Nutrition Support Blog: Enteral Feeding and Prone Position
January 31, 2014
It is cold and flu season in Virginia and like most hospitals, this time of year we inevitably have more cases of respiratory failure that lead to acute lung injury and ARDS. In years past our ICU physicians have placed some patients with ARDS into the prone position (on their stomach) for a portion of each day to acutely improve oxygenation. Older research suggested that proning patients with ARDS improved oxygenation, but overall morbidity and mortality did not appear to be improved. However, more recent research has indicated that early proning of patients with severe ARDS, for a longer number of days, can improve patient outcomes1,2. Naturally, we have seen an increased number of patients with ARDS being proned recently.
If you are interested in more details about the rational, mechanics and other details about proning patients with ARDS, I recommend the following review article:
Previously, our patients were only proned for several days, and EN was just held temporarily, or only provided while the patient was supine. The most recent data suggests that our patients may benefit from more days of proning and we will need to more fully address nutrition issues. Unfortunately, there are no randomized studies of different nutrition protocols while patients are in the prone position and the recent large multicenter study did not include any information about the way that nutrition was provided2.
One study has suggested that patients in the prone position may be at greater risk of emesis, but patients were not randomized into the groups3. Selection bias because of who met the criteria to be proned, versus who did not need to be proned, could explain the difference in the frequency of emesis.
One modest-sized (72 total patients) before-after study suggested that feeding tolerance may be improved if patients have the bed tilted to elevate the head by 25 degrees, prophylactic prokinetic medication (intravenous erythromycin) with slow advancement of EN rate4. Questions still remain about the optimal protocol for patients that are proned, and there does not appear to be any data regarding gastric versus small bowel feeding while patients are proned. Considering the favorable results of the study in June2, I was a bit surprised that there were no abstracts regarding EN in the prone position presented at the recent Society of Critical Care Medicine. http://journals.lww.com/ccmjournal/toc/2013/12001
In the absence of great data we are considering each case on its own merits, and employing prokinetics and small bowel feeding where needed, while keeping in mind that the GI tract generally works, and how just a “few” years ago we were frequently turning off enteral feedings for normal amounts of gastric fluids. We will keep scanning the literature and if new studies turn up, you can be sure they will find a place on our e-journal club in the future.
“Scio ne nihil scire” (I know that I do not know)
1. Gattinoni L, Taccone P, Carlesso E, Marini JJ. Prone position in acute respiratory distress syndrome. Rationale, indications, and limits. Am J Respir Crit Care Med. 2013;188(11):1286-1293.
2. Guérin C, Reignier J, Richard JC, et al . PROSEVA Study Group. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013;368:2159–2168.
3. Reignier J, Thenoz-Jost N, Fiancette M, et al. Early enteral nutrition in mechanically ventilated patients in the prone position. Crit Care Med. 2004;32(1):94-99.
4. Reignier J, Dimet J, Martin-Lefevre L, et al. Before-after study of a standardized ICU protocol for early enteral feeding in patients turned in the prone position. Clin Nutr. 2010;29(2):210-216.