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October–December 2010 Journal of Trauma Nursing • Volume 17, Number 4 201

Prone Positioning in TraumaPatients: Nursing Roles andResponsibilities

Jessica R. Chadwick, MSN, RN, CCNS

■ ABSTRACTOne of the leading causes of mortality in the intensivecare unit is Acute Respiratory Distress Syndrome(ARDS). Acute Respiratory Distress Syndrome can occuras a result from multiorgan dysfunction syndrome andsepsis. In the trauma population, ARDS accounts for anincrease in mortality as well as morbidity and disability.Nurses have an essential role in the care of the traumapatients with ARDS or acute lung injury patients.Respiratory treatments such as airway pressure releaseventilation and chest physiotherapy are utilized often forARDS treatment. A lesser used therapy, intermittentprone positioning has also been found to be effective inincreasing the pulmonary gas exchange in traumapatients. This article will explain the nursing roles andresponsibilities in the initiation, continuation, and cessa-tion of intermittent prone positioning.

■ KEY WORDSIntermittent prone Positioning, Nursing responsibility,Oxygenation, Trauma

In the context of the acute lung injury (ALI)/AcuteRespiratory Distress Syndrome (ARDS), it has been

shown that dependent portions of the lung undergo themost alveolar collapse.1 Supine positioning is primarilyresponsible for this increased atelectasis.2 The dorsal lungfields comprise over 50% of the lung tissue, which results

Author Affiliation: Emergency Department, Inova FairfaxHospital, Falls Church, Virginia.

I want to thank Kathryn VonRueden, RN, MS, FCCM for herpatience in editing, and all for the knowledge that she hasgiven to the Class of 2009.

Correspondence: Jessica R. Chadwick, MSN, RN, CCNS,Inova Fairfax Hospital, 3300 Gallows Rd. Falls Church,VA22042, ([email protected]).

DOI: 10.1097/JTN.0b013e3181ff2813

in a significant decrease in functional alveoli, and, there-fore, a reduction in functional residual capacity.Clinicians began seeking ways to optimize the dorsal lungfield’s efficacy, and decrease the dependent alveolar col-lapse. An effective means of achieving this goal is inter-mittent prone positioning (IPP).

In the mechanically ventilated patient, ventilation: perfu-sion (V:Q) ratios are drastically different than the sponta-neously breathing individual. When patients breathespontaneously their ventilation distribution is relativelyhomogeneous.3 However, during mechanical ventilationwith positive pressure, gas travels the “path of least resist-ance” to the ventral portion of the lung, in the supine patient.

In animals, it has been found that there is a morehomogeneous distribution of ventilation when patientsare placed in the prone position versus supine.1 Theincrease in homogeneity is attributed to the repositioningof the pressure from the intrathoracic organs (heart andlung), leading to an alteration in pleural pressures.1

Increased homogeneity in ventilation leads to anincreased utilization of functional alveoli and thereforeimproved gas exchange and oxygenation.

The heart is responsible for compressing 7% to 42%of the left lung and 11% to 16% of the right lung in thesupine position.1 This compression is relieved when thepatient is placed in the prone position. Another source oflung compression is the abdomen. In the supine position,gravity is pushing down on the abdominal contents caus-ing them to displace the diaphragm upward into the chestwall (Figure 1).4 This displacement and pressure weakensthe diaphragmatic excursion and therefore reduces lungexpansion. When a patient is placed in the prone posi-tion, the abdominal contents remain uncompressed, andthe diaphragm is able to contract, allowing normal lungexpansion.

In the supine position, patients are able to producemore ventral chest wall movement owing to the freedomof the ventral rib cage; however, this causes the dorsalportion of the chest wall to have little or no impact inchest wall movement.5 Since ventilation follows chestwall movement, increased ventral wall movement wouldlead to preferential ventral ventilation. When the patient

C L I N I C A L C A R E

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202 Journal of Trauma Nursing • Volume 17, Number 4 October–December 2010Copyright © 2010 Society of Trauma Nurses. Unauthorized reproduction of this article is prohibited.

is placed in the prone position, the ventral mobility is decreased, and therefore chest wall movement becomesmore synchronyous between the ventral and dorsalregions, leading to increased homogeneity in ventilation.

