We thank Anthony Pietropaoli, Physical Therapists of the Critical Care Service at Strong Memorial Hospital, John Horvath, Michael Maxwell, E. Kate Valcin, and Craig Woeller.

1. Procedure: preparation
<ol>
	<li>Have the team establish that the patient is a good candidate for prone positioning with respect to the hemodynamic status.</li>
	<li>Obtain a provider order for prone positioning, which should ideally indicate the number of hours in prone position.</li>
	<li>Explain the procedure to the patient (if not sedated) and/or significant other. 
	NOTE: Consider the time of day and the staff on hand regarding when to begin the proning cycle. This is especially relevant if there are multiple patients on a unit/ward that need to be placed in the prone position8.</li>
	<li>Ensure all the potential participants are notified of the plan, including the RT.</li>
	<li>Obtain an arterial blood gas sample for analysis, from an indwelling arterial line, or via arterial puncture prior to the procedure8.</li>
	<li>Transfer the patient onto a pressure-redistributing surface prior to beginning the proning cycle19.</li>
	<li>Use a slide sheet or air transfer matt to avoid caregiver injury.</li>
	<li>If a feeding tube is in use, check the integrity of the securement or use a bridle to reduce any chance of dislodgement.</li>
	<li>Stop the tube feed.</li>
	<li>Meticulously secure all intravascular catheters and place foam dressings on the skin under the hubs and ports if the patient will be lying on them when in the prone position. 
	NOTE: If the patient is on isolation, initiate a wearable sensor for continuous glucose monitoring, if applicable and available.</li>
	<li>Make note of the length of the ET at the lips or teeth. Remove the headboard.</li>
	<li>If a commercial ET holder is in use, have the RT and ICU nurse remove this device and secure the tube with tape approved for the securement of critical tubes.</li>
	<li>Place foam dressings on the face, including over the cheeks and the top lip, prior to taping the ET tube. Optional: place foam dressings on the chin, nose, and forehead20 (Table 1).</li>
	<li>Suction the ET and mouth and perform oral hygiene.</li>
	<li>Apply foam dressings to both knees and any other bony prominences or areas of risk, i.e., sternum and under medical devices that cannot be moved20,21.</li>
	<li>Empty drains, urinary collection bag, and ostomy pouches.</li>
	<li>If the patient is pharmacologically paralyzed or if the eyelids are not closed, instill lubrication in eyes, and then close the lids and secure them with gentle tape.</li>
	<li>Check for immediate availability of a team member who is competent in intubation and the accessibility of an emergency intubation kit, code cart, extra electrodes, extra bed linen, pillows, and foam dressings of various sizes.</li>
	<li>Discontinue non-essential infusions and monitoring prior to initiating the procedure. Disconnect tube feeding, remove oximetry probe and blood pressure cuff if the patient also has an arterial line, remove leg devices for deep vein thrombosis prevention and heel boot(s), and unhook urinary catheter securement.</li>
	<li>Monitor pulse oximetry or invasive arterial blood pressure throughout the procedure.</li>
	<li>Assess pain and sedation status immediately prior to proning and treat accordingly by administering medication to optimize sedation and prevent pain.</li>
</ol>
2. Procedure: supine to prone
<ol>
	<li>Have the assigned ICU nurse in collaboration with the charge nurse assemble the adequate number of nursing staff; ideally four (two on either side of the bed) plus the RT, but as many staff as available and needed for the patient size, to facilitate a safe procedure. Let the team members introduce themselves, if needed, and discuss each team member&#39;s role prior to proceeding.
	<ol>
		<li>Put the RT in charge of airway at the head of bed (HOB).</li>
		<li>Put the ICU nurse in charge of monitoring critical intravascular lines and assisting the RT.</li>
		<li>Have other team members monitoring the drains and other tubes and assisting with linens and roll.</li>
		<li>Assign the wound nurse, or skin champion if available, to direct prevention measures for bony prominences and skin under medical devices and assist with bed linen roll.</li>
		<li>Designate a team member to watch the monitor.</li>
		<li>Have a healthcare provider available inside or just outside the room, available to reintubate if necessary.</li>
	</ol>
	</li>
	<li>Check for securement of chest tubes and any other percutaneous tubes.</li>
	<li>Have the RT or Provider, with the ICU nurse, decide the direction in which the patient will be rolled and communicate it to the other team members. 
	NOTE: Ideally plan to roll toward the ventilator, away from central venous lines.</li>
	<li>Have the RT/Provider adjust ventilator settings as ordered/required.</li>
	<li>Lay the patient flat on the bed in the supine position (Figure 1).</li>
	<li>Create a bed roll using an extra slide sheet or air transfer pad, flat bed sheet, and under pad. Inflate the mattress to the maximum extent, if applicable.</li>
	<li>Using the slide sheet or air lift under patient, pull the patient to the edge of the bed that is furthest from the ventilator.</li>
	<li>Place the bed roll so that it can be unrolled onto the side of the bed that is opposite to the ventilator.</li>
	<li>Tuck the linen roll under the patient on the ventilator side. Ensure that only 25%-30% of the roll is tucked under the patient.</li>
	<li>On the count of the team member at the HOB, carefully roll the patient from supine up to a 90&#176; side-lying position with the patient&#39;s face toward the ventilator (Figure 2).</li>
	<li>Move the telemetry electrodes from the patient&#39;s chest to the patient&#39;s back (Figure 3). 
	NOTE: Placement of new electrodes on the back can also occur when the patient is lying prone.</li>
	<li>Place a pillow on the bed that will be positioned under the patient&#39;s chest/shoulders.</li>
	<li>If the patient is inflexible and/or has tight hip flexors, place a pillow under the hip/pelvis and/or an air cushion under the knees.</li>
	<li>On the count of the team member at the HOB, carefully lay the patient prone with a pillow under the upper chest/shoulders, and center the patient in the middle of the bed with the top of patient&#39;s head at the top edge of the bed (Figure 4).</li>
