Acute Respiratory Distress Syndrome: Manual Prone vs. Automatic Prone Therapy

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Overview of the Framework

Acute respiratory distress syndrome (ARDS) occurs due to buildup in the alveoli in a patient’s lungs. The accumulated fluid then keeps the lungs from getting enough air, resulting in less than the required oxygen in the blood. Consequently, this deprives the body organs of the oxygen essential to keep them performing their function, exposing epithelial layers of organs such as the lungs and other pulmonary arteries to develop issues that result in metabolic and structural damage. According to Tzotzos et al. (2020), the condition may develop from simple instances to moderate and subsequently severe ARDS, requiring invasive mechanical ventilation (IMV) and exhibiting poor prognosis.

Artificial ventilation of the lungs can be achieved in several ways that have been clinically proven. The most common occurs by inserting a plastic tube through the nose or mouth into the trachea. In cases where the patients need to be under the ventilator for several days, the doctors may consider tracheostomy, which involves inserting a tube through the front part of the neck. The tube is then attached to the ventilator to enable the patient to breathe as expected. Pathological changes are first localized with subsequent development infiltration and interstitial edema and then involvement in the pathological process of the interalveolar space (Doglioni et al., 2021). The current study explores the benefits of manual prone compared to automatic prone therapy for ARDS patients in the intensive care unit (ICU).

The Rationale for the Selection of Prone Therapy for ARDS Patients in the ICU

Population health is critical for healthcare professionals, facilities, and providers. It is mainly associated with the health outcomes of specific categories of individuals, including their distribution. Such groups can include employees, disabled people, ethnicities, ARDS Patients, and any other category defined by the healthcare system. Each group’s outcomes are essential in policy-making, which is critical in the public and private sectors. Population health in prone therapy is crucial because it gives information needed by various stakeholders to understand what they can do individually and collectively to ensure that patients have better health outcomes. ARDS patients require prone therapy, hence comparing manual and automatic prone therapies and choosing a cost-effective method. According to Morata et al. (2021), manual prone positioning has the same results as those derived from automatic prone. Still, manual prone has fewer complications, risks of interruptions during the therapy, and is less expensive. Consequently, this study compares manual prone and automatic prone therapy for ARDS patients in the ICU.

Synthesis of Evidence-Based Peer-Reviewed Literature

This section explores past research on population health in line with ARDS patients. It focuses on the goals the therapy should meet in addressing the health outcome of ARDS patients. Moreover, it explores differences between manual and automatic prone therapies by highlighting the positioning methods, resource utilization, risks and injuries, duration of hospital stay, and barriers to access. The differences revealed in the literature are critical to understanding and making an informed choice regarding a therapy method a hospital can consider for its ARDS patients in ICU.

The Overarching Need for Prone Therapy

ARDS patients are, in most cases, those who have difficulty breathing due to complications in their respiratory system. This category needs special care so the patients can incur lower treatment costs or stay for shorter periods. Consequently, the overarching needs for prone therapy comprise achieving the goals of respiratory support in line with the medically proven principles of pronation.

Respiratory support comprises the methods meant to maintain body gas exchange through the lungs, reduce the work of breathing, and provide time for restoring lung functions. Some patients can maintain adequate gas requirements in their lungs with spontaneous breathing with oxygen inhalation and positive end-expiratory pressure or through various non-invasive respiratory support methods (Hanouz et al., 2018). Firstly, the targeted oxygen values can remain higher by minimally sufficient oxygenation for patients with brain pathology. Secondly, the tolerable hypercapnia technique is essential when there is a need to remove carbon dioxide in severe ARDS and the absence of brain pathology (Grant et al., 2019). Moreover, the method is also essential when it is critical to achieving the target level of PaCO2 or going beyond the protective ventilation protocol while maintaining the PaCO2 level of no more than 80 mm Hg. Thirdly, prevention of further lung damage, including the MVL apparatus (the concept of safe MVL): prevention of hyperoxia, prevention of volutrauma (Grant et al., 2019). Thus, the choice of a prone therapy method depends on several factors, including positioning methods, associated risks and dangers, and accessibility of the devices.

Positioning and Practices in Therapy

Manual positioning of the abdomen is the first methodology described in the literature. This method is still in use today as researchers work to improve the safety and ease of performing manual prone positioning. Manual prone therapy is effectively used “to increase monoaminergic output centrally (reducing pain levels) that can lead to alterations in monoamine levels” (Albin et al., 2019, p. 2). Assistive rotators have been explicitly designed to assist in the manual positioning of the patient in the correct prone position or to aid in repositioning. Special beds are also used that mechanically rotate the patient into the correct position.

