STARS Prone Patient Ventilation Protocol - STARS air ambulance
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STARS Prone Patient Ventilation Protocol
Basic Tenets
All of these patients should be considered highly infectious as there is generally always an
infectious pathogen of some sort at least contributing to what is going on and even if there isn’t
one proven yet, it is best practice to assume there will be one found at some point.
Before recommending or performing prone ventilation, all efforts to maximize oxygenation prior
to transport should be exhausted as it is far safer to transport a patient in a normal supine or
lateral position. These efforts should include:
1. Making sure FiO2 is 1.0
2. Optimize chest wall compliance (e.g. gastric decompression, loosen any chest
restraints, escharotomy in circumferential truncal burn patients, sitting patient up as
much as possible)
3. Adequate sedation and paralysis to reduce work of breathing
4. Other less limiting positioning maneuvers (e.g. good lung down, sitting the patient up
as much as possible)
5. Higher levels of PEEP
6. Optimizing cardiac output and subsequent O2 delivery
7. Consider accepting lower SpO2 if the patient is not exhibiting evidence of the end
organ effects of true hypoxia
8. Recruitment maneuvers
9. Increasing inspiratory time
10. Consider accepting higher plateau pressures (normoxemia may not be safely
achievable)
It is less than ideal to transport these patients at all. In all cases a very detailed discussion
between the involved TP, and the sending and receiving ICU MDs must have occurred
discussing moving a proned patient before it occurs. There must be a clear reason to move
these patients (for instance, they are being considered for ECMO) and it must be absolutely
clear that the receiving ICU Physician is onboard with respect to the patient’s expected illness
trajectory, with respect to bed and talent resource availability, and with the significant, likely to
be fatal risks of transport should anything go wrong. Consider bringing in a Medical Director to
further assist in the process of making sure an attempt at movement is in the best interests of
the patient, staff, and system.
Moving a patient in a prone position is a low frequency, extremely high risk event, that requires
careful planning and our very best team work.
AHS Proning Procedure Adapted from ICU:
PURPOSE
To provide guidance on safely placing a patient in prone positioning.
OVERVIEW OF PRONING
Owner: Mike Betzner
Last Update: March 2020
Prone positioning is most commonly used to optimize oxygenation in patients with acute lung
injury or ARDS. In ARDS, consolidation in lung tissue is patchy and gravity dependent. In the
supine position gravity dependent perfusion can match gravity dependent consolidation which
may lead to severe VQ mismatch.
Proning increases ventilation to dependent lung zones by matching gravity dependent perfusion
to ventilated alveoli, thus decreasing the shunt fraction.
Proning may also have a greater negative pleural pressure which may increase pressure to
open and maintain airway patency. This results in ventilation in dependent areas of the lung with
better perfusion match. There may be some general improvements in hemodynamics once in
prone position.
POLICY STATEMENTS
A Transport Physician or assigned delegate (Transport Fellow or Senior Resident) must be
present for the initial prone positioning procedure. Prone positioning should only be done when
there are adequate personnel to support complications.
Inclusion criteria for prone positioning will be any ventilated patient with a diagnosis of severe
adult respiratory distress syndrome (ARDS) as evidenced by one of the following:
a. An Oxygen Index (OI) greater than or equal to 20 (see MDCalc.com for calculation of
this https://www.mdcalc.com/oxygenation-index).
b. b. A PaO2/FiO2 (P/F) ratio less than or equal to 100 when receiving and FiO2 of 0.60
or greater.
The following potential exclusion criteria for prone positioning will be considered in collaboration
with the multi-disciplinary team:
k. Acute bleeding
l. Spinal instability/known or suspected spinal fracture
m. Pregnancy in 3rd trimester
n. Unstable intracranial pressure
o. Unstable sternum
p. Ventricular assist device
q. Intra-aortic balloon pump
r. Multi-trauma patients with unstable extremity or pelvic fractures
s. Large abdomen/gross ascites
t. Anterior chest tubes
u. Open abdominal wound
v. Open chest
w. Patient’s height or weight exceed our stretcher capacity
POINTS OF EMPHASIS
1. Proning effects may not be immediate and it may take several hours to see the positive
effects. Ideally, this should be done by the sending site before we get there. If the patient
has deteriorated between the time of the initial call and our arrival, it may be left to our
team to try this maneuver.