	<li>Have team members at the head of the bed rotate the patient&#39;s head either left or right, and place the bed pillow under the head. Ensure that the patient&#39;s face is on the very edge of the pillow so that the nose is free from pressure, and there is adequate room for the ET and ventilator tubing for suctioning.</li>
	<li>Ensure that the patient&#39;s arms are placed in the swimmer&#39;s crawl position: the face is toward the prominent hand, palmar side down, wrist in neutral, elbow lower than the shoulder, and elbow flexed6,22. Ensure that the contralateral arm is extended down alongside the body, with a pillow under the anterior shoulder and arm, palmar side of the hand facing up.</li>
	<li>Place a pillow horizonal to the patient under both the lower legs to allow the knees to be slightly flexed and disallow extreme plantar flexion and avoidance of pressure injuries on the feet and toes.</li>
	<li>Reconnect the monitoring equipment and tubes that were disconnected prior to prone positioning.</li>
	<li>Complete a skin assessment of the sacrum, coccyx, and buttocks. Place a protective foam dressing on the sacrum in anticipation of returning to supine positioning after the prescribed prone time.</li>
	<li>Place the bed in reverse Trendelenburg&#39;s position, approximately 30&#176; for complication avoidance8,12.</li>
	<li>Restart tube feeding if applicable.</li>
</ol>
3. Procedure: position changes while lying prone
<ol>
	<li>Mobilize the patient every 2-3 h for pressure injury avoidance and to optimize the drainage and suctioning of secretions from the lung segments into the central airway. 
	NOTE: The exact frequency of repositioning of the patient may be influenced by both patient factors, such as hemodynamic tolerance and staffing factors6.</li>
	<li>Ensure the availability of a minimum of three caregivers for position changes. Have the RT take charge of managing the ET and two additional caregivers, one an ICU nurse, assist with mobilizing the patient.</li>
	<li>Take the bed out of the reverse Trendelenburg&#39;s position to a flat position, parallel to the floor.</li>
	<li>Using a slip sheet or air transfer pad, pull the patient up in bed if needed (with mattress inflated to the maximum extent if applicable).</li>
	<li>Carefully move the arm that is bent at the elbow down to the patient&#39;s side.</li>
	<li>After suctioning the patient&#39;s airway and mouth as needed, have the RT secure the ET and lift the patient&#39;s head off the pillow.</li>
	<li>Wait for the nurse at the HOB to pull out the pillow from under the patient&#39;s head while the RT rotates the head to the opposite direction. Ensure that the pillow is flipped or the pillow case changed and the head placed back on the edge of the pillow, with no pressure on the nose or ET.</li>
	<li>Bring up the arm on the side that the head is facing is now in swimmer&#39;s position, elbow bent and lower than the shoulder, wrist in neutral.</li>
	<li>Ensure that the contralateral arm is in neutral alongside the body, with a pillow tucked to support the anterior shoulder and arm, palmar side of the hand facing up. 
	&#8203;NOTE: For an inflexible patient and/or those with limited neck rotation, a pillow can be slightly tucked under the abdomen on the side the head is turned toward to facilitate neck rotation and ensure off-loading of nose and chin.</li>
</ol>
4. Procedure: prone to supine
<ol>
	<li>Assign an ICU nurse to collaborate with the charge nurse in assembling an adequate number of staff to complete the procedure. 
	NOTE: Typically, at least four staff members are required, but assemble as many as needed for the patient&#39;s size and to facilitate a safe procedure. Team members introduce themselves if needed and discuss each team member&#39;s role prior to proceeding.
	<ol>
		<li>Ensure that the RT or Provider is in charge of airway at the HOB.</li>
		<li>Put the critical care nurse in charge of monitoring critical intravascular lines and assisting the RT.</li>
		<li>Have the other team member(s) monitor drains and other tubes and assist with linens and the turn.</li>
	</ol>
	</li>
	<li>Empty drains and the urinary collection bag.</li>
	<li>Ensure protective foam dressing is on the sacrum.</li>
	<li>Have a team member watch the monitor.</li>
	<li>Have the provider inside or outside the room, available to reintubate if necessary.</li>
	<li>Allow the decision for the direction in which patient will be rolled to be made jointly by the RT and the critical care/ICU nurse. Roll the patient toward or away from the ventilator, depending on the location of the central venous lines, IV pump locations, and preference of the RT and ICU nurse.</li>
	<li>Disconnect non-critical tubing and devices.</li>
	<li>Take the bed out of the reverse Trendelenburg to a flat position parallel to the floor. Inflate the mattress to the maximum extent, if applicable.</li>
	<li>Carefully straighten the arm/hand that is across from the face and gently place it at the patient&#39;s side.</li>
	<li>Remove all the pillows from underneath the patient, including the chest, lower legs, and lateral trunk if applicable.</li>
	<li>Pull the patient to the side of the bed furthest from the direction of the turn.</li>
	<li>Create the bed roll with a slip sheet or air transfer pad, flat sheet, or under pad. Roll it up lengthwise and tuck 20% under the patient on the side the patient will roll toward.</li>
	<li>Gather extra electrodes/wires for the heart monitor.</li>
	<li>Have the RT adjust the ventilator settings as required/ordered.</li>
	<li>After a clear plan for the turn is established, tuck the patient&#39;s hand on the side that the patient will be turned toward, palm side up under the thigh.</li>
	<li>Carefully turn the patient 90&#176; onto their side, hold the patient briefly in this position while the heart monitoring electrodes are removed from the back, and new ones are placed on the chest. 
	NOTE: If preferred, placement of new electrodes can also occur after the patient is lying supine.</li>
	<li>On the count of the team member at the HOB, gently lower the patient to the supine position.</li>
	<li>Reconnect the tubes/monitoring equipment that were removed for the turn.</li>
	<li>Have the RT with the ICU nurse check the positioning of the ET and securement of all intravascular lines, tubes, and monitoring equipment. Adjust the angle of the bed as appropriate. 
	NOTE: Typically, 30&#176; of head elevation is required.</li>
</ol>