The prone position reduces the difference between dorsal and ventral Ptp, making ventilation more uniform, resulting in less ventral alveolar hyperinflation and dorsal alveolar collapse. As a result, the reduction in alveolar distension limits ventilator-associated lung damage from overdistension and cyclic atelectasis (Pan & Qiu, 2020). Ventilation on the abdomen also recruits the alveoli that collapse during ventilation on the back. This process can continue for a long time while the patient is lying on their stomach, receiving appropriate positive end-expiratory pressure. The result is improved ventilation and oxygenation, which many patients maintain even after returning to the supine position.

On the other hand, mechanical pronation beds are created with specialty to provide care in acute and critical conditions, which helps them in slow and gentle positioning of the patient. The kinetic bed enables gentle and safer patient repositioning with its air-filled modular inflatables, which increases the potential number of ARDS patients to be treated in the prone position (St John, 2021). Moreover, automatic pronation allows for safe vent equipment and IV device placement, which protects the patient during therapy. The fasteners that secure the patient into the bed ensure that the process is smooth and safe from prone to supine positions, with fewer nursing staff (St John, 2021). The beds mostly have safeguards that help the positioning much easier and with better treatment outcomes.

Risks and Dangers

Skin care and prevention of its breakdown is a critical area addressed by manual prone therapy. During the therapy session, pressure is applied to various structures based on the patient’s position (Schnettler et al., 2020). It is easier in manual pronation to moisturize and apply a barrier between the different parts that share moisture, which prevents measures against skin complications. Moreover, the clinicians attending to the patient can observe red spots, thus repositioning the patient. However, prone ventilation may not be considered for patients with spinal instability or risk it, those with open wounds, chest tubes, or pregnant women.

While manual pronation is more effective in skin care for the affected patients, it is also associated with several potential risks. According to Chiu et al. (2021), the manual turning of the individual from prone to supine position can result in physical injuries to the nursing staff and the patient, who can fall in the process. Wiggermann et al. (2020) indicate that the most common incidence among the nursing team during manual prone therapy is back injury resulting from heavy lifting. Moreover, surfaces can catch tunings during turning, consequently creating more harm to the patient. Manual pronation can also lead to unintended extubation and line dislodgments, resulting in deaths that can be prevented within automatic prone therapy.

On the other hand, mechanical pronation is mainly associated with injuries to the skin and face due to long hours of prone therapy. According to Johnson et al. (2022), the skin may become reddish or blister due to a more extended period of contact between the skin and the surface of the machines. Morata et al. (2021) reveal that a prolonged period with automatic pronation may result in other complications such as transient facial edema, wound dehiscence, endotracheal, contractures, and arterial or venous access loss. These diseases associated with longer therapy sessions are worse compared to the injuries associated with manual pronation.

Resource Utilization

Manual pronation involves several nursing staff turning a patient from prone to supine positions and vice versa. According to Gordon et al. (2019), it requires between three and five nurses to attend to one patient, and the number may increase in cases where a patient is obese or extremely heavy. Besides the nurses, manual pronation requires the presence of a respiratory therapist tasked with managing the Endotracheal Tube (ETT) (Mattioli et al., 2020). Moreover, manual pronation requires the use of sheets and pillows placed on top of the patient to prevent any injuries to the patient’s face. Other resources needed include special guards to protect the patient and the nurses from potential injuries. If such resource miss or are overly costly, manual pronation can fail to meet its goals or result in more damage to the patient.

On the other hand, autopronation requires fewer physicians, especially in obese patients, and therefore can reduce the burden on hospital staff. Only three nurses are needed to ensure safety during axial rotation (Ferchow et al., 2020). In response to perceived difficulties in positioning patients with ALI/ARDS in the supine position, several manufacturers have developed devices, frames, or complete bed systems to assist staff in efficiently and safely positioning recumbent patients. These techniques may require extensive staff training and are often quite expensive, limiting their availability in some hospitals; the authors do not use them in their ICU. Others use the Rotoprone Therapy System, an automated system that allows for multiple prone therapy intervals over a long period (Bayne, 2020). This method has some advantages due to its automated use but is somewhat limited due to the daily cost of renting a bed. In the supine II study, the supine position was applied using this rotary bed in 20 participating centers and manually in the remaining five centers.

Accessibility

Accessibility to the two therapy methods is a crucial factor in the choice of pronation. According to Cotton et al. (2020), several barriers may impede access to a device to pronate a patient who detests manual pronation. The major challenge is the cost of the beds and all the related devices. Autopronation machines may cost as much as $1000 per day when used, which some hospitals may consider too expensive. Cotton et al. (2020) indicate that training of nursing staff may also be a barrier to using the autopronation devices since many may not have had access to such machines before. This may cause an issue where thorough training is required to ensure success and safety outcomes. Specialty devices may also prove challenging to access in rural areas even when suburban hospitals have the resources to acquire and use them.

