NUR 4320 Module 1 ARDS Paper: Low Tidal Volumes and Prone Positioning in Severe Respiratory Failure Example

Six Milliliters and Sixteen Hours: Protective Ventilation and Proning for Severe ARDS in an Elizabeth ICU

Student Name

B.S.N., Accelerated Second Degree, Thomas Edison State University

NUR-4320: Nursing Care of Clients with Complex Health Conditions

Mentor Name

Month Day, Year

Six Milliliters and Sixteen Hours: Protective Ventilation and Proning for Severe ARDS in an Elizabeth ICU

The Patient

Everything about Mr. Castillo and this unit is fictional. Mr. Castillo, 52, a warehouse supervisor, came to the emergency department with five days of fever and cough and was found to have pneumonia in both lungs. High-flow oxygen did not stop his saturation from falling, and he was intubated. In the ICU, his ratio of arterial oxygen to inspired oxygen, the PaO2/FiO2 ratio, was 88 on a positive end-expiratory pressure of 12, meeting the definition of severe ARDS. Chest imaging showed patchy opacities in both lungs that were not explained by heart failure. His wife and two teenage children waited in the family room.

What Is Happening in His Lungs

In ARDS, inflammation damages the membrane between air sacs and capillaries, and protein-rich fluid floods the air sacs. Large parts of the lung collapse or fill with fluid, leaving a much smaller area of functioning lung. Ventilating this smaller lung with normal-sized breaths overstretches the remaining healthy tissue and can cause further injury. This idea, that the ventilator itself can injure the lung, is the reason for lung-protective ventilation.

Smaller Breaths

In a trial run by the Acute Respiratory Distress Syndrome Network (2000), patients with acute lung injury and ARDS were randomly assigned to small breaths, sized at 6 mL/kg with predicted body weight as the base, with plateau pressure held at or under 30 cm of water, or to the traditional approach of 12 mL/kg and a higher pressure limit. The trial was stopped early because mortality was lower with smaller breaths, 31 percent compared with about 40 percent, and patients in the lower tidal volume group had more days without ventilator support. Predicted body weight comes from a formula using height and sex, not from actual weight, so that a heavier patient does not receive larger breaths.

Turning Prone

Guérin et al. (2013) studied patients whose PaO2/FiO2 ratio stayed under 150, randomly placing them face down for sixteen or more hours daily or leaving them on their backs. At 28 days, 16 percent of the prone group had died, compared with about 33 percent of the supine group, and the benefit persisted at 90 days. Complications were not more frequent in the prone group in this experienced setting. Proning improves oxygenation by allowing better-ventilated areas of the lung to receive blood flow and by making lung inflation more even.

The Guideline

Fan et al. (2017) issued a joint guideline on mechanical ventilation in adults with ARDS. It made strong recommendations for lower tidal volumes, 4 to 8 mL per kilogram of predicted weight, and plateau pressures below 30 cm of water, and for proning sessions longer than twelve hours daily in severe ARDS. It recommended against routine high-frequency oscillatory ventilation and made conditional recommendations about higher positive end-expiratory pressure and recruitment maneuvers.

Nursing Diagnoses

The student identified impaired gas exchange related to alveolar flooding and collapse, risk for pressure injury and airway displacement related to prone positioning and risk for ineffective coping in the family.

Protective Ventilation at the Bedside

The student calculated Mr. Castillo's predicted body weight from his height, 170 centimeters, as about 66 kilograms, so 6 mL/kg meant a tidal volume of about 400 mL, and confirmed with the nurse and respiratory therapist that the ventilator was set accordingly. The student learned to read the plateau pressure during the respiratory therapist's checks and to report a value above 30.

Proning Safely

Proning requires a team of five or six people with defined roles: one person at the head controls the endotracheal tube and calls each step. Before turning, the team checked tube depth and secured it, suctioned the airway, protected the eyes with lubricant and tape, placed foam dressings on the forehead, chin, chest, knees and other pressure points and organized lines and drains. After the turn, the student helped position his arms in a swimmer's position that changed every two hours and checked his face for pressure. His oxygen saturation improved within an hour. He remained prone for sixteen hours and was turned back for a skin check and mouth care before the next session.

Sedation and Comfort

Mr. Castillo received sedation to tolerate the ventilator and proning. The student assessed sedation with the unit's scale and pain with a behavioral pain tool, since he could not speak. The student also learned the ventilator-associated pneumonia prevention measures the unit followed, such as mouth care and raising the bed's head whenever he lay on his back.

The Family

His wife was frightened by seeing him face down. The student explained why proning helps, invited her to sit near his head and talk to him and arranged for the nurse to update the family after each turn.

Evaluation

After four days of proning sessions, his PaO2/FiO2 ratio rose above 200, proning was stopped and his ventilator settings were reduced. He had no pressure injuries on his face and no unplanned extubation.

Nursing Hands in ARDS Care

Until this rotation, the student had thought of the ventilator as the respiratory therapist's machine and the patient's lungs as the physician's concern. Watching the team turn Mr. Castillo showed how much of ARDS care rests on nursing hands: the pressure dressings placed before each turn, the eye care, the lines traced from pump to skin and the family member coached on where to sit. It also showed that two of the most effective treatments in critical care cost almost nothing. A smaller breath and a different position saved more lives in the trials than many expensive drugs ever have.

Limits

The proning trial took place in centers experienced with the technique, and less experienced units may see more complications. A student assists with proning under direction and does not change ventilator settings.

Conclusion

Mr. Castillo's severe ARDS called for two evidence-based measures. The ARDS Network trial showed that smaller breaths save lives, the PROSEVA trial showed that long prone sessions do too and the guideline made both strong recommendations. Careful verification of settings, safe proning and attention to skin, airway and family carried the evidence to the bedside.

References

Acute Respiratory Distress Syndrome Network. (2000). Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. New England Journal of Medicine, 342(18), 1301-1308. https://doi.org/10.1056/NEJM200005043421801

Fan, E., Del Sorbo, L., Goligher, E. C., Hodgson, C. L., Munshi, L., Walkey, A. J., Adhikari, N. K. J., Amato, M. B. P., Branson, R., Brower, R. G., Ferguson, N. D., Gajic, O., Gattinoni, L., Hess, D., Mancebo, J., Meade, M. O., McAuley, D. F., Pesenti, A., Ranieri, V. M., . . . Brochard, L. J. (2017). An official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice guideline: Mechanical ventilation in adult patients with acute respiratory distress syndrome. American Journal of Respiratory and Critical Care Medicine, 195(9), 1253-1263. https://doi.org/10.1164/rccm.201703-0548ST

Guérin, C., Reignier, J., Richard, J.-C., Beuret, P., Gacouin, A., Boulain, T., Mercier, E., Badet, M., Mercat, A., Baudin, O., Clavel, M., Chatellier, D., Jaber, S., Rosselli, S., Mancebo, J., Sirodot, M., Hilbert, G., Bengler, C., Richecoeur, J., . . . Ayzac, L. (2013). Prone positioning in severe acute respiratory distress syndrome. New England Journal of Medicine, 368(23), 2159-2168. https://doi.org/10.1056/NEJMoa1214103