<ol><li>Menk, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Current+and+evolving+standards+of+care+for+patients+with+ARDS%5BTitle%5D)+AND+%22Intensive+Care+Medicine%22%5BJournal%5D)">Current and evolving standards of care for patients with ARDS.</a> Intensive Care Medicine. 46 (12), 2157-2167 (2020).</li>
<li>Villar, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Dexamethasone+treatment+for+the+acute+respiratory+distress+syndrome%3A+a+multicenter%2C+randomized+controlled+trial%5BTitle%5D)+AND+%22The+Lancet.+Respiratory+Medicine%22%5BJournal%5D)">Dexamethasone treatment for the acute respiratory distress syndrome: a multicenter, randomized controlled trial.</a> The Lancet. Respiratory Medicine. 8 (3), 267-276 (2020).</li>
<li>The RECOVERY Collaborative Group. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Dexamethasone+in+hospitalized+patients+with+COVID-19%5BTitle%5D)+AND+%22The+New+England+Journal+of+Medicine%22%5BJournal%5D)">Dexamethasone in hospitalized patients with COVID-19.</a> The New England Journal of Medicine. 384 (8), 693-704 (2021).</li>
<li>Tomazini, B. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Effect+of+dexamethasone+on+days+alive+and+ventilator-free+in+patients+with+moderate+or+severe+acute+respiratory+distress+syndrome+and+COVID-19%5BTitle%5D)+AND+%22Journal+of+the+American+Medical+Association%22%5BJournal%5D)">Effect of dexamethasone on days alive and ventilator-free in patients with moderate or severe acute respiratory distress syndrome and COVID-19.</a> Journal of the American Medical Association. 324 (13), 1307-1316 (2020).</li>
<li>Guérin, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Prone+positioning+in+severe+acute+respiratory+distress+syndrome%5BTitle%5D)+AND+%22The+New+England+Journal+of+Medicine%22%5BJournal%5D)">Prone positioning in severe acute respiratory distress syndrome.</a> The New England Journal of Medicine. 368 (23), 2159-2168 (2013).</li>
<li>Binda, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Nursing+management+of+prone+positioning+in+patients+with+COVID-19%5BTitle%5D)+AND+%22Critical+Care+Nurse%22%5BJournal%5D)">Nursing management of prone positioning in patients with COVID-19.</a> Critical Care Nurse. 41 (2), 27-35 (2021).</li>
<li>Guérin, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Prone+position+in+ARDS+patients%3A+why%2C+when%2C+how+and+for+whom%5BTitle%5D)+AND+%22Intensive+Care+Medicine%22%5BJournal%5D)">Prone position in ARDS patients: why, when, how and for whom.</a> Intensive Care Medicine. 46 (12), 2385-2396 (2020).</li>
<li>Rowe, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Development+of+clinical+guidelines+for+prone+positioning+in+critically+ill+adults%5BTitle%5D)+AND+%22Nursing+in+Critical+Care%22%5BJournal%5D)">Development of clinical guidelines for prone positioning in critically ill adults.</a> Nursing in Critical Care. 9 (2), 50-57 (2004).</li>
<li>Spece, L. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Low+tidal+volume+ventilation+use+remains+low+in+patients+with+acute+respiratory+distress+syndrome+at+a+single+center%5BTitle%5D)+AND+%22Journal+of+Critical+Care%22%5BJournal%5D)">Low tidal volume ventilation use remains low in patients with acute respiratory distress syndrome at a single center.</a> Journal of Critical Care. 44, 72-76 (2018).</li>
<li>Shelhamer, M. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Prone+positioning+in+moderate+to+severe+acute+respiratory+distress+syndrome+due+to+COVID-19%3A+A+cohort+study+and+analysis+of+physiology%5BTitle%5D)+AND+%22Journal+of+Intensive+Care+Medicine%22%5BJournal%5D)">Prone positioning in moderate to severe acute respiratory distress syndrome due to COVID-19: A cohort study and analysis of physiology.</a> Journal of Intensive Care Medicine. 36 (2), 241-252 (2021).</li>
<li>Traylor, A. M., Tannenbaum, S. I., Thomas, E. J., Salas, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Helping+healthcare+teams+save+lives+during+COVID-19%3A+insights+and+countermeasures+from+team+science%5BTitle%5D)+AND+%22The+American+Psychologist%22%5BJournal%5D)">Helping healthcare teams save lives during COVID-19: insights and countermeasures from team science.</a> The American Psychologist. 76 (1), 1-13 (2021).</li>
