Clinical Practice Guidelines for the Prevention and Management of Pressure Injury in Critically Ill Patients Undergoing Prone Position Ventilation: A Systematic Review
Restricted accessReview articleFirst published online 2025
Clinical Practice Guidelines for the Prevention and Management of Pressure Injury in Critically Ill Patients Undergoing Prone Position Ventilation: A Systematic Review
This systematic review was conducted to assess the quality of clinical practice guidelines (CPGs) on prevention and management of pressure injury (PI) in patients undergoing prone position ventilation (PPV) and summarize the recommendations based on the analyses of the CPGs.
Recent Advances:
We searched the PubMed, Cochrane library, Embase databases, guideline websites, professional association, quality standards, and Wound-Related Research Journals from January 1, 2010 to August 31, 2024. Included guidelines were those with recommendations for prevention and management of PI in patients undergoing PPV published in English. Four researchers independently assessed the eligible studies and extracted the data. Appraisal of Guidelines Research & Evaluation (AGREE II) instrument and the Reporting Items for Practice Guidelines in Healthcare checklist were used to assess the quality of the CPGs.
Critical Issues:
A total of 13 CPGs were included in this review. AGREE II demonstrated that the highest mean score was based on the scope and purpose and was 73.65 ± 10.91, whereas the lowest mean score was based on the editorial independence and was 49.79 ± 19.49. The scores of inter-rater agreements for AGREE-II quality appraisal ranged from 0.86 to 0.96. Recommendations for prevention and management of PI in patients undergoing PPV were inconsistent.
Future Directions:
The included CPGs were limited due to methodological issues and exhibited discrepancies in the coverage of important topics. Therefore, existing evidence should be used to propose identifiable recommendations and strengthen the rigor and standardization of guideline development in future research.
Get full access to this article
View all access options for this article.
References
1.
FanE, Del SorboL, GoligherEC, et al.An official American Thoracic Society/European society of intensive care medicine/society of critical care medicine clinical practice guideline: Mechanical ventilation in adult patients with acute respiratory distress syndrome. Am J Respir Crit Care Med, 2017; 195(9):1253–1263; doi: 10.1164/rccm.19511erratum
2.
Critical Care Respiratory Care Group. Critical care medicine branch, chinese medical association. Standardized procedure for prone ventilation therapy in patients with acute respiratory distress syndrome. Chinese Journal of Internal Medicine, 2020; 59(10):781–787.
3.
MunshiL, Del SorboL, AdhikariNKJ, et al.Prone position for acute respiratory distress syndrome. A systematic review and meta-analysis. Ann Am Thorac Soc, 2017; 14(Suppl 4):S280–S288; doi: 10.1513/AnnalsATS.201704-343OT
4.
SudS, FriedrichJO, AdhikariNK, et al.Effect of prone positioning during mechanical ventilation on mortality among patients with acute respiratory distress syndrome: A systematic review and meta-analysis. CMAJ, 2014; 186(10):E381–E90; doi: 10.1503/cmaj.140081
5.
LucchiniA, BambiS, MattiussiE, et al.Prone position in acute respiratory distress syndrome patients: A retrospective analysis of complications. Dimens Crit Care Nurs, 2020; 39(1):39–46; doi: 10.1097/DCC.0000000000000393
6.
RushRB, RushSW, ReinauerRM, et al.Vitrectomy for diabetic complications: A pooled analysis of randomized controlled trials using modern techniques and equipment. Retina, 2022; 42(7):1292–1301; doi: 10.1097/IAE.0000000000003471
7.
WangI, WalkerRM, GillespieBM, et al.Risk factors predicting hospital-acquired pressure injury in adult patients: An overview of reviews. Int J Nurs Stud, 2024; 150:104642; doi: 10.1016/j.ijnurstu.2023.104642
8.
LiaoX, MengL, ZengZ. Prone position ventilation for the relief of acute respiratory distress syndrome through improved pulmonary ventilation: Efficacy and safety. Nurs Crit Care, 2024; 29(2):255–273; doi: 10.1111/nicc.12948
9.
GirardR, BaboiL, AyzacL, et al.; Proseva trial group. The impact of patient positioning on pressure ulcers in patients with severe ARDS: Results from a multicentre randomised controlled trial on prone positioning. Intensive Care Med, 2014; 40(3):397–403; doi: 10.1007/s00134-013-3188-1
10.