Owner: Mike Betzner
Last Update: March 2020
2. Carefully monitor the patient’s tolerance to turning and to being in the prone position as
the patient’s cardiopulmonary status may deteriorate. If the cardiopulmonary parameters
do not stabilize following the turn, the physician may consider intervening with
adjustments to vasopressors or fluid management. If, after the initiation of the
intervention, the patient’s cardiopulmonary parameters are not stabilized, the patient
may have to be returned to the supine position.
3. Prone positioning has many benefits for maximizing oxygenation, but can also be
associated with complications, particularly skin breakdown and eye injury (orbital
compression), as well as endotracheal tube and central/arterial line dislodgement (high
risk!). Careful assessment and attention to nursing care is imperative for the patient
positioned prone. Attentive eye care, skin care and pressure relief is required on a
regular basis.
4. Current settings on the hospital ventilator should be mimicked as closely as possible on
the STARS transport ventilator. It is important to make it very clear, that the patient may
not be moved at all, if we cannot safely oxygenate and ventilate the patient with our
equipment. It is an unfortunate fact that many of these patients are simple too unstable
to move at all. The assistance of our ICU colleagues will help in these decisions.
PERSONNEL PERMITTED TO PERFORM PROCEDURE
At minimum, 5 personnel are required to prone a patient safely:
• At least one RN and RRT must be present from the sending site
• STARS EMT-P and STARS-RN
• Transport Physician or assigned delegate must be present if the patient has not been
tested in the prone position already. This team member is responsible for ensuring all
lines/drains/circuits are in safe positions (see below).
EQUIPMENT
Pillows X 3
2-sheets
Duoderm for any potential pressure points
Head positioning devices (gel pads, foam head rest)
PROTOCOL / PROCEDURE: PRONING
PATIENT AND ENVIRONMENT PREPARATION
1. Explain the purpose for using prone positioning to the patient and family. From a
transport point of view, it is also important to explain to the family that their relative is
critically ill, and that if anything goes wrong during the prone procedure and particularly
Owner: Mike Betzner
Last Update: March 2020
during flight, the mortality is extremely high. In particular, if a patient arrests in the prone
position, there is little more we can do to resuscitate them in the back of an air
ambulance.
2. All of these patients should have a sutured-in-place art line as frequent assessments of
PaO2 will be necessary. With this in mind, STARS AMC should upload additional
cartridges if a mission of this nature is accepted. Three additional cartridges should be
uploaded so a total of six are available per flight.
3. Ensure the following preparations are made:
• ETT is secure with twill ties or tape to the far side of the mouth opposite the
ventilator (to avoid traction on the corner of the mouth from the tubing).
Alternatively, you can use the Thomas ETT holder, but need to take particular
care that no pressure is exerted on this holder during rolling or once rolled.
• Plan to end the proning maneuver, with the patient’s face turned towards the
ventilator and with the ventilator and circuit as close to the patient as possible.
Proning should happen on the hospital bed and hospital ventilator circuit 1st, to
ensure it is tolerated and that it results in improved oxygenation and/or
hemodynamics. Only then, should the patient be 1st transferred onto comparable
settings on the STARS ventilator, and then if that is tolerated, transferred to the
STARS stretcher.
• Mouth and ETT are suctioned.
• EVAC suction tubing has been disconnected.
• Oxygen saturation monitor is on and the line is positioned so does not end up
wrapped around the patient after the proning maneuver.
• Continuous end tidal CO2 monitoring is in place and monitored throughout the
proning procedure.