<li>Gonzalez-Seguel, F., Pinto-Concha, J. J., Aranis, N., Leppe, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Adverse+events+of+prone+positioning+in+mechanically+ventilated+adults+with+ARDS%5BTitle%5D)+AND+%22Respiratory+Care%22%5BJournal%5D)">Adverse events of prone positioning in mechanically ventilated adults with ARDS.</a> Respiratory Care. 66 (12), 1898-1911 (2021).</li>
<li>Dirkes, S., Dickinson, S., Havey, R., O'Brien, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Prone+positioning+Is+it+safe+and+effective%3F%5BTitle%5D)+AND+%22Critical+Care+Nursing+Quarterly%22%5BJournal%5D)">Prone positioning Is it safe and effective?</a> Critical Care Nursing Quarterly. 35 (1), 64-75 (2012).</li>
<li>Wiggermann, N., Zhou, J., Kumpar, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Proning+patients+with+COVID-19%3A+a+review+of+equipment+and+methods%5BTitle%5D)+AND+%22Human+Factors%22%5BJournal%5D)">Proning patients with COVID-19: a review of equipment and methods.</a> Human Factors. 62 (7), 1069-1076 (2020).</li>
<li>Dickinson, S., Park, P. K., Napolitano, L. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Prone-positioning+therapy+in+ARDS%5BTitle%5D)+AND+%22Critical+Care+Clinics%22%5BJournal%5D)">Prone-positioning therapy in ARDS.</a> Critical Care Clinics. 27 (3), 511-523 (2011).</li>
<li>Poor, A. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Implementing+automated+prone+ventilation+for+acute+respiratory+distress+syndrome+via+simulation-based+training%5BTitle%5D)+AND+%22American+Journal+of+Critical+Care%22%5BJournal%5D)">Implementing automated prone ventilation for acute respiratory distress syndrome via simulation-based training.</a> American Journal of Critical Care. 29 (3), 52-59 (2020).</li>
<li>Weller, J., Boyd, M., Cumin, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Teams%2C+tribes+and+patient+safety%3A+overcoming+barriers+to+effective+teamwork+in+healthcare%5BTitle%5D)+AND+%22Postgraduate+Medical+Journal%22%5BJournal%5D)">Teams, tribes and patient safety: overcoming barriers to effective teamwork in healthcare.</a> Postgraduate Medical Journal. 90 (1061), 149-154 (2014).</li>
<li>Papazian, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Formal+guidelines%3A+management+of+acute+respiratory+distress+syndrome%5BTitle%5D)+AND+%22Annals+of+Intensive+Care%22%5BJournal%5D)">Formal guidelines: management of acute respiratory distress syndrome.</a> Annals of Intensive Care. 9 (1), 69(2019).</li>
<li>Team, V., Jones, A., Weller, C. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Prevention+of+hospital-acquired+pressure+injury+in+COVID-19+patients+in+the+prone+position%5BTitle%5D)+AND+%22Intensive+%26+Critical+Care+Nursing%22%5BJournal%5D)">Prevention of hospital-acquired pressure injury in COVID-19 patients in the prone position.</a> Intensive & Critical Care Nursing. 68, 103142(2021).</li>
<li>National Pressure Injury Advisory Panel. Pressure injury prevention PIP tips for prone positioning. , Available from: 
 <a target="_blank" href="https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/posters/npiap_pip_tips_-_proning_202.pdf">https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/posters/npiap_pip_tips_-_proning_202.pdf</a> (2020).</li>
<li>Martel, T., Orgill, D. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Medical+device-related+pressure+injuries+during+the+COVID-19+pandemic%5BTitle%5D)+AND+%22Journal+of+Wound%2C+Ostomy+and+Continence+Nursing%22%5BJournal%5D)">Medical device-related pressure injuries during the COVID-19 pandemic.</a> Journal of Wound, Ostomy and Continence Nursing. 47 (5), 430-434 (2020).</li>
<li>Miller, C., O'Sullivan, J., Jeffrey, J., Power, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Brachial+plexus+neuropathies+during+the+COVID-19+pandemic%3A+a+retrospective+case+series+of+15+patients+in+critical+care%5BTitle%5D)+AND+%22Physical+Therapy%22%5BJournal%5D)">Brachial plexus neuropathies during the COVID-19 pandemic: a retrospective case series of 15 patients in critical care.</a> Physical Therapy. 101 (1), 191(2021).</li>
</ol>

