Proning in COVID-19 Patients: The Benefits and Risks

A facedown fight against COVID-19.

Since the novel COVID-19 virus first emerged, healthcare practitioners have been searching for anything in hopes that it would help improve patient outcomes. In March 2020, little was known about the efficacy of pharmaceuticals let alone any other viable treatment options. Fast forward to today, we have enough peer-reviewed evidence to support several therapies. In fact, healthcare workers and clinical researchers have a lot to be proud of! Effective vaccines have been deployed and we have uncovered a handful of treatments that are actually working. One technique in particular has caught on, and more and more hospital ICUs are using it — proning — placing COVID-19 patients on their stomachs as a way to increase the amount of oxygen to the bottom and back portions of the lungs.

How does proning help?

In the supine position, the lungs are compressed by gravity and other forces -- including the internal organs. This position can cause hyperinflation of alveoli in the ventral lung while causing alveolar collapse (atelectasis) in the dorsal part of the lung. Gravity complicates things by pushing blood downward toward the poorly oxygenated alveoli in the posterior lung, creating a ventilation/perfusion mismatch. This mismatch is thought to drive rapid deterioration of patients with conditions that compromise breathing. Furthermore, the longer patients are mechanically ventilated, the greater the risk that prolonged immobility will lead to delirium and generalized weakness.

Proning relieves some of the pressure on the heart and lungs that occurs when lying on the back, and it can help clear respiratory secretions. It also plays a significant role in reducing the effects of prolonged immobility and can even reduce the time spent on mechanical ventilation by improving strength and endurance.

Benefits of Proning:

In summary, research has found that when proning is used in patients with severe ARDS (acute respiratory distress syndrome) and hypoxemia not improved by other means, it has the benefit of:

• better ventilation of the dorsal lung regions threatened by alveolar collapse;
• improvement in ventilation/perfusion matching; and
• potentially an improvement in mortality.

Proning To Avoid Mechanical Ventilation and Intubation:

Aside from the use of proning in ICUs for intubated patients, awake proning is being utilized as a preventative measure in COVID-19 patients to defer invasive ventilation and improve oxygenation. A study published in October 2020 revealed awake prone positioning showed marked improvement in P/f ratio and SpO₂ in COVID-19 patients with improvement in clinical symptoms and a reduced rate of intubation.

In a separate study published in the American Journal of Respiratory and Critical Care Medicine, oxygenation in non-ventilated patients rapidly improved after prone positioning, and at one hour after assuming a prone position, median oxygen saturations had increased from 94% (IQR, 91–95%) to 98%. Interestingly, after prone positioning, work of breathing had also improved, as evidenced by a reduced median respiratory rate from 31 (IQR, 28–39) to 22 (IQR, 18–25) breaths/minute. There were no adverse events with prone positioning. At 28 days of follow-up, all patients had been discharged from the hospital to their homes.

Finally, a study published in the Journal of the American Medical Association found that the use of the prone position in awake, spontaneously breathing patients with COVID-19 severe hypoxemic respiratory failure was associated with improved oxygenation. In addition, patients with an SpO₂ of 95% or greater after one hour of the prone position was associated with a lower rate of intubation.

Side Effects of Proning

Though the benefits of proning far outweigh the risks, placing patients in this position may put them at risk for complications such as pressure injuries, airway complications, facial injuries, peripheral nerve injuries, musculoskeletal injuries, and cognitive impairment. In fact, affected patients may have long-lasting impediments towards functional recovery without proper rehabilitation intervention. Thus, rehabilitation during and after hospitalization due to COVID-19 is a key component in the continuum of care.

Next article: Proning COVID-19 Patients & The Critical Need for Rehabilitation

References:

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