• Lines are positioned to avoid traction during the turn. Place lines at head (IJ or
subclavian lines) or foot (femoral) of bed. The art line transducer should be taped
either to the chest wall at the 4th intercostal space, mid-axillary line or the lateral
upper arm to approximate the phlebostatic axis. Make sure both art lines and
central lines are sutured in place with good sealed dressings. Re-zero the art line
at the end of the proning procedure.
• ECG electrodes and defibrillation pads are repositioned (or removed with
Transport Physician order) to avoid excessive pressure points.
• Foley and / or rectal drainage bag is positioned at the end of the bed. Ensure the
catheter drainage line does not get wrapped around the patient’s leg as this can
become a pressure point. Ensure a kink does not develop in the line as urinary
Owner: Mike Betzner
Last Update: March 2020
retention can negatively impact hemodynamics.
• Chest tube drainage unit is positioned at the end of the bed. Make sure the chest
tube is well secured (both well sutured and well secured with a proper chest tube
dressing).
• For the proning procedure, hold enteral feeds for a minimum of 1 hour prior to
turning. Enteral feeds should be held completely for transport.
• Ensure suction is disconnected and naso/orogastric tube is placed up and around
patient’s face. Tubing should never be left under a patient as it may kink and or
result in a pressure point.
• Maximally inflate the bed if able.
• Brakes are applied on the bed.
3. Ensure the patient is adequately sedated and/or paralyzed.
4. Perform baseline comprehensive assessment and note cardiopulmonary parameters to
assess patient’s tolerance to prone positioning.
ACTUAL PRONING PROCEDURE
1. It is recommended that those personnel participating in the prone watch the below linked
instructional video: https://www.youtube.com/watch?v=Hd5o4ldp3c0
2. Any team member is empowered to call ‘STOP’ during the procedure if they have any
concern at any time.
3. The RRT at the head of the bed will lead the count and any position change is done at
the direction of the RRT. Particular care must be taken to support the ventilator tubing
and tube during transfer to make sure a disconnect does not occur and that tubing does
not get kinked (it is very easy to kink the ETT in particular during the turn). It is also
important that the ETT and tubing is accessible from the patient’s right side in the supine
position, so that when the patient is transferred to the STARS stretcher, the connections
and suction are easily accessible.
Owner: Mike Betzner
Last Update: March 2020
4. Place a single bedsheet flat under the patient. Remove any wrinkles. Place three pillows
on the patient: one at the torso below the clavicle; one at the hips; one over the legs.
The pillows help reduce pressure over boney prominences while in the prone position.
5. After tucking the patient’s arms under their buttocks on each side, place a 2nd sheet
over the patient and 3 pillows, and tightly roll the edges of the sheet under the patient,
and then 2nd sheet over the patient and pillows, together up each side.
6. To help with the logistics of this roll (if it has not been done already on the outbound leg
of the mission) do the following:
• Position the hospital ventilator on supine patient Left
• Slide patient to the supine patient Right side of the hospital bed
• Slide the patient up the bed so the head is over the end of the bed
• Turn the head of the patient to supine patient Right
• Flip patient as per below to their Left side
• Slowly roll the patient into the supine position
• Slide the patient back down the bed and place a C-cushion or similar
padding under the patient’s face in order to keep pressure off the face
and ETT
6. Holding the cocooned sheet edges, rotate the patient up onto his/her lateral side ensuring the
patient is facing the ventilator. To continue to prone: Individuals holding the top part of the
sheets (by patient shoulders/hips furthest from the bed) work with individuals holding the
Owner: Mike Betzner
Last Update: March 2020
bottom part of the sheets (closest to the bed) to rotate the patient onto their stomach.
7. Either direction; ensure that body mechanics look appropriate and the patient appears
comfortable). Place patient in reverse Trendelenburg at 30° if able.
Importantly, on our transport
stretchers, both arms will need to be
by the patient’s sides.
8. Place patient in reverse Trendelenburg at 30° if able (applies to hospital beds only; this
cannot be done with our transport stretchers).
Owner: Mike Betzner
Last Update: March 20209. Place 5 lead ECG on back of patient’s shoulders and back for continuous cardiac monitoring.