The authors do not have any conflicts of interest to disclose.

The most important nursing part in the process of proning a critically ill intubated patient is the preparation. For example, there needs to be extensive consideration and gathering of needed supplies to have available, including tape to secure the ET, foam dressings to pad bony prominences, extra electrodes for cardiac monitoring, extra bed linens, pillows and under pads; all essential for an efficient process and safe patient experience.
Availability of needed supplies, skilled staff, clear ...

The care for patients with ARDS has greatly improved over the past five decades. Menk et al. reviewed the standards for ventilatory management, pharmacotherapy, and adjuncts to ventilation in treating this inflammatory process1. Individualized ventilation pressure and volume limitation, use of positive end expiratory pressure (PEEP) for oxygenation and lung recruitment, and spontaneous breathing trials to minimize diaphragm atrophy are mainstays of care that continue to evolve1. In a multicenter randomized controlled trial, Villar et al. found that the early administration of dexamethasone to patients with moderate-to-severe ARDS reduced time on the ventilator and overall mortality2. Additional multicenter randomized clinical trials, such as RECOVERY and CoDex, studied the use of dexamethasone in patients with COVID-19-related ARDS. They found that early administration of dexamethasone to patients with COVID-19 and moderate or severe ARDS, along with standard care, reduced time on the ventilator and resulted in lower 28-day mortality3,4.
Prone positioning, an effective ventilatory adjunct for patients with moderate-to-severe ARDS, is not a new intervention. Guerin et al. demonstrated that prone positioning for ARDS significantly lowers 28- and 90-day mortality and increases the chance for successful extubation5.&#160;Yet placing a patient in the prone position is not without risk; iatrogenic complications such as ET obstruction, central catheter displacement, and pressure injury can occur when attempting this maneuver with a mechanically ventilated patient6,7.
Prior to the COVID-19 pandemic, some institutions initiated prone positioning for moderate-to-severe ARDS ad hoc or infrequently, akin to what Spece et al. reported about the slow adoption of low tidal volume ventilation for ARDS despite compelling evidence of its efficacy6,8,9. The COVID-19 pandemic though, demanded a rapid implementation of new knowledge, irrespective of previous gaps in the application of clinical research to patient care.
During the pandemic, both early anecdotal reports, as well as well-constructed studies later, established that proning not only improved physiologic parameters but also reduced patient mortality for patients with COVID-19 ARDS. Shelhamer et al. found that one in-hospital death was avoided for every eight patients with moderate-to-severe ARDS, who were proned during their ICU stay10. Prone positioning was strongly supported as a standard treatment for the COVID-19 patient with ARDS versus being a last-ditch maneuver1,7. However, staff shortages during the COVID-19 pandemic resulted in redeployment of non-critical care staff to critical care areas. These redeployed staff lacked expertise with this high-volume high-risk procedure11. Stressors on these teams both at work and at home resulted in uncertainty and difficulty in maintaining processes. It was imperative to develop a strategy to mitigate adverse events related to prone positioning12.
The goal of this protocol is to demonstrate the effectiveness of a team-based, step-by-step approach to the proning maneuver for patients with COVID-19 ARDS. We have shown that this procedure carries a low risk for device dislodgment and other adverse events. In the context of the COVID-19 pandemic, the occurrence of proning is frequent. The advantages of the technique used here include full visual and physical access to the patient with attached tubes, wires, and other equipment, less stress on the patient and healthcare workers by using a breathable transfer matt, and multidisciplinary team participation to decrease adverse outcomes13.
With other manual proning methods, such as the &#34;burrito&#34; method, attached tubes, lines, and wires cannot be visualized during the entire proning process14. Additional techniques found in the wider body of literature rely upon a portable proning frame or a specialized proning bed. Though effective, these methods may be prohibitive if the equipment is not readily available, is too expensive, or if staff lack interprofessional training on management of emergency situations that could occur while using the equipment14,15,16.
Teamwork 
The COVID-19 crisis revealed the need to adopt a team mentality because of the high volume of patients, scarcity of supplies, and human resources among hospital-based healthcare professionals. Although interprofessional collaboration in healthcare is not a new concept, being able to quickly pull together a team and perform a high-risk procedure is not something that most nursing staff and allied health professionals train to do17. Some staff discovered they had various levels of proficiency and confidence in relation to proning a patient, as well as competing ideas on the best approach with the least amount of patient complications.
Leadership, respect, adaptability, monitoring each other&#39;s performance, closed-loop communication, and team orientation are key elements for a safe and effective team17. Having a shared vision of the critical considerations can be achieved by promoting a standard operating procedure that supports safe and effective care for the patient who needs to be proned. Papazian et al. recommend having a written procedure and detailed training for proning teams18.
Simulation 
Practicing or simulating the proning maneuver using a multidisciplinary staff can be an effective tool for both new staff and a review for incumbent staff16. Being mindful and attentive to potential complications during and after proning can be achieved through focused education and multidisciplinary teams for proning8. An ICU nurse and respiratory therapist (RT) focused on critical tube and vascular access management, a wound specialist or skin champion focused on preventing skin injury, and a physical therapist assessing body mechanics and soft tissue injury prevention are examples of effective workload management. Maximum clinical benefit can be achieved by using the unique strengths of specialized staff19.

<table><tbody><tr><td>HoverMatt</td><td>HoverTech International</td><td>HM34SPU-B</td><td>Single patient use</td></tr><tr><td>Mepilex 4x4</td><td>Molnlycke Healthcare</td><td>294199</td><td>Strip cut and placed over top lip</td></tr><tr><td>Mepilex Border Flex 3x3</td><td>Molnlycke Healthcare</td><td>595200</td><td>Chin</td></tr><tr><td>Mepilex Border Flex 4x4</td><td>Molnlycke Healthcare</td><td>595300</td><td>Cheeks (and forehead if needed)</td></tr><tr><td>Mepilex Border Flex 6x6</td><td>Molnlycke Healthcare</td><td>595400</td><td>Knees (and anterior iliac crests if needed)</td></tr><tr><td>Mepilex Border Sacrum 8x9</td><td>Molnlycke Healthcare</td><td>282455</td><td>Sacrum</td></tr></tbody></table>

an educational video demonstration of how to prone a critically ill intubated patient

Early in the coronavirus disease 2019 (COVID-19) pandemic, it was reported that prone position was beneficial for mechanically ventilated COVID-19 patients with acute respiratory distress syndrome (ARDS). However, for staff in some small and large hospitals, experience with this intervention was low. Select hospitals were able to assemble proning teams; but, as facilities began to experience staffing shortages, they found proning teams unsustainable, and less specialized staff needed to learn how to safely prone patients.
Proning is a high-risk procedure-a lack of a standard approach can result in staff confusion and poor patient outcomes, including unintentional endotracheal tube (ET) loss, vascular access dislodgement, and skin breakdown. Given the acuity and high patient volume, translating a complex procedure into written policy may not be entirely effective. Critical care nurses, respiratory therapists, physical therapists, wound nurses, nurse practitioners, physician assistants, and medical doctors need to be prepared to safely perform this procedure for an acutely ill COVID-19 patient.
Communication, teamwork, and multidisciplinary collaboration are critical for complication avoidance. Interventions to prevent tube and vascular access dislodgement, skin breakdown, and brachial plexus and soft tissue injury must be implemented during the procedure. Repositioning the patient in the prone position, as well as returning the patient to supine positioning, should be components of a comprehensive proning plan.