KimM, KimJ, KwonSH, et al.Pressure controlled vs. volume-controlled ventilation during prone position in high-level spinal cord injury patients: A preliminary study. Korean J Anesthesiol, 2014; 67(Suppl):S43–S5; doi: 10.4097/kjae.2014.67.S.S43
11.
ZhangXC, QianSY, ZhangL, et al.Research progress of pressure injury associated with prone ventilation in patients with acute respiratory distress syndrome. Modern Nurse, 2024; 31(06):27.
12.
QianG, ZhangY, YangY, et al.Research progress on the current status and risk management of pressure injury caused by prone position ventilation. Chinese Nursing Research, 2024; 38(07):1223–1227.
Wound, Ostomy and Continence Nurses Society-Wound Guidelines Task Force. WOCN 2016 guideline for prevention and management of pressure injuries (Ulcers): An executive summary. J Wound Ostomy Continence Nurs, 2017; 44(3):241–246; doi: 10.1097/WON.0000000000000321
15.
YanM, ChenL, YangM, et al.Evidence mapping of clinical practice guidelines recommendations and quality for depression in children and adolescents. Eur Child Adolesc Psychiatry, 2023; 32(11):2091–2108.
16.
SunY, CaiYT, ChenJ, et al.An evidence map of clinical practice guideline recommendations and quality on diabetic retinopathy. Eye (Lond), 2020; 34(11):1989–2000; doi: 10.1038/s41433-020-1010-1
17.
FanM, LiuA, LuT, et al.Quality appraisal of clinical practice guidelines addressing massage interventions using the AGREE II instrument. Syst Rev, 2024; 13(1):83; doi: 10.1186/s13643-024-02503-6
18.
NgJY, BhattHA, RajaM. Complementary and alternative medicine mention and recommendations in pancreatic cancer clinical practice guidelines: A systematic review and quality assessment. Integr Med Res, 2023; 12(1):100921; doi: 10.1016/j.imr.2023.100921
19.
GrahamR, Miller WolmanD, GreenfieldS, et al.Clinical practice guidelines we can trust. Institute of Medicine (US) Committee on Standards for developing trustworthy clinical practice guidelines. The National Academies Press (US): Washington (DC); 2011.
20.
SanclementeG, AcostaJL, TamayoME, et al.Clinical practice guidelines for treatment of acne vulgaris: A critical appraisal using the AGREE II instrument. Arch Dermatol Res, 2014; 306(3):269–277; doi: 10.1007/s00403-013-1394-x
21.
BrouwersMC, KhoME, BrowmanGP, et al.; AGREE Next Steps Consortium. AGREE II: Advancing guideline development, reporting and evaluation in health care. CMAJ, 2010; 182(18):E839–E42; doi: 10.1503/cmaj.090449
22.
JiangM, GuanWJ, FangZF, et al.A critical review of the quality of cough clinical practice guidelines. Chest, 2016; 150(4):777–788; doi: 10.1016/j.chest.2016.04.028
23.
ZhangYB, ZhongXM, WangSY, et al.An evidence map of clinical practice guideline recommendations and quality on venous leg Ulcer. Adv Wound Care (New Rochelle), 2024; 13(3):140–152; doi: 10.1089/wound.2023.0079
24.
BartkoJJ. The intraclass correlation coefficient as a measure of reliability. Psychol Rep, 1966; 19(1):3–11; doi: 10.2466/pr0.1966.19.1.3
25.
Association for the Advancement of Wound Care. Association for the Advancement of Wound Care Guideline of Pressure Ulcer Guidelines. Ostomy Wound Manage, 2010; 10(1):1–14.
26.
European Pressure Ulcer Advisory Pane, National Pressure Injury Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers/injuries: Clinical practice guideline. EPUAP/NPIAP/PPPIA, 2019.
27.
National Institute for Health and Care Excellence. Pressure ulcers: Prevention and management. J Am Acad Dermatol, 2019; 81(4):893–902; doi: 10.1016/j.jaad.2018.12.068
28.
BeinT, BischoffM, BrücknerU, et al.S2e guideline: Positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders: Revision 2015: S2e guideline of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI). Anaesthesist, 2015; 64(Suppl 1):1–26.