■ NURSING ROLES AND RESPONSIBILITIESIN THE CARE OF THE PRONE PATIENTBarriers to Implementing IPPThe benefits of prone positioning have been reportedsince 1973;6 however, in some ICU’s this modality of careoften remains a last resort or impossible task. Many cli-nicians are aware of the improved oxygenation thataccompanies prone positioning; however, there remains alack of clinical data that shows that IPP improves mortal-ity. This lack of data has prevented the widespread use ofthis treatment.

Nurses have an extremely important role in the care ofthe prone positioned patient. This responsibility beginsprior to the initiation of the therapy. The staff nurse holdsthe power in many institutions to initiate IPP. On the “flipside” the nurses’ fears of proning a patient can eliminatethe option of this modality altogether. As Offner et al7

points out, reluctance is also related to the misconceptionof the complexity of the maneuver and risk of life-threat-ening complications. The limited knowledge of relativeversus absolute contraindications is a primary barrier ininitiating IPP. It is the nurses’ responsibility to understandthese contraindications thoroughly.

Another barrier in the use of prone positioning in thetrauma patient is the lack of consensus on the optimal

time and duration of prone positioning, and parametersfor measuring success.8 In the past, studies have focused agreat deal on the efficacy of prone positioning andadjuncts to prone positioning; however, limited researchhas been performed on the details of the procedure (ie,timing, duration, and measurement parameters).

Initiation of IPPNurses are important advocates in initiating advancedtherapies for their patients. Nurses who understand thephysiologic and evidence base of IPP earn trust from theteam that the procedure will be performed appropri-ately; leading to an increase in the utilization of suchtechniques.

On the basis of relevant studies, the triggers for initi-ation of IPP include the following: (a) Evidence ofALI/ARDS (defined as: acute bilateral infiltrates on chestx-ray, severe hypoxemia, no evidence of left atrial hyper-tension).9 (b) PaO2�FiO2 ratio (P:F) �200, (c) PositiveEnd-Expiratory Pressure (PEEP) �8 cm H2O.9 These arenot the only triggers for the implementation of IPP(Table 1), and do not take the place of clinical judgmentand physical assessment.

Continuation of IPPAs a member of the team who are at the beside 24/7,nursing staff have the unique ability to evaluate trends inpatient response on a minute to minute, hour to hour andday to day basis. Continuous bedside monitoring ofSvO2, patient agitation, hemodynamic parameters, and

Figure 1. Normal anatomy; supine positioning.

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abdominal compartment pressures, allow the staff tounderstand the patient’s response to proning, and betteranticipate patient needs.

Several schedules have been proposed for the supine toprone ratio. Michaels et al used a 6 hours prone, 6 hourssupine or 8 hours prone and 4 hours supine approach tooptimize the patient’s ventilation.10 The variation in pron-ing schedule is grossly regulated by the nursing staff.They are able to assess the patient tolerance and progressweaning ventilator support in a given position. This willkey them in to understanding when that patient will tol-erate changing positions. The nursing staff also plays animportant role in ensuring that the needs of the patientare met whereas the patient is in any given position.Schedules can be designed to balance nursing workload,patient safety, as well as improvement in lung functionwith decreased atelectasis.10 Michaels’ schedule (6 hoursprone/6 hours supine, or 8 hours prone/4 hours supine)appeared to be successful in satisfying patients and clini-cal staff, and is an excellent beginning schedule untilpatient response can be judged.

Cessation of IPPPremature discontinuation of IPP can quickly reverse itspositive effects; therefore, the cessation of prone posi-tioning needs to be carefully considered and involve allof the critical care team. However, the nursing staff, asthe team members that best know patient response andneeds, have an integral role in this evaluation. As shownin Table 1, criteria for cessation have not been welldefined. Each patient needs to be evaluated individuallyon the basis of his or her response to the procedure.Some patients progress rapidly, and therefore do notneed to continue IPP for extended periods of time; how-ever, other patients (ie, patients with multiple comor-bities, underlying lung pathology, or patients in severeARDS) may require IPP for much longer. Criteria forbeginning discussion of cessation of IPP suggested inseveral studies includes: FiO2 �.40, PEEP �8 cm H2O,P:F �250-300.11,12

Complications of ProningComplications related to proning are dependent on thepatient population. In trauma patients, the followingcomplications are more frequently identified, however,all are preventable. With proper education and a confi-dent group of practitioners the risk can be dramaticallydiminished.• Complication: Pressure necrosis, particularly in the

face and sacrum.7

• Prevention: Utilization of pressure relieving deviceson the face rest, frequent head turns, wound nurseconsult when patient initiated into IPP.