Following a review of step-by-step instructions of how to prone a critically ill intubated patient, critical care staff were able to return a safe demonstration of proning. Additional nursing leadership, e.g., a clinical nurse specialist, certified wound nurse, and/or a physical therapist is recommended to provide rapid decision-making during critical points, e.g., taping and repositioning the ET tube, as well as head and arm positioning. After a few practices, it is estimated that the procedure takes approximately 10-15...

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An Educational Video Demonstration of How to Prone a Critically Ill Intubated Patient

Proning a critically ill patient with severe acute respiratory distress syndrome (ARDS) is a complex but beneficial procedure. Excellent communication skills, team work, and multidisciplinary collaboration are critical for patient and staff safety. A standard procedure should be utilized when proning ventilated patients with tubes, drains, and vascular access devices.

Early in the coronavirus disease 2019 (COVID-19) pandemic, it was reported that prone position was beneficial for mechanically ventilated COVID-19 ...

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3.2K Views.  University of Rochester Medical Center/Strong Memorial Hospital. Proning a critically ill patient with severe acute respiratory distress syndrome (ARDS) is a complex but beneficial procedure. Excellent communication skills, team work, and multidisciplinary collaboration are critical for patient and staff safety. A standard procedure should be utilized when proning ventilated patients with tubes, drains, and vascular access devices.

Video: An Educational Video Demonstration of How to Prone a Critically Ill Intubated Patient

A Novel Rescue Technique for Difficult Intubation and Difficult Ventilation

We describe a novel non surgical technique to maintain oxygenation and ventilation in a case of difficult intubation and difficult ventilation, which works especially well with poor mask fit.
Can not intubate, can not ventilate" (CICV) is a potentially life threatening situation. In this video we present a simulation of the technique we used in a case of CICV where oxygenation and ventilation were maintained by inserting an endotracheal tube (ETT) nasally down to the level of the naso-pharynx while sealing the mouth and nares for successful positive pressure ventilation.
A 13 year old patient was taken to the operating room for incision and drainage of a neck abcess and direct laryngobronchoscopy. After preoxygenation, anesthesia was induced intravenously. Mask ventilation was found to be extremely difficult because of the swelling of the soft tissue. The face mask could not fit properly on the face due to significant facial swelling as well. A direct laryngoscopy was attempted with no visualization of the larynx. Oxygen saturation was difficult to maintain, with saturations falling to 80%. In order to oxygenate and ventilate the patient, an endotracheal tube was then inserted nasally after nasal spray with nasal decongestant and lubricant. The tube was pushed gently and blindly into the hypopharynx. The mouth and nose of the patient were sealed by hand and positive pressure ventilation was possible with 100% O2 with good oxygen saturation during that period of time. Once the patient was stable and well sedated, a rigid bronchoscope was introduced by the otolaryngologist showing extensive subglottic and epiglottic edema, and a mass effect from the abscess, contributing to the airway compromise. The airway was secured with an ETT tube by the otolaryngologist.This video will show a simulation of the technique on a patient undergoing general anesthesia for dental restorations.

We describe a technique to maintain oxygenation and ventilation using an endotracheal tube inserted nasally to the level of the naso-pharynx while sealing the mouth and nares for successful positive pressure ventilation.

We describe a novel non surgical technique to maintain oxygenation and ventilation in a case of difficult intubation and difficult ventilation, which ...

Guidelines for Elective Pediatric Fiberoptic Intubation

Fiberoptic intubation in pediatric patients is often required especially in difficult airways of syndromic patients i.e. Pierre Robin Syndrome. Small babies will desaturate very quickly if ventilation is interrupted mainly to high metabolic rate. We describe guidelines to perform a safe fiberoptic intubation while maintaining spontaneous breathing throughout the procedure. Steps requiring the use of propofol pump, fentanyl, glycopyrrolate, red rubber catheter, metal insuflation hook, afrin, lubricant and lidocaine spray are shown.

We describe guidelines to perform a safe and efficient elective fiberoptic intubation in pediatric patients while maintaining spontaneous ventilation.

Fiberoptic intubation in pediatric patients is often required especially in difficult airways of syndromic patients i.e. Pierre Robin Syndrome. Small ...

Expired CO2 Measurement in Intubated or Spontaneously Breathing Patients from the Emergency Department

Carbon dioxide (CO2) along with oxygen (O2) share the role of being the most important gases in the human body. The measuring of expired CO2 at the mouth has solicited growing clinical interest among physicians in the emergency department for various indications: (1) surveillance et monitoring of the intubated patient; (2) verification of the correct positioning of an endotracheal tube; (3) monitoring of a patient in cardiac arrest; (4) achieving normocapnia in intubated head trauma patients; (5) monitoring ventilation during procedural sedation. The video allows physicians to familiarize themselves with the use of capnography and the text offers a review of the theory and principals involved. In particular, the importance of CO2 for the organism, the relevance of measuring expired CO2, the differences between arterial and expired CO2, the material used in capnography with their artifacts and traps, will be reviewed. Since the main reluctance in the use of expired CO2 measurement is due to lack of correct knowledge concerning the physiopathology of CO2 by the physician, we hope that this explanation and the video sequences accompanying will help resolve this limitation.

Expired CO2 Measurement in Intubated or Spontaneously Breathing Patients from the Emergency Department

This video describes how to perform CO2 measurement in intubated as well as spontaneously breathing patients. The main clinical indications refer to emergency situations: (1) verifying adequate positioning of an endotracheal tube; (2) achieving normocapnia in trauma patients; (3) monitoring ventilation in the case of procedural sedation.