29.
DannetteA, MaureenA. Acute respiratory distress syndrome and prone positioning. AACN Adv Crit Care, 2018; 29(4):415–425; doi: 10.1055/s-0039-1685180
30.
GefenA, AlvesP, CiprandiG, et al.Device-related pressure ulcers: SECURE prevention. Second Edition. J Wound Care, 2022; 31(Sup3a):S1–S72; doi: 10.12968/jowc.2022.31.Sup3a.S1
31.
GriffithsMJD, McAuleyDF, PerkinsGD, et al.Guidelines on the management of acute respiratory distress syndrome. BMJ Open Respir Res, 2019; 6(1):e000420; doi: 10.1136/bmjresp-2019-000420
32.
HashimotoS, SanuiM, EgiM, et al.; ARDS clinical practice guideline committee from the Japanese Society of Respiratory Care Medicine and the Japanese Society of Intensive Care Medicine. The clinical practice guideline for the management of ARDS in Japan. J Intensive Care, 2017; 5:5:50; doi: 10.1186/s40560-017-0222-3
Registered Nurses’ Association of Ontario. Assessment and Management of Pressure Injuries for the Interprofessional Team, Third Edition. 2016. Available from: https://rnao.ca/bpg/guidelines/pressure-injuries [Last accessed: January9, 2023].
WangH, ZengT, WuX, et al.; Writing Committee Members. Holistic care for patients with severe coronavirus disease 2019: An expert consensus. Int J Nurs Sci, 2020; 7(2):128–134; doi: 10.1016/j.ijnss.2020.03.010
37.
TschannenD, AndersonC. The pressure injury predictive model: A framework for hospital-acquired pressure injuries. J Clin Nurs, 2020; 29(7–8):1398–1421; doi: 10.1111/jocn.15171
38.
HuangC, MaY, WangC, et al.Predictive validity of the braden scale for pressure injury risk assessment in adults: A systematic review and meta-analysis. Nurs Open, 2021; 8(5):2194–2207; doi: 10.1002/nop2.792
39.
BergstromN, BradenBJ. Predictive validity of the braden scale among black and white subjects. Nurs Res, 2002; 51(6):398–403; doi: 10.1097/00006199-200211000-00008
40.
SatoL, HeckLO, BimbattiKF, et al.Incidence of hospital acquired pressure injury in critically ill patients with COVID-19 in prone position admitted to the intensive care unit. Medicine (Baltimore), 2023; 102(18):e33615; doi: 10.1097/MD.0000000000033615
41.
ZhangQ. Construction and Evaluation of Nursing Scheme for Facial Pressure Injuries in Patient with Prone Position Ventilation. Peking Union Medical College; 2022.
42.
PengC, ChenWX, RenH, et al.Evidence summary for prevention of pressure ulcer in patients with prone position ventilation. Chinese J Nursing Education, 2021; 18(10):935–941.
43.
Rodríguez-HuertaMD, Díez-FernándezA, Rodríguez-AlonsoMJ, et al.Nursing care and prevalence of adverse events in prone position: Characteristics of mechanically ventilated patients with severe SARS-CoV-2 pulmonary infection. Nurs Crit Care, 2022; 27(4):493–500; doi: 10.1111/nicc.12606
44.
LyuY, HuangYL, LiZY, et al.Interventions and strategies to prevent medical device-related pressure injury in adult patients: A systematic review. J Clin Nurs, 2023; 32(19–20):6863–6878; doi: 10.1111/jocn.16790
45.
SmartH, OpinionFB, DarwichI, et al.Preventing facial pressure injury for health care providers adhering to COVID-19 personal protective equipment requirements. Adv Skin Wound Care, 2020; 33(8):418–427.
46.
LinF, WuZ, SongB, et al.The effectiveness of multicomponent pressure injury prevention programs in adult intensive care patients: A systematic review. Int J Nurs Stud, 2020; 102:103483; doi: 10.1016/j.ijnurstu.2019.103483
47.
HanXY. Analysis of risk factors for pressure injuries in patients ventilated in prone position and construction of a risk prediction model. Lanzhou University, 2023.
48.
