Background, Rationale and Benefits
The increased utilisation – over the past few decades – of various imaging modalities in the investigation of respiratory disease has provided clinicians with a more robust understanding of the physiology of acute respiratory failure. This laid the foundation for the introduction of prone positioning in the management of ARDS (Acute Respiratory Distress Syndrome), a strategy which has been effectively translated to manage patients with COVID-19.
The effectiveness of prone positioning – highlighted in several peer-reviewed studies – results from it shifting intra-abdominal and mediastinal organs anteriorly which reduces alveolar compression, thereby increasing oxygenation and perfusion in the in dorsal lung. This has translated clinically into increases in serum oxygenation (during proning and maintained afterwards) and reduced mortality.
There are however contraindications to the utilisation of prone position, which are discussed in more detail below.
Proning Inclusion and Exclusion Criteria
It is important to note that there are risks associated
Absolute:
- Spinal instability
- Open chest post cardiac surgery/trauma
- < 24hrs post cardiac surgery
- Central cannulation for VA ECMO or BiVAD support
Relative:
- Multiple Trauma e.g. Pelvic or Chest fractures, Pelvic fixation device
- Severe facial fractures
- Head injury/Raised intracranial pressure
- Frequent seizures
- Raised intraocular pressure
- Recent tracheostomy <24hrs
- CVS instability despite resuscitation with fluids and inotropes
- Previously poor tolerance of prone position
- Morbid obesity
- Pregnancy 2nd/3rd trimester
Application in COVID-19: A Step-by-Step Guide
prone_position_in_adult_critical_care_2019Is There A Place for Lateral Positioning?
Peer-reviewed data on the effectiveness peer-reviewed on the use of lateral position in patients with acute respiratory disease is limited. However, there have been anecdotal reports of it contributing to reduced mortality when used in the context of COVID-19, making it available as a strategy to consider in time pressured and resource-limited settings.
Sources & links
- NCBI | Does prone positioning improve oxygenation and reduce mortality in patients with acute respiratory distress syndrome? | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173887/
- NCBI | Prone position in management of COVID-19 patients: a commentary | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173887/
- FICM | Prone positioning in adult critical care | https://www.ficm.ac.uk/sites/default/files/prone_position_in_adult_critical_car e_2019.pdf
- Journal of Critical Care | Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: a retrospective study | https://www.acprc.org.uk/Data/Resource_Downloads/ProneinSpontbreathingretrospectivereview-Scaravilli.pdf
- The Lancet | Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study | https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30268X/fulltext
- Journal of Thoracic Disease | The efficacy and safety of prone positioning in adults patients with acute respiratory distress syndrome: a meta-analysis of randomized controlled trials | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4387391/
- Cochrane Library | Lateral positioning for critically ill adult patients | https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007205.pub2/full/fa