Prone Ventilation Step-By-Step Guide

Last update: April 17, 2020

Required equipment

• Hot room
  • At least 3 providers, 1 of which with airway proficiency (i.e. CRNA, RT) (in droplet/contact COVID PPE; ETT will be clamped during procedure so no aerosolization is anticipated)
  • 3-4 pillows
  • 2 flat draw sheets
  • Prone pack:
    • 2 copies of this checklist
    • Amber gel pad
    • 2-3 Covidien dry flow pads
    • ETT holder
    • Clamp for ETT
    • Pack of new EKG leads
    • Thin ear-protective foam pillow (white top from blue/white prone tube holder pillow)
    • Mepilex - 4"x4" bordered x 6, small sacral Mepilex x 2, 4"x4" Mepilex lite (unbrdered) x 2, 6"x6" bordered x 2
    • Small 30x51 fluidized positioner
    • Lucrilube with 1" silk tape
    • Sure Prep liquid skin protectant
• Cold room
  • 1 supervising provider
  • Extra ventilator circuit and ETT suction catheter
  • Airway cart with appropriate sized ETT

Preparation before any turn (can be started prior to prone team arrival)

• Verify absence of contraindications
  • Tracheal surgery of sternotomy in previous 15 days
  • Unstable spine, pelvic, or femur fractures
  • Massive hemoptysis
• Confirm ETT tip in good position (auscultation +/- U/S to rule out mainstem intubation
• Determine whether turn will be rightward or leftward (typically towards ventilator)
• Secure ETT, central lines, arterial line, and peripheral IVs
• Secure NG and/or feeding tube and Foley catheter
• Hold tube feeding, fully evacuate the stomach, and cap/clamp NG and/or feeding tubes
• Suction ETT and oral cavity
• Perform anterior surface skin care and any required wound care or dressing changes
• Empty all ostomy bags; secure all peritoneal catheters and drains
• Evaluate adequacy of sedation and/or paralytic; consider single-dose paralytic if patient not on paralytic infusion; consider viral filter at ETT if no paralytic to be used
• Prepare all lines and tubes:
  • Assure sufficient IV line length; add extensions as needed
  • Relocate all drainage bags to the ventilator side of the bed
  • Place all chest tube drains and Foley catheter drainage bags between the legs
  • Reposition all IV tubing running towards the head and off the ventilator side of the bed

Video resources to review:

• Kaiser Permanente educational video (YouTube) - Kaiser Permanente educational video
• PROSEVA study video (YouTube) - PROSEVA study video
• Critical Care Patient Proning Tutorial (YouTube)

Supine-to-prone turning procedure

• Supervising provider performs brief time-out
• Identify turn leader (usually the patient’s primary nurse)
• One provider on each side of the bed to manage turn
• Dedicated provider (usually RT/CRNA) at the head of bed to manage ETT
• Increase vent FiO2 to 100% and note the pre-turn vent settings and airway pressures
• Remove patient gown and any orthotic boots or devices
• Place new EKG leads on the patient's back and connect to monitor
• Remove chest EKG leads and any other non-critical skin-adherent material
  • Forehead/Cheek – cut Mepilex lite 4” x 4” into x” x 4” strips; place on cheekbones and forehead
  • Anterior Shoulders - 4” x 4” bordered foam on prominent area of shouldeea
  • Chest – 6” x 6” bordered foam over each breast/chest wall
  • Medial Elbows - 4” x 4” bordered foam over medial olecranon
  • Iliac crests – 4” x 4” bordered foam on anterior superior iliac zpine
  • Knees – Small zacral Mepilex over patella
  • Eyes with lacrilube gently taped closed prior to turn
• Flatten the bed
• Place amber gel pad under patient's torson with gel pad in direct contact with mattress
• Place a new, clean draw sheet under the patient
• Place 2 absorbent Dri-Flo pads directly on patient's skin - chest and pelvis

• Place three pillows:
  • Across chest
  • Across pelvis at level of iliac crest
  • Across shins
• Position arms at side with hands behind buttocks
• Place draw sheet overlying pillows
• Roll top and bottom sheets together at the patient’s sides
• Lift draw sheet and move the patient to the non-ventilator side of the bed until arm is hanging off, but the patient remains securely in bed; avoid sliding
• Prepare to unhook ETT from ventilator
  • Perform inspiratory hold and clamp ETT with hemostat
  • Turn ventilator on standby
  • Unhook ventilator from ETT
• Log-roll into the lateral decubitus position, with the dependent arm tucked under the chest; one side provider pulls straight up on the patient while the other side provider pushes under to keep patient at edge of bed
• Check all lines and tubes
• Complete the log-roll towards the ventilator and into the prone position
• Simultaneously turn the patient’s head towards the ventilator
• Prepare to hook ETT back to ventilator
  • Hook ventilator to ETT
  • Turn ventilator back on
  • Unclamp ETT
• Remove the flat sheet and expose the patient’s back
• Reassess ETT and all lines/tubes
• Place white offloading foam under head with ear in opening; slide Dri-Flow sheet under to catch secretions
• Raise the patient’s arm on the same side as the patient is facing
  • Be sure the raised arm shoulder is dropped, and elbow is below the level of the axilla
  • Place the opposite arm at the patient’s side, with palm facing up
  • Lift draw sheet and roll amber gel pad up under same side as patient is facing to microwedge that side up
• Adjust pillows to keep toes, knees, and abdomen floating
• Position penis, testicles and breasts to avoid inappropriate pressure
• Tilt the bed into slight reverse Trendelenburg (head up) - 15 degrees
• Use fluidized positioner as needed to offload any areas needing extra support because of patient body habitus
• Compete post-turn evaluation (see below)

