A novel head support device for prone positioning in acute respiratory distress syndrome.

Abstract

Sir, Acute respiratory distress syndrome (ARDS) is a life-threatening condition characterized by hypoxia and decreased compliance of the lungs. The Berlin definition is used for defining and predicting mortality and severity of the disease.[1] The Proning Severe ARDS Patients trial confirmed that prone position for 16 h/day offered a survival advantage of 10%–17%, recommending this intervention in patients with PaO2/FiO2 lower than 100.[2] Proning a ventilated patient requires cooperation of all intensive care unit (ICU) staff along with care to prevent pressure sores and to prevent damage on the face, endotracheal (ET) tube, nasogastric tube, and central venous catheter. Conventionally a silicon block with face indentation and ET tube outlet is used. This is not available in a tertiary care municipal hospital in Mumbai. Padded pillows, folded bed sheets, gauze bundles, and donut pillows have been used. We describe a novel method for head support with provision for ET tube outlet for prone ventilation, using ventilator tubing, Gamjee rolls, and gauze bandage. Two parallel lengths of corrugated ventilator tubing and a small noncompressible plastic attachment were used [Figure 1]. They were curved to fit patient's face shape and size. The noncompressible plastic attachment was placed in-between the two tubes and the ring covered with Gamjee roll [Figure 2]. The ET tube can be passed through the plastic conduit placed in-between the curved ventilator tubing [Figure 3].Figure 1: Two parallel plastic corrugated ventilator tubings and noncompressible plastic attachment as a conduit for the endotracheal tubeFigure 2: The corrugated tubing is curved to fit the face size with the endotracheal conduit in-between the two. The assembly is covered by a Gamjee rollFigure 3: The endotracheal tube can be passed through the noncompressible plastic conduit placed in-between the two ventilator tubingAfter fulfilling prerequisites, the head support and ET tube were held in place, resting on the forehead and chin when the patient was in supine position [Figure 4]. The patient was turned over for proning once the assembly was in place [Figure 5].Figure 4: Head support resting on the intubated patient's face with the endotracheal tube coming out of the noncompressible plastic conduit in supine positionFigure 5: Head support to the patient in the prone position with the endotracheal tubing coming out of the conduitThis method allows maintenance of prone position without the need for head to be turned laterally. Proning methods requiring the head turned laterally may compress jugular veins and are avoided in raised intracranial pressure. Lateral rotation is difficult in patients with cervical spine disease; hence, foam donuts are used that suspend the head off of the bed without lateral rotation. These donuts result in facial trauma as the head weight is supported by a smaller surface area.[3] Endotracheal tube presents a logistic difficulty during prone positioning, but using our head support, the tube does not have contact with bed or support padding and is free from undue torsion, pressure and is unlikely to kink. A study conducted in 2005 to evaluate the reduction in pressure sores using a prone head support (PHS) system with mask showed that the lips were most affected with erosion being the most common injury. The PHS system with its face mask reduced the extent and severity of pressure sores in patients in the prone position.[4] The literature is sparse for the implementation of such head support systems on larger scale and there remains a need for a device that would give the required support, is easily available in the ICU, and prevents pressure-related complications. Our technique ensures prone position without increasing the cost of patient care and vital facial structures and the ET tube are not damaged. The highlight of our novel technique is the noncompressible exit conduit for the ET tube, which makes ET tube care simple and effective. It may help prevent facial injuries and pressure sores caused during conventional prone positioning. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgment We would like to thank the doctors and also the nursing and supporting staff of the Intensive Respiratory Care Unit, Department of Chest Medicine and EPRC.