Carbon dioxide (CO2) along with oxygen (O2) share the role of being the most important gases in the human body. The measuring of expired CO2 at the mouth ...

Manufacture of a Multi-Purpose Low-Cost Animal Bench-Model for Teaching Tracheostomy

Tracheostomy is one of the most frequent procedures, performed through various techniques in the intensive care unit and emergency situations. Despite this, there is a lack of training on this procedure that affects its outcome, which is also dependent on operator's dexterity. Here, we take the specific training and simulation into consideration. This article aims to describe every step of the manufacture of a new multi-purpose low-cost animal bench-model, with the support of video and images, and to obtain an opinion about the quality of this model by administering a questionnaire to professionals with experience in the procedures. 
Ten experts in the technique were enrolled. The model scored an average of 3.45/5 for its anatomical realism; 4.75/5 for its usefulness as a training tool for simulation courses and assessments. The time necessary to build the model was 15 minutes, and the cost amounted to 10&#8364;. The animal bench-model was considered a very useful simulator for tracheostomy training and assessments. Therefore, it could be used as a tool for medical courses and residencies.

This article illustrates every step of the manufacture of a new multi-purpose low-cost animal bench-model for subglottic airway access management. All the procedures are shown in the video. The model's realism and its suitability for training the given clinical maneuvers were assessed by independent senior otolaryngologists and anesthesiologists.

Tracheostomy is one of the most frequent procedures, performed through various techniques in the intensive care unit and emergency situations. Despite ...

Image Acquisition using Portable Sonography for Emergency Airway Management

With its increasing popularity and accessibility, portable ultrasonography has been rapidly adapted not only to improve the perioperative care of patients, but also to address the potential benefits of employing ultrasound in airway management. The benefits of point of care ultrasound (POCUS) include its portability, the speed at which it can be utilized, and its lack of invasiveness or exposure of the patient to radiation of other imaging modalities.
Two primary indications for airway POCUS include confirmation of endotracheal intubation and identification of the cricothyroid membrane in the event a surgical airway is required. In this article, the technique of using ultrasound to confirm endotracheal intubation and the relevant anatomy is described, along with the associated ultrasonographic images. In addition, identification of the anatomy of the cricothyroid membrane and the ultrasonographic acquisition of appropriate images to perform this procedure are reviewed.
Future advances include utilizing airway POCUS to identify patient characteristics that might indicate difficult airway management. Traditional bedside clinical exams have, at best, fair predictive values. The addition of ultrasonographic airway assessment has the potential to improve this predictive accuracy. This article describes the use of POCUS for airway management, and initial evidence suggests that this has improved the diagnostic accuracy of predicting a difficult airway. Given that one of the limitations of airway POCUS is that it requires a skilled sonographer, and image analysis can be operator dependent, this paper will provide recommendations to standardize the technical aspects of airway ultrasonography and promote further research utilizing sonography in airway management. The goal of this protocol is to educate researchers and medical health professionals and to advance the research in the field of airway POCUS.

Point of care ultrasound (POCUS) is increasingly being utilized in airway management. Presented here are some clinical utilities of POCUS, including differentiating endotracheal and esophageal intubation, identification of the cricothyroid membrane in the event a surgical airway is required, and measuring anterior neck soft tissue to predict difficult airway management.

With its increasing popularity and accessibility, portable ultrasonography has been rapidly adapted not only to improve the perioperative care of ...

A Non-Intubation Protocol for Video-Assisted Thoracoscopic Surgery with Preserved Autonomic Breathing

Non-Intubated Video-Assisted Thoracoscopic Surgery

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the lung, and lobectomy. However, there is a high incidence of pulmonary complications arising from general anesthesia with tracheal intubation. Non-intubation with the preservation of voluntary breathing is an alternative to anesthesia. Non-intubation procedures minimize the adverse effects of tracheal intubation and general anesthesia, such as intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade, and post-operative nausea and vomiting. However, the steps for non-intubation procedures are not detailed in many studies. Here, we present a concise non-intubated protocol for the performance of video-assisted thoracoscopic surgery with preserved autonomic breathing. This article identifies the conditions necessary to convert from non-intubated to intubated anesthesia and also discusses the advantages and limitations of non-intubated anesthesia. In this work, this intervention was performed on 58 patients. In addition, the results of a retrospective study are presented. Compared with intubated general anesthesia, patients in the non-intubated video-assisted thoracic surgery group had lower rates of post-operative pulmonary complications, shorter operative times, less intraoperative blood loss, shorter PACU stays, a lower number of days to chest drain removal, less post-operative drainage, and shorter hospital stays.

Author Spotlight: A Non-Intubated Video-Assisted Thoracoscopic Surgery with Multimodal Analgesia and Sevoflurane Inhalation Anesthesia 

Here, we present a non-intubated protocol for performing video-assisted thoracoscopic surgery with preserved autonomic breathing.

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the ...

Awake Intubation in Difficult Airways: A Flexible Video Laryngoscope Method

The Flexible Rhino-Laryngoscope for Awake Nasotracheal Intubation

Difficulties or failures in securing the airway still occur and can lead to permanent disabilities and mortality. Patients with head and neck pathologies obstructing airway access are at risk of airway management failure once they lose spontaneous respiration. Awake flexible scope intubation is considered the gold standard for controlling the airway in such patients. Following a feasibility trial involving 25 patients with challenging airways, this article presents a step-by-step protocol for awake nasotracheal intubation using a flexible video rhino-laryngoscope, which is significantly shorter than conventional intubating flexible scopes. The flexible video laryngoscope only exceeds the intubating tube length by a few centimeters, allowing the tube to closely follow the flexible scope during the procedure. Once the scope reaches the pharynx, it can be easily manipulated with one hand, enabling the operator to focus on the safe advancement of the scope-intubating tube assembly through the glottis. Based on previous results and experience gained, this article highlights the potential benefits of the technique: the opportunity for a minimally invasive "quick look" preoperatively to establish a final management plan, a more convenient and safer tool for navigating distorted anatomy with a lower chance of intubating tube impingement and airway injury, and a fast and smooth procedure resulting in improved patient satisfaction.