Duration of Hospital Stay

Prone therapy is meant to ensure that the patient can be assisted in returning to normal breathing. According to Ehrmann et al. (2021), the longer a patient stays in therapy, the greater the benefits of the interventions given. Automatic prone usually takes a shorter time compared to manual prone therapy. Mitchell and Seckel (2018) indicate that the prone position in automatic prone therapy happens daily, especially in cases with no significant oxygenation improvements. However, manual prone therapy takes seven hours a day and can last between four and ten days. Since automatic proning takes longer per session, the therapy usually takes fewer days. The ease of treatment monitoring associated with manual prone therapy makes it easy for the attending medics to know the progress the patient makes while monitoring potential skin-associated risks.

The adverse effects of more extended hospital stays are mainly due to the patient’s position based on the device displacements, accidental extubation, device displacement, hemodynamic instability, vomiting, and pressure ulcers (Poon et al., 2021). Other effects, such as ocular complications, have also been associated with the prolonged prone position. Consequently, this suggests the detriments of longer stays, which become an issue regarding the choice of a better proning method between the manual and automatic ones.

Financial Analysis of Prone Therapy for ARDS Patients in the ICU

The financial aspects associated with Prone Therapy for ARDS Patients in the ICU differ widely from one organization to another and the severity of the condition. According to Baston et al. (2019), quality-adjusted life years (QALYs) resulting from automatic proning use yielded $31,156 in the long term. Baston et al. (2019) noted that the incremental cost-effectiveness ratio (ICER) stands at = $38,648 per QALY. Moreover, they indicated that if the society remits a total of $100,000 per QALYs, this would indicate that an intervention given to patients with moderate to severe ARDS can be a good value. On the other hand, the hospitals’ perspectives of these costs reveal that it requires $44,615 per patient who is fully treated and survives the ordeal. The finding indicated that if the healthcare facilities could pay $100,000 for every survival-to-discharge, then any intervention below $5,140 per client would be an effective value. However, this is not always the case since most healthcare facilities’ budget average $12,331 per patient. Consequently, it is crucial to find better and more cost-effective methods.

While Baston et al. (2019) give the general costs of proning, manual prone therapy is less costly. Manual proning intervention in the base case would produce more survivors to discharge at $5,242 compared to the general cost of $12,331. Extrapolating this, for every 100 severe ARDS patients in the hospital who invest in an intervention to increase the incidence of the prone position, an additional 7.2 will survive to discharge over current standards of care at the cost of $524,000. In other words, the Number Needed to Treat (NNT) for extra survival is 13.9. The change in prone patients had no significant effect on ICER between the final level of 24% and 95%, although higher rates accumulated more survivors to discharge. The intervention would also be of good value: $1,557 per patient with a willingness to pay $50,000 for survival to discharge and $12,306 per patient willing to pay $200,000 for survival to discharge. Thus, the project shows that profitability will be provided for both the clinic and the patient.

Executive Summary

ARDS is a condition that results in the buildup of fluids in a patient’s lungs, making it challenging for them to get enough oxygen to their body organs. This condition can be managed and eventually treated through manual or automatic therapy. This study considers manual therapy a better approach due to its benefits, such as low costs, convenience, fewer complications, and fewer interruptions during therapy. The study also explores past research on the goals of therapy interventions for ARDS patients, their principles, and their effectiveness. Moreover, it explores the positioning principles and explains the two types of therapy. Past research indicates that more extended hospital stays result in better ARDS intervention outcomes. The findings reveal that automatic prone takes longer per day and hence lasts fewer days than manual therapy. The frequency of prone position in manual prone therapy makes it a more effective method that results in fewer cases of skin complications and results in more survival.

The financial analysis of the manual prone therapy indicates that clients can pay as low as $5,242 for every survival. Investing more into manual proning therapy can lower costs for result-oriented interventions. The analysis further indicates that adding 100 more patients into the plan results in 7.2 more patients surviving, revealing that 1000 patients can pay for 72 others. Moreover, with more investments, a patient willing to pay $50,000 can survive at $1,557, while another willing to pay $200,000 for discharge can pay $12,306. Therefore, the return on investment is that the NNT for extra survival is 13.9. This increases access to treatment as more hospitals can benefit from the investment in case the society can pay the minimum required amounts to keep the projects running. Moreover, it improves the quality of care as more facilities have access to the needed financing and resources.

In conclusion, manual pronation provides several benefits, including easy access for inspection, increased safety, and less mortality compared to the prone position. Manual prone therapy at UPMC showed a decrease in HAPI; further studies are needed to confirm this conclusion. It is critical to consider technical, staffing, and product needs when developing established protocols for adopting proper manual pull as a ventilation strategy in the appropriate patient population. Therefore, it is crucial for the healthcare facilities to fully adopt manual prone therapy techniques to ensure that the health outcomes in ARDS can increase, thus attracting more funding.

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