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Good practices for prone positioning at the bedside : Construction of a care protocol
Rev Assoc Med Bras 2016; 62(3):287-293 287
REVIEW ARTICLE
Good practices for prone positioning at the bedside: Construction
of a care protocol
Vanessa Martins de Oliveira¹*, Michele Elisa Weschenfelder², Gracieli Deponti³, Robledo Condessa3, Sergio Henrique Loss4,
Patrícia Maurello Bairros2, Thais Hochegger2, Rogério Daroncho2, Bibiana Rubin5, Marcele Chisté2, Danusa Cassiana
Rigo Batista2, Deise Maria Bassegio2, Wagner da Silva Nauer3, Daniele Martins Piekala6, Silvia Daniela Minossi2,
Vanessa Fumaco da Rosa dos Santos2, Josue Victorino7, Silvia Regina Rios Vieira 8
1MD – Intensive Care Unit, Coordinator of the Multidisciplinary Group of Teaching and Research in PRONE of the Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
2Undergraduate Diploma Nurse at the Intensive Care Unit, HCPA, Porto Alegre, RS, Brazil
3MSc Physiotherapist at the Intensive Care Unit, HCPA, Porto Alegre, RS, Brazil
4PhD Intensive Care Physician and Nutrologist, HCPA, Porto Alegre, RS, Brazil
5Undergraduate Diploma Nutritionist at the Intensive Care Unit, HCPA, Porto Alegre, RS, Brazil
6Undergraduate Diploma Physiotherapist at the Intensive Care Unit, HCPA, Porto Alegre, RS, Brazil
7PhD Physician at the Intensive Care Unit, HCPA, Porto Alegre, RS, Brazil
8PhD Supervising Physician at the Intensive Care Unit, HCPA, Porto Alegre, RS, Brazil
Summary
Study conducted by the Grupo de Prona
do Hospital de Clínicas de Porto Alegre
(HCPA), Porto Alegre, RS, Brazil
Article received: 5/2/2015
Accepted for publication: 12/1/2015
*Correspondence:
Address: Rua Maranguape, 81/802,
Petrópolis
Porto Alegre, RS – Brazil
Postal code: 90690-380
Last year, interest in prone positioning to treat acute respiratory distress syn-
drome (ARDS) resurfaced with the demonstration of a reduction in mortality
by a large randomized clinical trial. Reports in the literature suggest that the in-
cidence of adverse events is significantly reduced with a team trained and expe-
rienced in the process. The objective of this review is to revisit the current evi-
dence in the literature, discuss and propose the construction of a protocol of
care for these patients. A search was performed on the main electronic databas-
es: Medline, Lilacs and Cochrane Library. Prone positioning is increasingly used
in daily practice, with properly trained staff and a well established care protocol
are essencial.
Keywords: adult respiratory distress syndrome, acute respiratory distress syn-
drome, ventral decubitus, respiratory failure, intensive therapy.
Introduction
Prone positioning has been studied as a strategy for the
treatment of acute respiratory distress syndrome (ARDS)
since 1974, gaining popularity for improving hypoxemia
in 70% of cases.1,2 The incidence of this syndrome has not
changed in Europe over the last ten years and mortality
remains high (40-50%) despite technological and thera-
peutic developments in recent decades.3,4 The significant
improvement of hypoxemia can be attested through nu-
merous mechanisms, among which we can observe a more
uniform distribution of transpulmonary pressure and the
generation of more negative pleural pressures, promoting
the improvement of the ventilation/perfusion ratio.5-10
Reduction in mortality with prone positioning is at-
tributed to the lowest degree of pulmonary stress and
strain, given that air distribution is more homogeneous
and slower.9,10,12-15 The various meta-analyses in the liter-
ature to date concluded that there was an improvement
in oxygenation, but no reduction in mortality.16,17,19,26
The conflicting results of studies and meta-analy-
ses,11,18,20-26,28 relating to mortality can be explained by the
heterogeneity among patients regarding confusion fac-
tors such as the severity of the pulmonary injury, the ven-
tilation strategy applied, and the different times for be-
ginning and the duration of prone positioning.18
Therefore, Guerin et al.4 designed a randomized study
(Proseva) with 466 patients with moderate ARDS in the
first 12-24 hours of diagnosis, using a homogeneous sam-
ple of considerable size. All patients underwent protec-
tive mechanical ventilation, with the duration of prone
positioning lasting on average 17 hours. This investiga-
tion demonstrated a significant reduction in mortality