Refractory Hypoxemia: Prone Positioning – Changes in the Exudative Phase (Nursing)

00:01 Now, you know the definition of Refractory Hypoxemia.

00:04 Let's talk about some of the interventions.

00:06 To I'm going to address here just briefly introduce you to them are prone positioning and ECMO.

00:13 I'm going to start with prone positioning.

00:15 Now you remember from nursing lab how you had to learn what supine was. and what prone is.

00:21 You know what those represent, but remember if a patient is in bed, we either usually have them supine on their back or return them to their right side or return them to their left side and prop them up with pillows.

00:35 Rarely, if ever do you see a patient on their belly, unless we're trying to address ARDS.

00:41 Now we use this with refractory hypoxemia, but there's a school of thought out there that says any patient with ARDS should be placed in the prone position for certain number of hours a day.

00:52 They think it's most effective if we start earlier in the stages, but again, there's going to be a lot of discussion about this.

00:59 The physicians you work with and the hospital where you practice will also have an opinion on top of the unique variables to each patient.

01:08 But I want you to know what prone positioning is.

01:11 So, you see what it looks like, this guy's not just taking a nap.

01:14 If you look closely, they're intubated.

01:16 So, off-screen, what would be there is a ventilator.

01:20 See that's the thing about ARDS, they're ventilated, they have lots of other tubes, multiple IVs, foley.

01:27 So, to get them into this position, it takes a trained and skilled team to do it.

01:33 So, why would we go through all that? Let me tell you what the theories are about the benefits of prone position.

01:40 Because of gravity, fluid tends to pool in the dependent alveoli in the lungs.

01:45 Now, that's back to you picturing.

01:47 What is supine? What is prone? Prone is laying on your belly.

01:52 Supine is on your back where we see most patients in critical care.

01:56 So, where are the dependent alveoli if I'm laying? Supine or on my back? They're in the back.

02:04 Oh yes, that makes sense because if we're thinking about fluid volume, or if we're thinking about overload, we always listened in the back and the basis of our patients because we know that's where crackles develop first.

02:17 So, fluid pools in the dependent alveoli in the lungs.

02:21 Most patients in critical care in a supine position.

02:25 So let's talk about relativity.

02:27 Some alveoli are more fluid filled than others.

02:30 Some have more air than others.

02:33 So, in relation to someone in ARDS, the dependent regions of alveoli are going to be more fluid filled in comparison to the non-dependent areas.

02:44 If I'm on my back, the alveoli in the back are the dependent areas.

02:49 If I'm on my belly, wow, now where are the dependent areas? They're in the front.

02:56 And that's actually the theory behind prone positioning.

03:00 That's what we're trying to accomplish.

03:03 The patient on their back or who's supine, the heart and mediastinum put added pressure on the lungs.

03:10 Now, also can increase the risk of atelectasis.

03:13 Now, that's a touchy subject in ARDS, atelectasis, that's the collapse of the alveoli.

03:18 We work really hard to try to reopen those airways but it's not always possible.

03:23 So, prone positioning of the patient may allow for the alveoli that our posterior to become 'recruited'.

03:30 Okay, that's a funny term.

03:31 Let me tell you what that means.

03:33 Let's review.

03:34 If I'm on my back, the dependent alveoli are in the back.

03:38 Right, these are the non-dependent alveoli.

03:41 So, if I take the patient and I flip them and I put them on their stomach.

03:45 Now, the dependent alveoli are in the front and the non-dependent ones are now in the back.

03:52 This gives these guys a fighting chance.

03:56 That's what the theory is.

03:58 If we can take the weight of that patient off of their back, off of those alveoli, give a chance for that fluid to drain more toward the front, we can recruit these alveoli and give them the fighting chance to try to open up and be useful now.

04:12 Now, who should not be prone position? There's a lot of things there but know that some people cannot tolerate this.

04:21 If they have spinal cord instability, you do not want to pick them up and flip them, right.

04:26 If they have a risk for spinal instability, this is not a good option.

04:30 If they have unstable fractures, parcticularly facial or pelvic fractures, think what lying on their stomach would do.

04:38 If they have burns anteriorly, if they have chest tubes, you're out.

04:43 If they have open wounds that cannot be sutured closed.

04:47 If they're in shock, that is not the time to be putting them in prone positioning.

04:51 If they're pregnant, if they've had a recent tracheal surgery, if they have elevated intracranial pressure because remember we need to keep that head of the bed elevated.

05:00 So should you memorize all this? No, this will make logical sense to you.

05:05 I just want you to know, what prone positioning looks like? How we think it helps the patient Most research supports if you do it earlier in the phases you have better results, but prone positioning doesn't work for everyone.