• Complication: Wound dehiscence.7

• Prevention: Splinting wounds prior to turning toprevent pulling on sutures, staples or wound bed.

• Complication: Hemodynamic instability (ie, Severehypotension and bradycardia associated with fluidshift and intrathoracic pressure changes).

• Prevention: Continue adequate fluid resuscitationespecially prior to turning; anticipate need forvasopressors, or inotropes during turning and fluidshifts.

• Complication: Accidental discontinuation of vascularand endotracheal access.14,15

• Prevention: Adequate staffing during turning proce-dure, assess the quality of securing devices prior toevery turn, perform a “time out” prior to turning toassess vascular, endotracheal, and bladder devices.

• Complication: Contractures of shoulder and hip.9

• Prevention: Consult physical therapy as soon as IPPis initiated; continue to perform passive range ofmotion when patient is in supine position.

• Complication: Nerve injury, such as brachial plexusinjury.

• Prevention: Change head and arm positions every 2 hours, consult physical therapy as soon as IPP isinitiated.

■ NURSING RESPONSIBILITYAs discussed, there are barriers to the initiation, continu-ation, and cessation of prone positioning; however, witheducation of evidenced based guidelines, nurses can over-come these barriers to provide a better standard of care.Critical care nurses can transition IPP from a “last ditcheffort” to a standard of care for the trauma patient withARDS. To facilitate this transition, nurses can use theF.L.I.P. approach.• F- Find the Current Policies at Your Institution.

Understanding your current policies gives a startingpoint for expanding on them, developing new ones,or simply reeducating your unit.

• L- Learn the Literature. Continuously review theliterature in relation to the specific patient popula-tion (ie, traumatic brain injury, multitrauma,pediatric, etc).

• I- Initiate a Protocol for Your Institution. Work withthe multidisciplinary team at your institution todevelop a standard of care, including an evidencedbased algorithmic approach for the critical aspectsof IPP (evaluation of the patient in a timely manner,initiation within 24 to 48 hours of onset ofALI/ARDS, continuation with constant reevaluation,and cessation after certain criteria has been met).

• P- Be a Patient Advocate. Develop an ongoing evaluation process for your new guidelines to

October–December 2010 Journal of Trauma Nursing • Volume 17, Number 4 203Copyright © 2010 Society of Trauma Nurses. Unauthorized reproduction of this article is prohibited.

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Table 1.

Summation of Relevant StudiesMedical vs

Study Sample Size Trauma Criteria for Initiation Criteria for Cessation

Fridrich et al9 20 patients Trauma ISS �16, evidence of clinical ARDS (acute bilateral

infiltrates on x-ray, severe hypoxemia, PAOP �18);

P:F � 200 mmHg at inverse ratio ventilation with PEEP

�8 cm H2O for more than 24 hours.

Not clearly defined

Voggenreiter

et al, 199911

22 patients Trauma “Mechanical Ventilation for �24 hours with FiO2 �50%

with PEEP �10 cm H2O, and/or constant or increasing

pulmonary densities in 2 or more quadrants after

mechanical ventilation for 48 hours.”11

FiO2 �30%, prone to

supine PaO2 difference

of �15 torr, and pul-

monary densities com-

prising �10% lung vol-

ume per chest com-

puted tomography.

Voggenreiter

et al14

40 patients Trauma ISS �16, P:F �200, PEEP �5 cm H2O or a P/F ratio �300

with PEEP �5 cm H2O with PAOP of 18 mmHg or less

or lack of evidence of left atrial HTN and pulmonary

infiltrates on CXR.

