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. 2024 Nov 25;30(4):e13208. doi: 10.1111/nicc.13208

The effect of swimmer position during prone ventilation on the onset of brachial plexus injury in the intensive care unit: A multiprofessional clinical study protocol

Filippo Binda 1,2,✉, Simone Gambazza 2,3, Federica Marelli 2, Veronica Rossi 2, Alessandro Galazzi 2, Cesare Del Monaco 2, Maurizio Vergari 2, Benedetta Ticozzelli 2, Mauro Panigada 4, Giacomo Grasselli 4,5, Maura Lusignani 6, Dario Laquintana 2
PMCID: PMC12209042  PMID: 39584220

Abstract

Background

Prone positioning improves oxygenation in adults with acute respiratory distress syndrome (ARDS) and has been extensively applied in intensive care units (ICU) during the COVID‐19 pandemic. Although some complications due to the manoeuvre are well known, brachial plexus injury after prone positioning is reported as a rare complication and the phenomenon could be either very rare or underestimated.

Aim

This study aimed to evaluate the effect of swimmer position during prone ventilation on the onset of brachial plexus injury in patients admitted to ICU for ARDS. The study will also evaluate the safety of prolonged prone positioning collecting data on any adverse events occurred.

Study Design

A prospective, observational cohort study will be conducted in a tertiary level ICU in the metropolitan area of Milano (Italy) specialized in advanced treatment of patients with ARDS. This observational study will report clinical data on the electromyography (EMG) and the muscle strength assessment, including comorbidities and cardio‐respiratory status. A baseline EMG will be performed within 2 h from the first pronation manoeuvre and immediately at the end of each pronation cycle. The functional assessment of patients will be also performed at the end of ICU stay and at hospital discharge.

Results

The primary outcome is to estimate the prevalence of brachial plexus injury in patients with ARDS placed in the swimmer position during prone ventilation. Secondary outcomes will also include the safety of the manoeuvre by evaluation of all adverse events classified as skin or ocular damage, loss of tube and vascular access and new pressure ulcers.

Relevance to Clinical Practice

The findings of this study will contribute to understand the possible benefits/harms of prone ventilation performed using swimmer position. Eventually, this will call for the development of specific and tailored rehabilitation programs for patients with upper limb injuries during ICU stay, including also timely follow‐up upon ICU‐discharge.

Keywords: brachial plexus neuropathies, intensive care units, peripheral nerve injuries, prone position, respiratory distress syndrome

What is known about the topic

  • The swimmer position during prone ventilation is recommended by international guideline.

  • Brachial plexus injury in patients with ARDS admitted to intensive care unit is reported as a rare complication of prone positioning, and its prevalence is not fully known.

What this paper adds

  • A standardized approach by a multidisciplinary team (including physiologic and instrumental measures) might be crucial to assess the onset of brachial plexus injury following prone positioning.

  • Early detection of signs of nerve injury will provide the basis for a tailored rehabilitation program.

1. BACKGROUND

Prone positioning has been used since the 1970s to improve oxygenation in adults with acute respiratory distress syndrome (ARDS) 1 and has been extensively applied in intensive care units (ICU) during the COVID‐19 pandemic. 2 , 3 The pandemic has dramatically increased cases of severe ARDS around the globe, and prone ventilation has become the mainstay of treatment. 4

Several systematic reviews and meta‐analyses have demonstrated that prolonged prone positioning (≥16 h) was associated with a significant survival benefit. 5 , 6 , 7 , 8 However, some complications due to the manoeuvre are recognized, including pressure ulcers. 9 , 10 Methods to avoid pressure ulcers are well implemented in clinical practice 11 but little is known about the proper positioning of upper limbs, which is currently a matter of debate, especially in relation to the potential consequences on the peripheral nerve injuries. 12 Current guideline recommends an alternating swimmer position for the upper limbs when a patient is under sedation in prone position, 13 and similar advice is provided in other recommendations. 14 , 15 This position consists in one arm abducted and one adducted with the head toward the abducted arm, without any type of external supporting devices (Figure 1).

FIGURE 1.

FIGURE 1

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Prone patient in swimmer position. Figure created with permission of BioRender.com.

