While prone positioning ventilation can improve symptoms and mortality in patients with ARDS due to COVID-19, it may cause patients feel uncomfortable over a long period of time, and even lead to adverse effects such as pressure injuries, pain, and dizziness. Currently, the application of prone position tools (such as soft pillows, cushions, and frame) during prone position surgery and prone position ventilation is aimed at reducing adverse events such as pressure injuries and nerve injuries. Minnis et al. reported that using Tony prone support, a polyurethane foam fold support cushion, can reduce the incidence of pressure marks and neuropraxias, as well as minimizing the risk of orbital and maxillofacial injury during spinal surgery or chronic pain procedures in the prone position[19]. Similar findings were investigated by Ruhland et al., wherein applying a polyurethane cushions to the thoracic, pelvis, and head of two patients in prone position ventilation due to ARDS and COVID-19 can prevent pressure injuries[20]. Moreover, Sun et al. found that using protective cushions around the orbit can avoided orbital compartment syndrome[21]. However, there are currently no RCT studies on the use of prone positioning tools for improving patient comfort and reducing adverse events during prone ventilation. Our RCT study found that modular new prone positioning tools can effectively enhance the comfort of patients during prone positioning and reduce adverse events such as artificial airway curvature, pressure injuries, and dizziness in contrast with soft pillows. However, there is no significant difference in intubation rates or mortality.
Long-term prone positioning has several disadvantages. Patients may experience discomfort and various adverse events (e.g., muscle fatigue and stress), leading to muscle pain and stiffness, incompletely expansion of lungs, breathing difficulties, chest oppression, which further results in hypoxemia, dizzy symptoms, and increased the risk of stress injury[22]. To address these issues, current clinical practice commonly utilizes regular repositioning that provides a comfortable position. In the past, ordinary soft pillows were commonly used in the ward, which had a soft texture and a tendency to sink during use. It generated pressure on the patients' eye sockets, chest, and abdomen, which could result in conjunctival congestion, pressure injuries, and limited respiratory function. Additionally, it required frequent assistance from a nurse or a caregiver to assist with positioning. It not only increased the risk of tracheal stenosis, obstruction, and even accidental detachment of the tube during positioning, but also added the workload of the nurse or the caregiver. Based on this, we designed modular new prone position tools, which consist of five modules: the head pad, chest pad, elbow pad, knee pad, and ankle pad, which can reduce the risk of pain and pressure injuries during the prone position. Among them, the head pad has a unique "U"-shaped recess design, which can distribute the weight of the head over the entire face when the patient is in prone position, avoid pressure on the orbital area, and reduce the risk of intraocular congestion. Additionally, the hollow design allows for an artificial airway to pass through without bending or moving out of place. Furthermore, the unique recess design of the chest pad can ensure that the chest and abdomen are suspended in air when the patient is in prone position, thus reducing the risk of dyspnea and dizziness caused by pressure on the chest during prone position ventilation. In our study, we observed significant differences in the rates of adverse events, such as pain, shortness of breath, dizziness, and pressure injuries between the observation group and the control group during the period of prone position. This suggests that modular new prone position tools can reduce the incidence of adverse events during prone positioning ventilation.
The extreme long duration of executing the prone position ventilation not only increases the workload of nurses or caregivers, but also causes discomfort to the patients during the execution, or even rejection of cooperation. Therefore, it is necessary to shorten the duration of executing the prone position ventilation. In addition, prolonged prone position ventilation can lead to discomfort in patients, including pain, dizziness, and dyspnea, which often requires frequent changes in position to ameliorate the situation. However, frequent changes in position during prone positioning ventilation can lead to fluctuations in blood pressure, curved artificial airways, and other complications, which not only affects the effectiveness of prone positioning ventilation, but also increases the difficulty of treatment for the underlying disease; consequently, the outcome and prognosis of the patient was impacted[23]. In our study, we observed that compared to soft pillows, modular new prone position tools could significantly shorten the time spent executing PP and the number of changes in position during PP while extending the duration of PP and the duration time when first needing to changes in position. This suggests that the modular new prone position tools can promote the efficiency of prone position execution and enhance patient comfort. The modular new prone position tools are made of high-density sponge with a medium hardness, which complies with the principles of human biomechanics and ensures enough support for the patient's head, chest, elbows, knees, and ankles in the prone position, thus improving their comfort. And its modular design is based on the comfortable posture of human prone position, which helps patients quickly achieve a comfortable prone position that avoids any posture adjustments. However, the results of this study showed that there was no significant difference in the mortality rate and intubation rate between the two groups, possibly due to the fact that both groups were able to receive prone position ventilation, with no significant differences in the treatment methods and mechanisms either. What’s more, although the control group patients spent less time in the prone position due to discomfort, this did not influence their overall outcomes.