Which strategy will the nurse use to improve oxygenation in the client with acute respiratory distress syndrome ARDS?

Prone positioning is a technique used to help patients with acute respiratory distress syndrome breathe better.

Widespread inflammation in the lungs may result in a life-threatening condition called acute respiratory distress syndrome (ARDS). Severe infections such as coronavirus disease 2019 (COVID-19) and influenza can cause ARDS. Breathing can be difficult for patients with ARDS.

Hospitalized patients typically lie on their backs, a position known as supine. In prone positioning, patients lie on their abdomen in a monitored setting. Prone positioning is generally used for patients who require a ventilator (breathing machine).

Prone positioning may be beneficial for several reasons: (1) In the supine position, the lungs are compressed by the heart and abdominal organs. Gas exchange, the process of trading carbon dioxide for oxygen, is reduced in areas of collapsed lung, resulting in low oxygen levels. In the prone position, lung compression is less, improving lung function. (2) The body has mechanisms to adjust blood flow to different portions of the lung. In ARDS, an imbalance between blood and air flow develops, leading to poor gas exchange. Prone positioning redistributes blood and air flow more evenly, reducing this imbalance and improving gas exchange. (3) With improved lung function in the prone position, less support from the ventilator is needed to achieve adequate oxygen levels. This may reduce risk of ventilator-induced lung injury, which occurs from overinflation and excess stretching of certain portions of the lung. (4) Prone positioning may improve heart function in some patients. In the prone position, blood return to the chambers on the right side of the heart increases and constriction of the blood vessels of the lung decreases. This may help the heart pump better, resulting in improved oxygen delivery to the body. (5) Because the mouth and nose are facing down in the prone position, secretions produced by the disease process in the lung may drain better.

Placement of Patients in the Prone Position

Movement of patients to a prone position involves risk of serious complications such as a dislodged breathing tube or very low blood pressure. A team of trained clinicians, including respiratory therapists, nurses, and a physician, are necessary to safely reposition a patient. Most hospitals maintain patients in a prone position for at least 12 hours per day, though practices vary. Proning sessions continue until there is a sustained improvement in oxygen levels, or if proning does not improve oxygen levels.

While prone positioning is generally limited to patients on a ventilator, voluntary, awake proning is being studied in patients with COVID-19. These patients require monitoring for worsening respiratory status.

Challenges of Prone Positioning for ARDS

Prone positioning is considered on an individual basis. Although it is beneficial in some settings, not all patients improve and some may worsen. With changes in position, medical devices, breathing tubes, and drains may dislodge (unintentionally fall out). If a breathing tube becomes dislodged, replacement in the prone position is difficult. Performing procedures or cardiopulmonary resuscitation (CPR) is also challenging in the prone position and may require immediate repositioning. Also, with prone positioning, pressure is placed on the shoulders, chest, knee, and face, predisposing these areas to pressure ulcers. This may also result in nerve injury.

Published Online: August 21, 2020. doi:10.1001/jama.2020.14901

Conflict of Interest Disclosures: None reported.

Sources: Aoyama H, Uchida K, Aoyama K et al. Assessment of therapeutic interventions and lung protective ventilation in patients with moderate to severe acute respiratory distress syndrome. JAMA Netw Open. 2019;2(7):e198116. doi:10.1001/jamanetworkopen.2019.8116

Marini JJ, Gattinoni L. Management of COVID-19 respiratory distress. JAMA. 2020;323(22):2329-2330. doi:10.1001/jama.2020.6825

Overview

Acute respiratory distress syndrome (ARDS) occurs when fluid builds up in the tiny, elastic air sacs (alveoli) in your lungs. The fluid keeps your lungs from filling with enough air, which means less oxygen reaches your bloodstream. This deprives your organs of the oxygen they need to function.

ARDS typically occurs in people who are already critically ill or who have significant injuries. Severe shortness of breath — the main symptom of ARDS — usually develops within a few hours to a few days after the precipitating injury or infection.

Many people who develop ARDS don't survive. The risk of death increases with age and severity of illness. Of the people who do survive ARDS, some recover completely while others experience lasting damage to their lungs.

Symptoms

The signs and symptoms of ARDS can vary in intensity, depending on its cause and severity, as well as the presence of underlying heart or lung disease. They include:

• Severe shortness of breath
• Labored and unusually rapid breathing
• Low blood pressure
• Confusion and extreme tiredness

When to see a doctor

ARDS usually follows a major illness or injury, and most people who are affected are already hospitalized.

Causes

The mechanical cause of ARDS is fluid leaked from the smallest blood vessels in the lungs into the tiny air sacs where blood is oxygenated. Normally, a protective membrane keeps this fluid in the vessels. Severe illness or injury, however, can cause damage to the membrane, leading to the fluid leakage of ARDS.

Underlying causes of ARDS include:

• Sepsis. The most common cause of ARDS is sepsis, a serious and widespread infection of the bloodstream.
• Inhalation of harmful substances. Breathing high concentrations of smoke or chemical fumes can result in ARDS, as can inhaling (aspirating) vomit or near-drowning episodes.
• Severe pneumonia. Severe cases of pneumonia usually affect all five lobes of the lungs.
• Head, chest or other major injury. Accidents, such as falls or car crashes, can directly damage the lungs or the portion of the brain that controls breathing.
• Coronavirus disease 2019 (COVID-19). People who have severe COVID-19 may develop ARDS.
• Others. Pancreatitis (inflammation of the pancreas), massive blood transfusions and burns.

Risk factors

Most people who develop ARDS are already hospitalized for another condition, and many are critically ill. You're especially at risk if you have a widespread infection in your bloodstream (sepsis).

People who have a history of chronic alcoholism are at higher risk of developing ARDS. They're also more likely to die of ARDS.

Complications

If you have ARDS, you can develop other medical problems while in the hospital. The most common problems are:

• Blood clots. Lying still in the hospital while you're on a ventilator can increase your risk of developing blood clots, particularly in the deep veins in your legs. If a clot forms in your leg, a portion of it can break off and travel to one or both of your lungs (pulmonary embolism) — where it blocks blood flow.
• Collapsed lung (pneumothorax). In most ARDS cases, a breathing machine called a ventilator is used to increase oxygen in the body and force fluid out of the lungs. However, the pressure and air volume of the ventilator can force gas to go through a small hole in the very outside of a lung and cause that lung to collapse.
• Infections. Because the ventilator is attached directly to a tube inserted in your windpipe, this makes it much easier for germs to infect and further injure your lungs.
• Scarring (pulmonary fibrosis). Scarring and thickening of the tissue between the air sacs can occur within a few weeks of the onset of ARDS. This stiffens your lungs, making it even more difficult for oxygen to flow from the air sacs into your bloodstream.

Thanks to improved treatments, more people are surviving ARDS. However, many survivors end up with potentially serious and sometimes lasting effects:

• Breathing problems. Many people with ARDS recover most of their lung function within several months to two years, but others may have breathing problems for the rest of their lives. Even people who do well usually have shortness of breath and fatigue and may need supplemental oxygen at home for a few months.
• Depression. Most ARDS survivors also report going through a period of depression, which is treatable.
• Problems with memory and thinking clearly. Sedatives and low levels of oxygen in the blood can lead to memory loss and cognitive problems after ARDS. In some cases, the effects may lessen over time, but in others, the damage may be permanent.
• Tiredness and muscle weakness. Being in the hospital and on a ventilator can cause your muscles to weaken. You also may feel very tired following treatment.

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