Head repositioning

• Identify turn leader (usually the patient’s primary nurse)
• At least one provder on each side of the bed
• Dedicated provider (usually RT/CRNA) at the head of bed to manage ETT
• Flatten bed
• Lift patient and unroll amber gel pad on side of raised arm
• Place raised arm down by patient side, palm facing up
• Remove white offloading foam ear protector
• Using bottom flat sheet, lift patient and move upward so that head is off bed; avoid sliding
• Carefully turn the patient’s head to the opposite side
• Resecure ventilator tubing suspended above the patient’s head
• Using bottom flat sheet, slide patient back down onto bed
• Reassess ETT and all lines/tubes
• Place white offloading foam under head with ear in opening
• Reposition ETT in holder towards up-facing side and check for lip and tongue pressure
• Reposition arms in modified swimmer’s crawl position
  • Raise the patient’s arm on the same side as the patient is facing
  • Be sure the raised arm shoulder is dropped, and elbow is below the level of the axilla
  • Place the opposite side arm at the patient’s side, with palm facing up
  • Lift draw sheet and roll amber gel pad up under same side as patient is facing to microwedge that side up
• Adjust pillows to keep toes, knees and abdomen floating
• Position penis, testicles and breasts to avoid inappropriate pressure
• Tilt the bed into slight reverse Trendelenburg (head up) - 15 degrees
• Complete post-turn evaluation (see above)

Prone-to-supine repositioning (planned)

• Identify turn leader (usually the patient’s primary nurse)
• At least one provider on each side of the bed
• Dedicated provider (usually RT/CRNA) at the head of bed to manage ETT
• Flatten the bed
• Increase vent FiO2 to 100% and note the pre-turn vent settings and airway pressures
• Remove patient gown if in place
• Place new EKG leads on the patient's chest and connect to monitor
• Remove back EKG leads and any other non-critical skin-adherent material
• Place sacral Mepilex foam adhesive pad to prevent pressure ulcers (if not already place)
• Unroll amber gel pad to lay flat on the bed
• Place both arms at the patient’s side with palms up
• Place 2 absorbent Dri-Flo pads directly on patient's skin - across back and pelvis
• Place clean draw sheet on top of patient
• Using the flat sheet under the patient, slide patient towards the side of the bed that they are facing, keeping the amber gel pad in place on the bed
• Prepare to unhook ETT from ventilator
  • Perform inspiratory hold and clamp ETT with hemostat
  • Turn ventilator on standby
  • Unhook ventilator from ETT
• Log-roll the patient into the lateral decubitus position facing the ventilator, and center the patient’s head
• Place a clean flat sheet on the bed
• Complete the log-roll towards the ventilator and into the supine position
• Prepare to hook ETT back to ventilator
  • Hook ventilator to ETT
  • Turn ventilator back on
  • Unclamp ETT
• Reassess ETT and all lines/tubes
• Reposition ETT in holder to avoid sustained lip and tongue pressure in one location
• Complete post-turn evaluation (see below)

Prone-to-supine repositioning (emergent)

• Identify turn leader (usually the patient’s primary nurse)
• At least one provider on each side of the bed
• Dedicated provider (usually RT) at the head of bed to manage ETT
• In an emergency, clamp and disconnect the ventilator circuit for the turn
• Place a draw sheet over patient’s back and roll it to join the draw sheet below
• Complete a one-step log-roll towards the ventilator and into the supine position
• Reconnect the ventilator circuit or Ambu bag and unclamp the ETT
• Reassess ETT and all lines/tubes
• Complete post-turn evaluation (see below) when abble

Post-turn evaluation

• Consider potential for accidental right mainstemming or dislodging of the ETT and auscultate or U/S if needed
• Reassess ventilator settings, O2 saturation, heart rate, and blood pressure
• Check and adjust all tube and line connections and function
• Check lips and tongue, and reposition ETT holder as needed to avoid recurrent pressure
• Check that all leads and other devices have been removed from the dependent surface of patient
• Check all aspects of the patient’s skin in contact with the bed for adequate Mepilex padding
• Check that toes/heels are floating
• Pad any fixed IV, arterial line, or connector sites at the skin with pink foam
• Document a thorough skin assessment, including any non-blanchable erythema in areas of pressure

Disclaimer

These documents and content on this website are guidelines during the COVID-19 pandemic. Because new information is released rapidly, these documents can be updated or changed at any time. These documents are in no way to be considered as a standard of care and the content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. The information in these documents is provided with no guarantees, accuracy, or timeliness. All content in these documents and website are for informational purposes only and do not constitute the providing of medical advice.