In ICU, the rotation of the head with face toward the abducted arm facilitates the access to intravenous lines, clear visual assessment and manipulation of the airway and avoids pressure on the face. 3 Furthermore, the rotation of the head advised within the swimmer position would maintain open the neural foramen on the adducted side, theoretically relieving local pressure on the emerging nerve roots. 16 By applying principles of tissue biomechanics and injury mechanisms, it is reasonable to assume that the primary causes of brachial plexus injury in patients positioned prone using swimmer position are likely compression and traction. 17 These forces can lead to periaxonal oedema, ischaemia of the vasa nervorum, demyelination and in severe cases, axonal degeneration. 18 Prolonged static position on ICU beds increases patients' exposure to localized compression in specific body areas. 19 Injury severity can vary widely from neurapraxia (conduction block) to more severe axonal injuries (high grade), with the latter potentially resulting in limited recovery and significant functional disability. 20 To date, only few case series and reports have described the occurrence of upper limbs peripheral nerve injuries resulting from the prone position. 21 , 22 , 23 , 24

At this time, the epidemiology of brachial plexus injury related to prone positioning is not fully known. Despite nerve compression injury after prone positioning is reported as a rare complication, the phenomenon could be either very rare or underestimated. 25 However, during the COVID‐19 pandemic, variations in the timing and clinical setting of peripheral nerve assessment may have contributed to modify the prevalence of this complication. 26 , 27

Further investigations with instrumental diagnostics are needed, especially after the outbreak of COVID‐19 pandemic, that has pushed ICU staff worldwide to adopt such manoeuvre, thus exposing many patients to potential prone‐related brachial plexus injury. To provide new insights into the mechanisms behind such complication, the proposed study will assess the time‐dependent relationship between nerve damage and prone positioning. By employing instrumental diagnostics, it will be possible distinguishing the immediate damage related to the swimmer position and evaluate the safety of the prone ventilation for cycles longer than 16 h.

2. AIM

The primary aim is to estimate the prevalence of brachial plexus injury in patients admitted to ICU for ARDS and exposed to prone positioning. In accordance with the study design developed, it would be possible to temporally assess the onset of the nerve injury along ICU stay after prone positioning, also determining its effect on brachial plexus injuries. Therefore, the secondary aim of the study is to evaluate the safety of swimmer position adopted during prone positioning.

3. DESIGN AND METHODS

This protocol is a prospective single‐centre observational study using clinical data from hospital records, including comorbidities, and data from instrumental diagnostic evaluations.

3.1. Setting

The study will be conducted in an ICU of an academic tertiary level hospital. This unit is a 12‐bed ICU in the Department of Anaesthesia, Intensive Care and Emergency of Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico (Milano, Italy). In particular, this ICU is a referral extracorporeal membrane oxygenation (ECMO) centre in the metropolitan area of Milano and it is specialized in advanced treatment of patients with ARDS.

3.1.1. Participants

Patients admitted to the ICU with severe ARDS from any cause (defined as PaO2/FiO2 < 150 mmHg and PEEP ≥ 5 cmH2O, despite optimization of ventilation settings), 28 including but not limited to COVID‐19, who are receiving invasive mechanical ventilation and require prone positioning to treat hypoxaemia, as determined by the medical team, will be included in the study.

3.1.2. Inclusion and exclusion criteria

Eligibility criteria are patients aged 18 years old or over, admitted to ICU for severe ARDS; the administration of sedation and neuromuscular blocking agents; the presence of endotracheal intubation and mechanical ventilation and use of prone positioning. Patients will be excluded if they present with ECMO; prone positioning performed in other centres; any contraindications to prone positioning; neurodegenerative disorders and previous known or documented brachial plexus injury.

3.1.3. Study procedure

The prone positioning manoeuvre will be performed by the nursing staff according to the guidelines of Intensive Care Society from United Kingdom. 13 Particularly, face and limbs will be placed according to the swimmer position, ensuring the face position in the direction of ventilator and limbs (one arm above head and opposite arm at side) positioned as to prevent abnormal extension or flexion against the shoulders and elbows. As per nursing practice, patients will lie on low air loss pressure mattress without using any thoraco‐pelvic supports, which are not recommended. 29