SillmonK, MoranC, ShookL, et al.The use of prophylactic foam dressings for prevention of hospital-acquired pressure injuries: A systematic review. J Wound Ostomy Continence Nurs, 2021; 48(3):211–218; doi: 10.1097/WON.0000000000000762
49.
ZhangC, ZhangS, WuB, et al.Efficacy of different types of dressings on pressure injuries: Systematic review and network meta-analysis. Nurs Open, 2023; 10(9):5857–5867; doi: 10.1002/nop2.1867
50.
GengJ, CaiY, LuH, et al.Moist dressings in the treatment of pressure injuries: A network meta-analysis. J Tissue Viability, 2023; 32(2):213–227; doi: 10.1016/j.jtv.2023.03.003
51.
McInnesE, Jammali-BlasiA, Bell-SyerSE, et al.Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev, 2015; 2015(9):CD001735; doi: 10.1002/14651858.CD001735.pub5
52.
ShiC, DumvilleJC, CullumN. Support surfaces for pressure ulcer prevention: A network meta-analysis. PLoS One, 2018; 13(2):e0192707; doi: 10.1371/journal.pone.0192707
53.
LiZZ, YangH, SuLX, et al.The effect of comprehensive nursing intervention in the prevention of pressure injury in ICU patients ventilated in prone position. Chinese J Med, 2017; 52(09):99–102.
54.
ZhouRS, LongY, LiZZ, et al.Effect of modified prone ventilation on pressure injuries in ICU patients. Chinese J Practical Nursing, 2018; 34(25):1974–1978.
55.
AlderdenJG, ShibilyF, CowanL. Best practice in pressure injury prevention among critical care patients. Crit Care Nurs Clin North Am, 2020; 32(4):489–500; doi: 10.1016/j.cnc.2020.08.001
56.
KabirF, YungDBY, da Cruz NizerWS, et al.Pressure injuries and biofilms: Microbiome, model systems and therapies. Wound Repair Regen, 2025; 33(1):e70005.
57.
GlenchurH, PatelBS, PathmarajahC. Transient bacteremia associated with debridement of decubitus ulcers. Mil Med, 1981; 146(6):432–433.
58.
EspejoE, AndrésM, BorralloRM, et al.; Complex Wounds Working Group. Bacteremia associated with pressure ulcers: A prospective cohort study. Eur J Clin Microbiol Infect Dis, 2018; 37(5):969–975; doi: 10.1007/s10096-018-3216-8
59.
Nery Silva PirettCC, BragaIA, RibasRM, et al.Pressure ulcers colonized by MRSA as a reservoir and risk for MRSA bacteremia in patients at a brazilian university hospital. Wounds, 2012; 24(3):67–75.
60.
BanksMD, WebsterJ, BauerJ, et al.Effect of supplements/intensive nutrition on pressure ulcer healing: A multicentre, randomised controlled study. J Wound Care, 2023; 32(5):292–300; doi: 10.12968/jowc.2023.32.5.292
61.
Reintam BlaserA, StarkopfJ, AlhazzaniW, et al.; ESICM Working Group on Gastrointestinal Function. Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines. Intensive Care Med, 2017; 43(3):380–398.
62.
SingerP, BlaserAR, BergerMM, et al.ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr, 2019; 38(1):48–79.
63.
LucchiniA, De FelippisC, PelucchiG, et al.Application of prone position in hypoxaemic patients supported by venovenous ECMO. Intensive Crit Care Nurs, 2018; 48:61–68.
64.
ReignierJ, Thenoz-JostN, FiancetteM, et al.Early enteral nutrition in mechanically ventilated patients in the prone position. Crit Care Med, 2004; 32(1):94–99.
65.
GuérinC, AlbertRK, BeitlerJ, et al.Prone position in ARDS patients: Why, when, how and for whom. Intensive Care Med, 2020; 46(12):2385–2396; doi: 10.1007/s00134-020-06306-w
66.
Expert Consensus Group on Mechanical Ventilation Care in the Prone Position in the Adult Critical Care Patient. Expert consensus on the care of adult critically ill patients on mechanical ventilation in the prone position. Chinese J Nursing, 2020; 55(suppl):150–155.
67.
HaoPY, LiQP. Analysis of the current situation and influencing factors of ICU nurses’ knowledge and beliefs about prone position ventilation. J Nursing Sci, 2022; 37(20):84–86.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
