumonia, major injuries in the head or chest and sepsis in the
lungs.
Prone Positioning of Patients With ARDS
Prone position can be defined as a position of the body wherein the person lies flat with
their chest down and the back up. The position is beneficial for the patient and aids in secretion
as well as redistribution of the extravascular lung water. Besides this, other benefits of the
position include an improvement of the lung condition and oxygenation. Prone position when a
patient is on mechanical ventilation has showed to reduce the mortality in patients dealing with
acute respiratory distress syndrome or ARDS. It is most beneficial within 72 hours of the
diagnosis and the patient is kept prone for up to nearly 20 hours in a day 4. Another reason why
the position is beneficial is because when a person lies in the prone position, their heart mostly
rests on the sternum. As a result, the pressure exerted on the lung as well as the pleura is less.
The position has proved to improve the oxygenation among the patients suffering from ARDS up
to 70% to 80%. Besides this, the use of Trendelenburg position while the patient is prone also
3 Khanna P, Sarkar S, Garg B. Anesthetic considerations in spine surgery: What
orthopaedic surgeon should know!. Journal of Clinical Orthopaedics and Trauma. 2020
May 11.
4 Martin J L, Badeaux J. Sepsis, An Issue of Critical Care Nursing Clinics of North
America E-Book. Elsevier Health Sciences; 2018 Aug 11.

helps in decreasing the pressure on the abdomen as well as prevent any kind of displacement of
elements in the stomach.
Procedure for achieving Prone Position
In order to achieve prone position, the patient is placed under general anaesthesia as well
as intubated on the hospital bed in a prone state. Apart from this, the patients can also be
manually positioned in the prone state. This is usually done with the help of assertive devices or
in some cases by using an automated bed. When a patient is being positioned manually, it is
important to ensure that there is sufficient number of staff members so that the patient can be
turned safely5. A Vollman Prone Positioner, which is a metal frame that is padded and has belt
buckles that ensure that the head, chest and abdomen of the patient is safe and secure, can help in
positioning the patient in the prone state. All these devices and procedures help the critical care
nurses in positioning the patient in the prone position. In case the patient experiences a cardiac
arrest, an automated bed helps in positioning them in prone state rapidly. Only trained teams and
healthcare practitioners who are qualified and have completed their education, should be
permitted to attempt this as the procedure is physically challenging as well as requires intensive
labour.
Indications and Nursing Implications
There are various research studies that have been conducted indicate that an early prone
positioning and that prone positioning for sufficient duration can be beneficial for the patients.
The procedure for initiating the prone position begins with assessing the patient, which is a
crucial activity for the critical care nurses6. Although there are many benefits of prone position,
there can still be some risks that are associated with the same. These risks are balanced by the
need to provide adequate oxygenation. This should be weighed on an individual basis and the
P/F ratio can be used in order to guide timing for the position for the patients to the critical care
nurses. Prone positioning should be implemented as early as possible for patients who suffer
from ARDS and should not just be used as a recue intervention. Critical care nurses should be
vigilant while taking care of such patients. They are required to conduct assessments of all the
5 Narendra D K, Muigai D, Guntupalli K K. Acute Respiratory Distress Syndrome in
Pregnancy. Critical Care Obstetrics. 2018 Sep 19:403.
6 Nguyen A. Use of Recruitment Maneuvers in Patients With Acute Respiratory Distress
Syndrome. Dimensions of Critical Care Nursing. 2018 May 1;37(3):135-43.

