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Proning

Q: What is proning?

Krishna: Proning or prone positioning is the placement of patients into a prone position so that they are lying on their stomach. This is used in the treatment of patients in intensive care with acute respiratory distress syndrome (ARDS). It has been especially tried and studied for patients on ventilators but during the COVID-19 pandemic, it is being used for patients with oxygen masks and CPAP as an alternative to ventilation. It MAY help fluids from building in one place in the lungs and enable them to have a larger breathing capacity and absorb those fluids easier and/or faster.

We reported it a year back when the doctors in New York start using it for Covid patients. Actually, seven years ago, French doctors published an article in the New England Journal of Medicine, showing that patients with ARDS who were on ventilators had a lower chance of dying if they were placed on their stomachs in the hospital.

If you feel breathless during covid, as some patients experience mild respiratory distress who do not need a ventilator, or those who could progress to severe respiratory distress, show improved oxygenation from proning.

Proning is the process of turning a patient with precise, safe motions from their back onto their abdomen (stomach) so the individual is lying face down.

It is especially beneficial in compromised COVID-19 patients with or without ventilator needs. “The position allows for better expansion of the dorsal (back) lung regions, improved body movement and enhanced removal of secretions which may ultimately lead to advances in oxygenation (breathing).”

The proning process should be done under expert guidance.

The patient will go through a series of manual turns that are done in a synchronized pattern. The patients will be moved laterally (sideways) followed by turning the patient on their side and finally onto their abdomen. Each position requires the patient’s heart rate, blood pressure and pulse oximetry (oxygenation level) to remain stable during each move. The process takes time, patience and skill to make sure that the patient remains stable. Patients are placed in the prone position for 16 to 18 hours and then placed in the supine position (lying horizontally with the face and torso facing up) for 6 to 8 hours if the oxygen levels are able to tolerate it.

Patients that may benefit from proning are evaluated by a critical care physician and/or pulmonologist to determine if a patient is a “good candidate” for proning.

However, a patient may be unqualified for proning if they have: Spinal instability, Unstable fractures,Open wounds,Burns,Tracheal surgery,A baby in utero (over 24+ weeks pregnant)

There may be additional complications that the doctors have to look out for on a case-by-case basis, such as cardiac (heart) abnormalities or prior abdominal surgery, to determine if proning would be beneficial.

Some risks associated with proning include:

Airway obstruction
Dislodgement of endotracheal tube
Pressure-related skin injuries
Facial and airway edema (swelling)
Hypotension (low blood pressure)
Arrhythmias (irregular heartbeat/rate)

The synchronized movements are done very slowly and methodically so the entire proning team can safely monitor the patient to prevent the associated risks.

Proning

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