Ensure good adherence to skin. Place defibrillation pads in an AP position ideally.
10. Secure the patient with stretcher straps across the body, including the shoulder straps, to
prevent unwanted forward movement on the stretcher in flight. Bilateral wrist restraints
should also be used for transport to prevent the patient form dislodging any line or tube
should they become under-sedated.
11. Make sure you can still access all of your required lines and that all connections are secure.
CARE IMMEDIATELY FOLLOWING PRONE POSITIONING
1. Assess the patient’s tolerance of turning procedure and for airway patency. In particular
ensure the ETT has not migrated or kinked and recheck tube cuff pressure.
2. Place patient in reverse Trendelenburg position up to 30° if possible to reduce the
incidence of aspiration if you haven’t done so already. This only applies to the initial roll
on the patient’s hospital bed. STARS stretchers are not capable of the Trendelenburg
position.
Owner: Mike Betzner
Last Update: March 20203. Reposition patient as necessary to minimize pressure points.
4. Re-zero hemodynamic monitoring lines.
5. Reconnect NG/OG tube to suction.
6. After the initial turn, obtain blood gases and record and updated hemodynamic profile
ASAP.
7. If the patient improves once in a prone position, then the patient can first be transferred
to the STARS ventilator, with settings comparable to those of the sending facility’s
ventilator, and then if tolerating that, to the STARS stretcher. The patient should remain
on all hospital monitoring equipment until after this transfer has occurred and tolerance
of this move is proven. If stable post this transfer, then switch the patient to our
monitoring equipment and pumps. If the patient cannot tolerate coming out of the
Trendelenburg position onto our stretcher, they should either not be transported at all, or
they should not be proned for transport.
8. Measure arterial/mixed venous blood gases within 30 min of proning or as per Transport
Physician order.
9. Document on the STARS ePCR:
• Patient’s response to proning + any subsequent position changes if possible.
• Any complications that occurred.
• Full set of vitals as well as blood gas after the initial turn.
ONGOING PATIENT MONITORING AND CARE
1. Continue with regular assessments:
• Follow oxygenation and hemodynamic status closely to monitor for
deterioration.
• Monitor ventilator flow waveforms and EtCO2 waveforms.
• Watch for changes in peak and plateau pressure values
• Chest and heart sounds can be assessed by slipping stethoscope under the
patient’s chest. Be careful not to dislodge any lines in the process.
2. Take particular care to reduce any pressure the endotracheal tube circuit is exerting on
the patient's face and corner of the mouth.
3. For male patients ensure genitalia are not being compressed between the patient’s legs
or by the pelvic pad/pillow
Owner: Mike Betzner
Last Update: March 20204. Ensure wet or soiled linen (i.e. due to the accumulation of oral secretions or wound
drainage) is changed in a timely to manner to avoid excoriation of the skin.
5. Assess ETT ties/holder q15min to ensure no cuts or breakdown to the back of the neck
and the corners of the mouth. Check ETT position q5min to make sure no migration has
occurred.
6. Place a C-foam/gel ring/rolled towel under the head when placed in the lateral position to
ensure that the patient’s orbit and eye is supported free of the bed surface
7. Check, lubricate, and close the patient’s eyes minimum q2h to prevent corneal drying,
abrasion, or infection.
8. Avoid over extension of the neck with positioning
COMPLICATIONS IN FLIGHT
1. ETT migration or extubation can easily occur. If you think the ETT has migrated out,
consider putting a bougie (straight end 1st) down the ETT, deflate the cuff, and then
gently re-insert the tube over the bougie to the prior recorded correct depth. Re-inflate
the cuff and check your ETCO2 waveform. If hypoxia rapidly worsens and or you have no
ETCO2 waveform, extubation has very likely occurred. Your only recourse at this point is
try and quickly insert a iGel LMA after removing the ETT. This may well be a fatal event
as these patients will have stiff lungs and higher airway pressures than can be
reasonably delivered via an LMA. Realistically, trying to roll the patient and re-capture
the airway will not be doable in the back of the aircraft.