3.1.4. Diagnostic evaluations

Electromyography (EMG) will be performed by neurophysiopathology technicians to evaluate the occurrence of brachial plexus injury using the instrumentation available (Nemus 2, EB Neuro, Italy). To rule out nerve injuries at ICU admission, an EMG will be performed within 2 h from the first pronation manoeuvre. Then, EMG will be performed immediately at the end of each pronation cycle. Neurophysiopathology technicians will be on call around the clock, including overnight and weekends, to ensure that EMG measurements are conducted promptly, regardless of when prone positioning occurs, thereby minimizing the risk of missing data. Particularly, somatosensory evoked potential (SSEP) and sensory action potential (SAP) will be obtained from radial, ulnar, median and sural nerves. In case patients are awake, compound muscle action potential (CMAP) will be obtained as well. The signs of upper limbs peripheral nerve injuries will be considered by the presence of at least one of the following: (a) SSEP N20 latency of radial nerve and ulnar nerve >10% compared to baseline; (b) SSEP N20 amplitude of radial nerve and ulnar nerve <50% compared to baseline; (c) SAP amplitude of radial nerve, ulnar, median and sural nerves <50% compared to baseline; and (d) CMAP amplitude of ulnar and median nerve <50% compared to normative data.

The upper limb muscles strength will be evaluated using the Medical Research Council (MRC)‐Score, in awake and cooperative patients. Physiotherapists will use dynamometer (MusTec HD, Mustec, Netherlands) to measure quadriceps strength, as gold standard of muscle strength assessment in cooperative patients. As per clinical practice, functional assessment of patients at the end of ICU stay and hospital discharge will be also performed, including the assessment of sensory loss.

3.1.5. Other evaluations

To describe the safety of prone positioning manoeuvre, data on any adverse events will be collected as well, classified as interruption of the manoeuvre, loss of vascular access, endotracheal tube displacement or unplanned extubation, onset of new pressure ulcers and ocular or auricle damage after prone positioning.

3.2. Data collection tools and methods

Patient demographic and anthropometric measures (age, sex, height, weight, body mass index), comorbidities (Charlson Comorbidity Index), respiratory and haemodynamic status and tissue oxygenation (arterial blood gas test parameters and peripheral oxygen saturation) will be collected at enrolment. Among all the collected variables, there will also be included information regarding the position of the upper limbs while on prone position and the results from the EMG and the muscle strength assessment (Table 1).

TABLE 1.

Timeline of measures to be collected along the study period.

Timing EMG assessment Muscle strength assessment
T 0—Within 2 h after the first cycle of prone positioning SSEP of radial and ulnar nerves Not applicable
SAP of radial, ulnar, median and sural nerves
T 1—At the end of the first cycle of prone positioning SSEP of radial and ulnar nerve
SAP of radial, ulnar, median and sural nerves
T 2—At the end of the second cycle of prone positioning SSEP of radial and ulnar nerves
SAP of radial, ulnar, median and sural nerves
T n —At the end of the nth cycle of prone positioning SSEP of radial and ulnar nerve
SAP of radial, ulnar, median and sural nerves
T D —Before ICU discharge SSEP of radial and ulnar nerve Upper limbs muscles strength:

  • MRC‐scale

  • Dynamometer
SAP of radial, ulnar, median and sural nerves
CMAP and F‐wave of ulnar and median nerves
T HD—Before hospital discharge Upper limbs muscles strength:

  • MRC‐scale

  • Dynamometer
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Abbreviations: CMAP, compound muscle action potential; EMG, electromyography; ICU, intensive care unit; MRC, Medical Research Council Scale; SAP, sensory action potential; SSEP, somatosensory evoked potential.

3.3. Data analysis

All clinical and instrumental variables will be collected using a specific electronic case report form (REDCap—Research Electronic Data Capture). 30 Metrics will be reported descriptively using mean and standard deviation or median and interquartile range. The number of patients with brachial plexus injury will be reported as prevalence and as incidence rate at ICU discharge, considering the whole length of ICU stay. If possible, statistical modelling will be used to describe the causal association of brachial plexus injury with time‐dependent covariates; candidate variables will be selected by using direct acyclic graphs. The association between radial, median and ulnar SSEP latency and time spent prone will be investigated as well. Uncertainty will be reported using 95% confidence interval around mean and/or proportion, as appropriate. All analyses will be done using the open‐software R. 31

3.3.1. Sample size

In our university‐teaching hospital, EMGs performed to rule out a diagnosis of brachial plexus injury were 18/1870 (0.96%) in 2018. Despite this low proportion, considering a prevalence of 8%–13% reported in the literature 32 , 33 and the insufficient understanding of prone positioning's neurological effects, we hypothesized a similar extent of neuropraxia due to prone positioning in critically ill patients evaluated using EMG signals. To ensure a confident estimation within a 15% margin of error, we aimed to detect at least 8% occurrence of brachial plexus injury linked to prone positioning. Accordingly, the sample size calculation determined that 54 patients would be necessary to achieve this precision. 34