Not clearly defined

Offner et al7 9 patients Trauma Refractory hypoxia in postinjury ARDS patients despite

multiple ventilator alterations

Not clearly defined

Gattanoni et al5 Over 300

patients

Medical ARDS/ALI as defined as: P:F �200 with PEEP �10 cm H2O,

bilateral pulmonary infiltrates on CXR, and PAOP

�18 mmHg or lack of evidence of left atrial

hypertension

Study was ended at

10 days

Pelosi et al13 16 patients Medical ALI (not well defined) Not clearly defined

Mancebo et al15 136 patients Medical Meeting the American-European consensus conference

definition for ARDS with intubation, and diffuse bilateral

infiltrates on CXR.

Not clearly defined

Johnannigman

et al1

16 patients Mixed medical and

trauma

PaO2/FIO2 �200 mmHg, PCWP �18 mmHg, Bilateral

infiltrates on anteroposterior chest radiographs, and a

relevant mechanism of injury.

Not clearly defined

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Weaknesses/ Adjunct Proning Duration Limitations Complications therapies Findings

20 hours/day unless

emergency or unable to

tolerate

None identified Shoulder and

hip contractures

(2 patients)

None Increase in PaO2, decrease in intrapulmonary

shunt and decrease in A-a gradient.9

8 hours/day Frequent

bronchoscopy

Swelling and edema of

lips and eyelids

Vasodilators,

low-dose

dopamine,

and inotropes

based on

need

A significant decrease in intrapulmonary shunt,

weaning of FiO2, and a decrease in

pulmonary densities.11

�8 hours/day with

maximum of

23 hours/day

Small sample

size, IPP did

not shorten

ventilator days

Pressure sores, skin lesions,

endotracheal tube displacement

(occurred equally in both the

supine and prone groups)

Blood

transfusion

An improvement in oxygenation and

decreased development of pneumonia

after only 4 days.14

Patients remained prone

until need for nursing

care, or procedure.

Initiated IPP late

in the course

of ARDS.

1 abdominal wound dehiscence,

2 patients experienced skin

necrosis to face and upper chest

wall, 1 cardiac arrest with

successful resuscitation.

Steroids,

Vasopressors,

Nitric Oxide

(NO), HFJV

Decreased FiO2 requirements, increased

P:F

10 days No significant

decrease in

mortality

One surprising finding during this

study was the number of

complications, such as

displacement of tubes,

pressure sores, etc were

equal between both groups.

None �70% of patients improved oxygenation

2 hours Very brief study

of only 2 hours,

sedated and

paralyzed all

study patients13

None identified None Oxygenation improved without changes in

end, expiratory lung volume13

20 hours/day 21% of supine

subgroup

crossed over

to prone

group before

completion of

study.

Conjuctival hemorrhage (2 patients),

pressure sores (2 patients),

Removal of pulmonary artery

catheter with subsequent

cardiac arrest with successful

resuscitation (1 patient), Removal

of foley catheter and NG tube

(1 patient each), unplanned

extubation with successful

reintubation (1 patient)

Vasopressors 15% absolute and a 25% relative reduction

in intensive care unit mortality compared

with those who were ventilated supine

(not statistically significant)

Not clearly defined This study only

used stable

patients, which

is not realistic

when applying

its findings to

trauma critical

care.

No clinically significant

complications

Nitric oxide

(NO)

Increasing PaO2/FIO2 to 219 �/�20 mmHg

and decreasing Qs/Qt 27 �/�10%

(continues )

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assess efficacy, complications, and opportunity for improvements. Also, it is important to shareyour experiences with other units and health professionals.

CONCLUSIONNursing staff play a vital role in the care of their patientsand the betterment of patient outcomes. When caring fora trauma patient with ARDS, nurses are responsible forseeking out modalities of care that may benefit thepatient, while causing the least harm. Equipping nursingstaff with the proper education and resources necessaryto carry out advanced respiratory skills, such as IPP, willlead to sooner initiation, more consistent continuation,timely cessation of care, and decreased pulmonary relatedmortality.13

REFERENCES

1. Johnannigman JA, Davis K, Miller SL, et al. Prone positioning andinhaled nitric oxide: synergistic therapies for acute respiratory distresssyndrome. J Trauma. 2001;50:589-596.

