Higher PEEP levels have not been well-tested in ARDS prone positioning trials. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. Because each stakeholder had an active role in the development of the new process, the completed guideline became the Inaugural Interprofessional Clinical Practice Guideline. We updated a meta-analysis on this topic. ARDS is managed by treating the underlying cause of respiratory distress, through lung-protective mechanical ventilation strategies and ICU support including nutrition delivery and infection prevention. Several previous studies looked at proning, and all clearly show that proning in patients with severe ARDS improves oxygenation. 10, 11 Prone positioning is recommended for at least 12 hours a day in patients with moderate to severe ARDS. Cardona S, Downing J, Alfalasi R, Bzhilyanskaya V, Milzman D, Rehan M, Schwartz B, Yardi I, Yazdanpanah F, Tran QK. Severe ARDS is acute hypoxemia with a P/F ratio (PaO2 from blood gas/FiO2 as a decimal) of <150 mmhg, FiO2 > .60 on 5+ cm of PEEP. The guidelines require a team huddle, which is led by the nurse caring for the patient, before the prone positioning procedure. Online ahead of print.  |  Team V, Team L, Jones A, Teede H, Weller CD. The final result of proning is that the overall lung inflation is more homogeneous from dorsal to ventral than in the supine position, with more homogeneously distributed stress and strain. Highlights from the Respiratory Failure and Mechanical Ventilation 2020 Conference. doi: https://doi.org/10.4037/aacnacc2018161. In the still ongoing COVID-19 pandemic prone positioning has largely been adopted by clinicians and is even used before intubation in spontaneously breathing patients. Guérin C, Reignier J, Richard JC, et al; PROSEVA Study Group. What follows is a description of how we updated our procedures and guidelines in our health care system. Not all patients are candidates for this therapy, so consult the manufacturer's guidelines for the proning device you're using. Paul Welsh*, who is 6… The updated procedures in the guidelines have improved teamwork and efficiency, changing the process from a purely nursing one to one that is interdisciplinary. Proning for COVID-19 is being widely adopted and recommended for patients who have developed ARDS, and is even being prescribed by some clinicians for patients who are not ventilated ( Bamford et al., 2020 ; US National Library of Medicine, 2020 ). Prone positioning is discontinued on day 4, when the PaO2/FIO2 ratio is 263 mm Hg, the FIO2 is 60%, and PEEP is 10 cm H2O. Specifically, the rationale for high positive end-expiratory pressure (PEEP) and prone positioning in early COVID-19 ARDS has been questioned. AACN Adv Crit Care 15 December 2018; 29 (4): 415–425. Respir Care. Guérin C, Reignier J, Richard J-C, et al. In 1967, Ashbaugh et al1  published a report describing the acute onset of tachypnea, hypoxemia, and decreased compliance as respiratory distress syndrome in 12 adult patients who did not respond to conventional therapy at the time. Prone positioning has now assumed its rightful place in the armentarium of ARDS management. More homogeneous ventilation: Prone positioningreduces the difference between the dorsal and ventral pleural pressure, and the compliance of dorsal and ventral lung is therefore more homogeneous. An updated study-level meta-analysis of randomised controlled trials on proning in ARDS and acute lung injury. The latest PROSEVA (Proning Severe ARDS Patients) trial confirmed these benefits in a formal randomized study. During the implementation of the guideline, several strategies were used to meet education needs of the staff, including face-to-face education sessions, a video of the entire process developed by the ICU team, a quick reference sheet for the step-by-step process, and web-based education that provided details for each discipline. Prone positioning has been used for many years in patients with acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), with no clear benefit for patient outcome. The patients had signs and symptoms similar to respiratory distress in infants, and thus the syndrome was termed adult respiratory distress syndrome.1  Eventually, adult respiratory distress syndrome was changed to acute respiratory distress syndrome (ARDS).2–4, The first consensus definition of ARDS was determined at the 1994 American-European Consensus Conference, later revised to the 2012 Berlin definition.5,6  The Berlin definition outlines timing of symptom onset, details chest imaging and edema findings, stratifies ARDS into 3 main categories based on specified oxygenation criteria (mild, moderate, severe), and removes the term acute lung injury from the original definition (Table 1).6,7, Typical development of ARDS is within 7 days of a known risk factor, with pneumonia, aspiration of gastric contents, and sepsis leading to nearly 85% of cases.2,4  The mortality rate for ARDS has decreased in the last decade, from a reported hospital mortality of up to 90% down to a reported 46%; intensive care unit (ICU) mortality currently is reported at 38%.5,8  Annually, nearly 200 000 patients in the United States are diagnosed with ARDS; worldwide, the syndrome is responsible for 10% of all ICU admissions and occurs in 23% of patients undergoing mechanical ventilation.9,10  The long-term morbidity of critical illness coupled with ARDS is extensive, with substantial physical, neuropsychiatric, and neurocognitive impairment reported in patients for as long as 5 years after recovery.11  Cognitive impairment has been reported in up to 100% of patients at discharge and in nearly 20% of patients after 5 years.12  Compromised quality of life including depression and post-traumatic stress disorders has been reported in patients and their families.12.