Abstract
Acute respiratory distress syndrome (ARDS) is associated with high mortality rates . The
aim of treatment and ventilation is to improve oxygenation. Prone positioning improves
oxygenation in patients with ARDS by shifting blood flow to undamaged or better ventilated
regions of the lung. Critical care nurses follow the current guidelines with respect to prone
positioning, which are mostly based on the medical aspects of the treatment. Prone
positioning challenges nursing care of these patients. The research question that emerges
is: Which nursing interventions during prone positioning will benefit the patient and reduce
or eliminate complications?
The purpose of this research is to do a systematic review in order to: Explore the evidence
in support of the beneficial nursing interventions during prone positioning of ventilated
patients and to develop evidence-based nursing guidelines with regard to the nursing
process.
The research design can be described as an exploratory, descriptive and retrospective
systematic review. The population consisted of experimental study designs, as well as
comparative, non-randomised and observational studies on nursing interventions during the
prone positioning process. Selected studies included a population of adult or paediatric
subjects who were ventilated and turned into the prone position, and the search strategy
was restricted to articles published or translated into English. Studies that included animals
or neonates were excluded from this review.
The data collection process involved the systematic extraction of relevant data onto
standardised data abstraction forms and the assessment of the methodological quality of
each study. Data were summarised into evidence tables and data from randomised
controlled trials were used for meta-analysis. There were thirteen randomised controlled
trials, of which only seven could be included for quantitative analysis.
Forty five clinical trials involving prone positioning were identified, with a total population of
2 148 patients. Outcomes that were measured, included oxygenation outcomes, responder
and non-responder groups, haemodynamic outcomes, complications in the prone position,
mortality, the length of sta y in the intensive care units and the total number of ventilated
days.
Prone positioning showed significant increases in the PaO2 and PaO2 / FiO2 ratio. The
effect of the outcomes compared against the different ventilation, sedation, nutrition and
positioning protocols had inconclusive results. Haemodynamic variables had insignificant
increases in the prone position. Pulmonary artery wedge pressure (PAWP) however, did
show a significant increase in the prone position. Complications related to prone positioning
were insignificantly less than expected. Patients treated in the prone position were
ventilated for an insignificantly shorter period of time, but had a longer ICU stay, although
the results were also insignificant. The mortality of patients in the selected trials was 33.5%.
Evidence gained from the selected studies could be used to develop nursing guidelines,
despite inconclusive results related to some of the measured outcomes.
Dr. Elzabé Nel