2. Vollman K. Prone positioning for the ARDS patient. Dimens Crit CareNurs. 1997;16:184-193.

3. Dries DJ. Prone positioning in acute lung injury. J Trauma.1998;45:849-852.

4. Murray TA, Patterson LA. Prone positioning of trauma patients withacute respiratory distress syndrome and open abdominal incisions. CritCare Nurse. 2002;22:52-56.

5. Gattanoni L, Tognoni G, Pesenti A, et al. Effect of prone positioningon the survival of patients with acute respiratory failure. N Engl J Med.2001;345:568-573.

6. Piehl MA, Brown RS. Use of extreme position changes in acute respi-ratory failure. Crit Care Med. 1976;4:13-14.

7. Offner PJ, Haenel JB, Moore EE, et al. Complications of prone venti-lation in patients with multisystem trauma with fulminant acute res-piratory distress syndrome. J Trauma. 2000;48:224-228.

8. Lin F, Chen Y, Chang H, Chang S. Effect of body position on gasexchange in patients with idiopathic pulmonary alveolar proteinosis:no benefit of prone positioning. CHEST. 2005;127:1058-1064.

9. Fridrich P, Krafft P, Hochleuthner H, Maurtiz W. The effects of long-term prone positioning in patients with trauma-induced acute respira-tory distress syndrome. Anesth Analg. 1996;83:1206-1211.

10. Michaels AJ, Wanek SM, Dreifuss BA, et al. A protocolized approachto pulmonary failure and the role of intermittent prone positioning. J Trauma. 2002;52:1037-1047.

11. Voggenreiter G, Neudeck F, Aufmkolk M, et al. Intermittent pronepositioning in the treatment of severe and moderate posttraumatic lunginjury. Crit Care Med. 1999;27:2375-2382.

12. Davis JW, Lemaster DM, Moore EC, et al. Prone ventilation in traumaor surgical patients with acute lung injury and adult respiratory distresssyndrome: is it beneficial? J Trauma. 2007;62:1201-1206.

13. Pelosi P, Tubiolo D, Mascheroni D, et al. Effects of prone positioningon respiratory mechanics and gas exchange during acute lung injury.Am J Respir Crit Care Med. 1998;157:387-393.


Table 1.

Summation of Relevant Studies (Continued)Medical vs

Study Sample Size Trauma Criteria for Initiation Criteria for Cessation

Summary of relevant research studies on prone positioning. ISS, Injury Severity Score; ALI, Acute Lung Injury; ARDS, Acute Respiratory Distress Syndrome; CXR, Chest

X-Ray; HFJV, High Frequency Jet Ventilation; HTN, hypertension; IPP, Intermittent Prone Positioning; NG, Nasogastric; NO, Nitric Oxide; PAOP, Pulmonary Artery Occlusion

Pressure; PEEP, Positive End-Expiratory Pressure; P:F, PaO2/FiO2 ratio.

Michaels et al10 40 patients Mixed medical and

trauma

P:F �200 initiated the algorithm leading to IPP P:F �250 in the supine

position with FiO2 �.50

and PEEP is “stable”

Davis et al12 53 patients Trauma ALI or ARDS FiO2 �40% with PEEP

�5 cm H2O and

improvement of

P:F �50%.

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14. Voggenreiter G, Aufmkolk M, Stiletto RJ, et al. Prone positioningimproves oxygenation in post-traumatic lung injury-a prospective ran-domized trial. J Trauma. 2005;59:333-343.

15. Mancebo J, Fernandez R, Blanch L, et al. A Multicenter Trial of pro-longed prone ventilation in severe acute respiratory distress syndrome.Am J Respir Crit Care Med. 2006;173:1233-1239.


Weaknesses/ Adjunct Proning Duration Limitations Complications therapies Findings6 hours cycles, or if patients

are oxygenating better in

the prone position they

are changed to an 8 hours

prone/4 hours supine

protocol

Mixed population

makes applica-

tion to strictly

trauma popu-

lation difficult

None Utilized an

algorithmic

approach

Increase in P:F and SvO2. Utilizing algorithm

they were able to successfully wean all

of their patients to a FiO2 �50% within

48 hours.

4 hour cycle Only 28% of

patients with

ARDS were

enrolled in

study d/t

exclusion

criteria, supine

group had 3x

patients than

prone group

None identified Vasopressors Improved P:F, and decreased mortality.

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