body systems frequently. High risk complications for patients suffering with ARDS include
pressure ulcers, obstruction of the endotracheal tube etc. in order to assess the patient’s response
to being positioned prone is assessing improvements in the P/F ratio.
Feedback
ARDS still continues to be one of the reasons for increased mortality among patients and
thus, it is important for the critical care nurses to understand the pathophysiology of the
condition, different indications of the prone positioning as well as the important interventions of
nursing for the patients7. Also, prone positioning can help the patients dealing with ARDS up to
a great extent. This is because when they are positioned in the prone state, the alveoli are aerated
in adequate volumes. There are various research studies that have been conducted for ARDS
patients and mainly focus on the duration, timing as well as overall effectiveness of prone
positioning in treating ARDS patients. There are different procedures as well as devices that
assist the critical care nurses in positioning the patients in prone state.
Discussion
It is essential for the healthcare professionals like critical care nurses and other staff
members to be qualified and experienced in assisting and providing care to the patients that deal
with acute respiratory distress syndrome or ARDS. The condition is evident acutely but
progresses in a rapid manner. There are different therapies that are used in order to maintain a
stable condition of the patients and can include partial liquid ventilation, neuromuscular blocking
agents, intravascular oxygenation and so on. Early prone positioning has demonstrated that it is
beneficial and can lead to better outcomes for them8. Assessment of the patient is the basis for
initiating prone positioning and is performed by critical care nurses. Besides this, the nurses are
also required to assess the skin condition of the patient before turning them to prone position as
there can be a breakdown of the skin. This is also because when the patient is prone, there is a
considerable pressure on the forehead as well as cheeks. It is important to take appropriate
measures in order to make sure that the skin breakdown is minimized. While implementing these
7 O’Connor E and et. al., Interventions to prevent perinatal depression: evidence report
and systematic review for the US Preventive Services Task Force. Jama. 2019 Feb
12;321(6):588-601.
8 Omura K and et. al., Frequency and outcome of post‐extubation dysphagia using nurse‐
performed swallowing screening protocol. Nursing in critical care. 2019 Mar;24(2):70-5.

measures and providing care to ARDS patients, critical care nurses should be vigilant. They
should conduct frequent assessments of the different body systems of the patient.
CONCLUSION
From the above report, it can be concluded that ARDS or acute respiratory distress
syndrome is a condition wherein there is a failure of the respiratory system and is generally
characterised by inflammation in the lungs that is widespread. Some symptoms of the condition
include shortness of breath, rapid breathing etc. The condition is cannot be cured, although it can
be treated under the supervision of a healthcare professional. The condition of ARDS is critical
and requires an emergency care. Prone positioning has proved to be beneficial for patients
dealing with the condition and only critical care nurses and other health care staff members who
are trained and have completed their education should be permitted to attempt this particular
intervention.

REFERENCES
Books & Journals
Engström J and et. al., Physiological changes associated with routine nursing procedures in
critically ill are common: an observational pilot study. Acta Anaesthesiologica
Scandinavica. 2017 Jan;61(1):62-72.
Falkenstein B A and et. al., The economic and clinical impact of an early mobility program in the
trauma intensive care unit: a quality improvement project. Journal of Trauma Nursing|
JTN. 2020 Jan 1;27(1):29-36.
Khanna P, Sarkar S, Garg B. Anesthetic considerations in spine surgery: What orthopaedic
surgeon should know!. Journal of Clinical Orthopaedics and Trauma. 2020 May 11.
Martin J L, Badeaux J. Sepsis, An Issue of Critical Care Nursing Clinics of North America E-
Book. Elsevier Health Sciences; 2018 Aug 11.
Narendra D K, Muigai D, Guntupalli K K. Acute Respiratory Distress Syndrome in Pregnancy.
Critical Care Obstetrics. 2018 Sep 19:403.
Nguyen A. Use of Recruitment Maneuvers in Patients With Acute Respiratory Distress
Syndrome. Dimensions of Critical Care Nursing. 2018 May 1;37(3):135-43.
O’Connor E and et. al., Interventions to prevent perinatal depression: evidence report and
systematic review for the US Preventive Services Task Force. Jama. 2019 Feb
12;321(6):588-601.
Omura K and et. al., Frequency and outcome of post‐extubation dysphagia using nurse‐
performed swallowing screening protocol. Nursing in critical care. 2019 Mar;24(2):70-5.
Online
ARDS. 2020. [Online]. Available through:<
https://www.mayoclinic.org/diseases-conditions/ards/symptoms-causes/syc-20355576>.