3.4. Ethical and research approvals

The study protocol was approved by the ethical committee of Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico ‐ Milano, Italy (approval number 202_2022). The protocol is also registered on ClinicalTrials.gov (ID: NCT05693038). As written informed consent cannot be obtained from the patient prior to data collection, consent will be obtained from the patient's guardian or legally authorized surrogate in accordance with Legislative Decree no. 101/2018, which implements the General Data Protection Regulation (EU) 2016/679 at the national level. The study will be conducted in accordance with the standard of Good Clinical Practice (GCP), the ethical principles that have their origin in the Declaration of Helsinki and with the respect to the European clinical practice, in compliance with all international guidelines and national law regulation in Italy.

4. DISCUSSION

This protocol represents a pioneering investigation into the association between the swimmer position and brachial plexus injuries among patients admitted to ICU, using a comprehensive multidisciplinary assessment approach. To date, literature has provided limited clarity on the causal pathway of brachial plexus injury in patients with ARDS treated with prone positioning. In particular, during the COVID‐19 pandemic, the increased use of the prone positioning has been documented, although information on this matter is characterized by heterogenous literature consisting of single case reports and case series. 35 Many of these articles poorly reported and described the upper limbs nerve injuries. 36 , 37 , 38 , 39

Therefore, the study design outlined in this protocol becomes particularly relevant, including the use of EMG during each pronation cycle and functional evaluation at discharge. These assessments would potentially detect early signs of nerve injury and allow for a specific evaluation of upper limbs function. Furthermore, it is plausible that patients diagnosed with upper limbs nerve injuries in the acute phase may experience persistent functional limitations even after hospital discharge. 40

Currently, different early rehabilitation programs have shown improvements in physical‐related outcomes in patients with critical illness. For this reason, it is crucial to implement interdisciplinary and interprofessional follow‐up programs to enhance functioning and quality of life, with increased patient‐reported satisfaction. 41 The findings of this protocol may have the potential to change the clinical management of patients requiring prone positioning for ARDS. Regardless of the outcome, our results will provide an unbiased assessment of the safety of this manoeuvre. The strengths of the protocol include its prospective design, the presence of physiologic and instrumental repeated measures during prone positioning, and standardized approach to evaluating brachial plexus injuries in different time frames by a multidisciplinary team, composed by critical care nurses, neurophysiopathology technicians, physiotherapists and physicians.

5. LIMITATIONS

The study could have some limitations. First, it will not be possible to analyse pre‐exposure characteristics of patients requiring prone position manoeuvre before ICU admission. Second, the high expertise level of the intensivists and ICU nurses on prone positioning could minimize some risks related to this manoeuvre, thus limiting the generalizability to other less‐skilled staff worldwide.

6. IMPLICATIONS FOR PRACTICE

There is a need to timely detect brachial plexus injuries in critically ill patients. The knowledge coming from this study will contribute to understand the possible benefits/harms of pronation performed using swimmer position. Eventually, this will call for the development of specific educational initiatives for healthcare professionals involved in ICU setting: specialized training is crucial to ensure safe positioning of patients during life‐saving manoeuvre. Additionally, such results could encourage the development of more specific and tailored rehabilitation programs for patients with upper limb injuries in the early phase, including also timely follow‐up upon ICU‐discharge.

7. CONCLUSIONS

This study protocol introduces a novel approach to identify early signs of brachial plexus injuries both during and after prone positioning. For the first time, it offers a timely assessment of potential nerve injuries resulting from adopting the swimmer position during prone ventilation. By providing early detection, our approach enhances the ability to promptly address and mitigate any resulting complications.

AUTHOR CONTRIBUTIONS

All authors contributed to literature review, methodological design, manuscript preparation and editing. All authors read and approved the final version of the manuscript.

FUNDING INFORMATION

This study was partially funded by the Italian Ministry of Health—Current research IRCCS.

Binda F, Gambazza S, Marelli F, et al. The effect of swimmer position during prone ventilation on the onset of brachial plexus injury in the intensive care unit: A multiprofessional clinical study protocol. Nurs Crit Care. 2025;30(4):e13208. doi: 10.1111/nicc.13208

DATA AVAILABILITY STATEMENT

Data available on request from the authors.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Data available on request from the authors.

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