Author Spotlight: Advancing Awake Nasotracheal Intubation with Flexible Video Rhino-Laryngoscopes

Presented here is a protocol for awake nasotracheal intubation using a flexible rhino-laryngoscope with a 300 mm working length. As this tool is minimally invasive and easy to manipulate, awake intubation performed with a flexible rhino-laryngoscope is well-tolerated, fast, and safe for patients with difficult airways.

Difficulties or failures in securing the airway still occur and can lead to permanent disabilities and mortality. Patients with head and neck pathologies ...

COVID-19 / Coronavirus Outbreak: Protecting The Airway - Endotracheal Intubation

In pandemic times, medical staff is becoming a key resource in fighting the infection. To achieve the best medical care, relevant techniques and procedures have to be taught to medical staff to reduce the risk of infection. COVID patients often need mechanical ventilation due to progredient respiratory insufficiency, so an endotracheal intubation becomes a critical procedure in managing these&#160;patients. This procedure has an increased risk of infection due to aerosol formation and working with an unsecured airway. Patient safety should not be neglected, and complications like hypoxaemia and aspiration should be avoided. At the same time, personal protection from infection is of utmost importance becuase&#160;human resources in a pandemic crisis must be preserved. This video shows the procedure of endotracheal intubation while taking personal infection protection into account.&#160;

COVID-19 / Coronavirus Outbreak: Protecting the Airway - Endotracheal Intubation

In pandemic times, medical staff is becoming a key resource in fighting the infection. To achieve the best medical care, relevant techniques and ...

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Coronavirus / COVID-19 Procedures

COVID-19 / Coronavirus Outbreak: How to perform complete prone positioning in COVID-Patients

In pandemic times, medical staff is becoming a key resource in fighting the infection. To achieve the best medical care, relevant techniques and procedures have to be taught to medical staff while reducing the risk of infection. COVID-19 patients often develop an acute respiratory distress syndrome with respiratory failure. Prone positioning&#160;is established as a core component of management in COVID-19 patients, to enable ventilation of a greater lung area and thereby improve gas exchange. This video shows the prone positioning of a COVID-19 patient while taking personal infection protection into account.

COVID-19 / Coronavirus Outbreak: How to Perform Complete Prone Positioning in COVID-Patients

Endotracheal Intubation I: Procedure

Endotracheal or ET intubation is a critical medical procedure used to secure a patient&#39;s airway, often in acute respiratory distress, apnea, upper airway obstruction, ineffective clearance of secretions, high risk for aspiration, or during general anesthesia.
The ET tube comprises various components, including a standard adaptor to attach a bag-valve-mask (BVM) or ventilator, a cuff, a pilot balloon, and radiopaque markings along its length to measure the insertion distance. The tube sizes usually range from 7.0 to 8.0 millimeters in internal diameter, with females typically requiring a 7.0 mm tube and males an 8.0 mm tube. A larger diameter tube can reduce breathing resistance, facilitate easier suction and removal of secretions, and enable bronchoscopy if needed.
Purpose
The primary purpose of endotracheal intubation is to establish and maintain a patent airway for individuals who cannot maintain an adequate airway independently. It includes patients with respiratory distress, those who are comatose, undergoing general anesthesia, or experiencing extensive edema of upper airway passages. It is also used to bypass an upper airway obstruction, prevent aspiration, permit connection to a mechanical ventilator, or facilitate the removal of tracheobronchial secretions.
Tubes
There are two main types of endotracheal tubes: orotracheal and nasotracheal. Although uncomfortable, orotracheal insertion is often preferred, especially in emergencies, due to its ease of insertion and ability to accommodate a larger tube, facilitating ventilation. Nasotracheal insertion, while better tolerated by patients, is more complex and requires a narrower tube.
Procedure
The procedure involves inserting the ET tube through the mouth or nose, passing it through the vocal cords, and into the trachea with the help of a laryngoscope or bronchoscope. Oral ET intubation is preferred because the airway can be secured rapidly. The tube can remain in place for up to two weeks and is connected to a ventilator for control of respirations and ventilation of the lungs.
In some cases, airway pressure release ventilation (APRV) promotes spontaneous breathing in ventilated patients by cycling between higher and lower Continuous Positive Airway Pressure (CPAP) pressure levels. It helps open the alveoli and promotes better gas exchange.
Nursing Management
Nursing management involves periodically monitoring vital signs, evaluating blood gas levels, observing the patient&#39;s response to respiratory support, and identifying complications associated with endotracheal intubation. Nurses aim to improve the patient&#39;s comfort by providing reassurance, facilitating communication, and delivering oral care to keep the mouth and lips free of crusts and mucus. Position changes every two hours are essential to prevent atelectasis, and humidification is necessary to keep the inspired air moist.
After removing the endotracheal tube, the patient is positioned in a high-Fowler&#39;s or semi-Fowler&#39;s stance to encourage maximum expansion of the chest and lungs. Nurses frequently observe the patient for signs of laryngeal edema and increased respiratory distress; emergency respiratory support equipment must always be available.

Endotracheal or ET intubation is a critical medical procedure used to secure a patient&#39;s airway, often in acute respiratory distress, apnea, upper ...