2. Cardiac arrest is not amenable to CPR in the prone position. If this occurs, and is not
responsive to medication interventions, there is nothing more you can do and the TP will
realistically have to terminate resuscitative efforts.
3. Line disconnects of any and all varieties are definitely a risk. Please carefully check all
connections with any patient repositioning or movement.
REFERENCES
1. Abroug, F. et al. (2011). An updated study level meta-analysis of randomized controlled
trials on proning in ARDS and acute lung injury. Critical Care Medicine, 15(R6).
2. Davis, J.W. et. Al (2007). Prone ventilation in trauma or surgical patients with acute lung
injury and adult respiratory distress syndrome: is it beneficial. The Journal of Trauma
Injury, Infection and Critical Care, 62(5), 1201-1206.
Owner: Mike Betzner
Last Update: March 20203. Diaz, J. V., Brower, R., Calfee, C.S., & Matthay, M. A. (2010). Therapeutic strategies for
severe acute lung injury. Critical Care Medicine, 38, (8), 1644-1650.
4. Gattinoni, L. & Protti, A. (2008). Ventilation in the prone position: For some but not for
all? Canadian Medical Association Journal, 179, (9), 1174-1176.
5. Guerin, S. et at. (2013). Prone positioning in severe acute respiratory distress syndrome.
New England Journal of Medicine, 369(23).
6. Hu, S.L. et al. (2014). The effect of prone positioning on mortality in patients with acute
respiratory distress syndrome: A meta-analysis of randomized controlled trials. Critical
Care Medicine, 18(R109).
7. Laux, L., McGonigal, M., Thieret, T., & Weatherby, L. (2008). Use of prone positioning in
a patient with acute respiratory distress syndrome: A case review. Critical Care
Quarterly, 31, (2), 178-183.
8. Mancebo, J., Fernandez, R., Blanche, L., Rialp, G., Gordo, F., Ferrer, M... Albert, R. K.
(2006). A multicenter trial of prolonged prone ventilation severe acute respiratory
distress syndrome. American Journal of Respiratory and Critical Care Medicine, 173,
1233-1239.
9. Nortje, S., Nel, E., & Nolte, A. (2008). Evidenced-based nursing interventions and
guidelines for prone positioning of adult, ventilated patients: A systematic review. Health
SA Gesondheid, 13, (2), 61-73.
10. Rowe, C. (2004). Development of clinical guidelines for prone positioning in critically ill
adults. British Association of Critical Care Nurses, Nursing in Critical Care, 9, (2), 50-57.
11. Sud, S., Friedrich, J.O., Neill, K., Adhikari, J., Taccone, P., Mancebo, J.... & Guerin, C.
(2014). Effect of prone positioning during mechanical ventilation on mortality among
patients with acute respiratory distress syndrome: a systematic review and meta-
analysis. Canadian Medical Association Journal, 186(10).
Alberta Health Services Calgary Zone Critical Care Unit Manual Policy and Procedure
12. Della Volpe, J.D., Lovett, J., Martin-Gill, C., Guyette, F.X.. Transport of Mechanically
Ventilated Patients in the Prone Position. Prehospital Emergency Care, Sept-Oct 2016,
Vol 20/#5.
13. Hersey, D., Witter, T., Kovacs, G. Transport of a Prone Position Acute Respiratory
Distress Syndrome Patient. Air Med Journal 37 (2018) 206-210.
Owner: Mike Betzner
Last Update: March 202014. Cornejo, R., Ugalde, D., Llanos, O., et al. Prone Position Ventilation Used during a
Transfer as a Bridge to ECMO Therapy in Hantavirus-Induced Severe Cardiopulmonary
Syndrome. Case Reports in Critical Care. Vol 2013. Article ID 415851. 4 pages.
15. Flabouris, A., Schoettker, P., Garner, A. ARDS with Severe Hypoxia - Aeromedical
Transportation During Prone Ventilation. Anaesth Intensive Care 2003; 31: 675-678.
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