What is Proning and How Does it Help with COVID-19 Patients?

SARS-CoV-2 virus causes pneumonia that is identified through fever, dyspnea, acute respiratory symptoms and named COVID-19. This disease exacerbates in a number of patients and causes pulmonary edema, multi-organ failure, and acute respiratory distress syndrome (ARDS). 

Prevalence of ARDS among COVID-19 patients has been reported to be up to 17%. Among the introduced treatment methods for management of ARDS patients, prone position can be used as an adjuvant therapy for improving ventilation in these patients.

What is proning?

Lying face down is known as proning, it is a medically accepted position to improve oxygenation. It is especially beneficial in compromised COVID-19 patients with or without ventilator needs. If a patient’s oxygen levels drop below 94% (when measured at home on an oximeter), the patient can lie on their tummy; this position improves ventilation and enables comfortable breathing

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).

Prone positioning has been shown to improve oxygenation for decades. However, proning in awake, non-intubated patients gained acceptance in the last few months since the onset of coronavirus (COVID-19) pandemic. To overcome the shortage of ventilators, to decrease the overwhelming burden on intensive care beds in the pandemic era, and also as invasive ventilation was associated with poor outcomes, proning of awake, spontaneously breathing patients gathered momentum. 

Being an intervention with minimal risk and requiring minimum assistance, it is now a globally accepted therapy to improve oxygenation in acute hypoxemic respiratory failure in COVID-19 patients. We thus reviewed the literature of awake proning in non-intubated patients and described a safe protocol to practice the same.

Significance of proning

Physical position affects the distribution and volume of air in the lungs, and can have direct effects on the expansion of the lungs to permit the exchange of oxygen & carbon dioxide in the blood. 

In the last few years, prone positioning has been used increasingly in the treatment of patients with Acute Respiratory Distress Syndrome (ARDS) and this is now considered a simple and safe method to improve oxygenation. It is a medically accepted process that involves turning a patient with precise, safe motions, from their back onto their abdomen so that the individual is lying face down to improve breathing.

Proning is required only when the patient experiences difficulty in breathing and the SpO2 decreases below 94%. Regular monitoring of SpO2, along with other signs like temperature, blood pressure, and blood sugar, is important during home isolation. Missing out on Hypoxia (compromised oxygen circulation) may lead to worsening of complications. 

Therefore, advice must be taken from the doctor on ways to effectively practice proning at home.

Physiological effects of proning

In the supine position, the lungs are compressed by the heart and abdominal organs. Gas exchange, the process of trading carbon dioxide for oxygen, is reduced in areas of collapsed lungs, resulting in low oxygen levels. In the prone position, lung compression is less improving lung function. 

The body has mechanisms to adjust blood flow to different portions of the lung. Prone positioning redistributes blood and air flow more evenly, reducing this imbalance and improving gas exchange. 

With improved lung function in the prone position, less support from the ventilator is needed to achieve adequate oxygen levels. This may reduce risk of ventilator-induced lung injury, which occurs from overinflation and excess stretching of certain portions of the lung. 

Prone positioning may improve heart function in some patients. In the prone position, blood returns to the chambers on the right side of the heart increases and constriction of the blood vessels of the lung decreases. This may help the heart pump better, resulting in improved oxygen delivery to the body.

Because the mouth and nose are facing down in the prone position, secretions produced by the disease process in the lung may drain better.

How does it help with COVID-19 patients?

Patients experiencing mild respiratory distress who do not need a ventilator, or those who could progress to severe respiratory distress, show improved oxygenation from proning.

There is not enough evidence at this time to prove that proning alleviates patients needing ventilators. “What we can see, though, is that oxygenation is temporarily improved. This is why proning has become part of the plan of care during the COVID-19 pandemic.”

Some investigators have reported the application of prone positioning in spontaneously breathing, non-intubated patients treated with standard oxygen therapy, continuous positive airway pressure (CPAP), or non-invasive ventilation.In this setting, prone positioning seems to improve oxygenation and might decrease respiratory effort, which could be particularly beneficial in patients at increased risk of self-induced lung injury. 

Therefore, this position might postpone or avoid tracheal intubation and its inherent risks (both linked to the procedure itself and to subsequent superinfections). A decrease in the need for intubation, and subsequent admission to ICU, might also prove beneficial in resource-limited scenarios. At the same time, this procedure could carry some risks associated with the change of position (eg, vomiting, thromboembolism) or delayed intubation.

Who requires self proning or awake proning? When should you do it?

Proning techniques are done in hospitalised intubated patients. Self proning or awake proning is being suggested in patients with COVID-19 recently to improve oxygenation. 

Note: Self-proning is a good way to boost oxygen levels at critical times when securing medical help may not be possible or manage symptoms at home. However, remember, it is only one of the ways that guarantee temporary relief and not a proper alternative for hospitalized care or oxygen support.

Not all patients who test positive for coronavirus and put under home care need the help of proning. However, the ones who may be facing oxygen deprivation, or waiting for medical help, simply lying down on your stomach could be a great help.

Proning should be especially tried when oxygen levels start to drop below 94% and continue to fluctuate through the day if external support is hard to find.

To sleep in the prone position, one needs to have plenty of pillows and keep changing positions on a half-hourly basis.

Indications of Awake Proning

All patients with SpO2 <94% and RR >22/minute should be advised early awake proning.

Though the benefits of awake proning in mild COVID-19 disease have not been studied, the strategy is still encouraged. Patients on oxygen supplementation via nasal prongs, oxygen mask, NRBM, HFNC, and NIV, can be safely self-proned, as per their tolerance and comfort.

Inclusion Criteria: (Must meet all criteria)

• Confirmed COVID-19 disease and High Risk PUIs
• Hypoxemia requiring high flow nasal cannula
• Increasing high flow nasal cannula requirement
• Able to understand their situation and communicate and cooperate with procedure
• Able to independently reposition

How to do Awake Proning?

• Understand the procedure and its benefits through your doctor or nurse
• try to maintain the position for 30 minutes to 2 hours.
• Alternative lateral and semi-prone positions may be tried if the patient is unable to prone completely.

How to breathe in proning positions?

One may prone for up to 16 hours a day, in multiple cycles, suitable to a patient’s comfort and ability. Pillows may be adjusted slightly to alter pressure areas and for comfort. Keep a track of any pressure sores or injuries, especially around the bony prominence. If this is done with a help of a caregiver:

Place one pillow below the neck

Place one or two pillows below the chest through the upper thighs

Place two pillows below the shins

For self-proning:

• You will need 4-5 Pillows
• Regular alterations in lying position
• It is best not to spend more than 30 minutes in each position, after 30mins lie on each side, then sit up before going back to proning

According to The National Disaster Management Authority (NDMA) the correct way to achieve the benefits of proning.

1. If the patient is on oxygen support, then turn the head to the left/right side and continue O2 support.

2. Place the pillows under the head, chest, and pelvis for support, but the abdomen should not be compressed.

Step 1

30 minutes to 2 hours: Lying on your belly

Step 2

30 minutes to 2 hours: Lying on your right side

Step 3

30 minutes to 2 hours: Sitting up

Step 4

30 minutes to 2 hours: Lying on your left side

Step 5

Then go back to position 1: Lying on your belly

Proning is very beneficial for COVID-19 patients with breathing complications, especially during home isolation.

A word of Caution:

• Avoid proning for an hour after meals
• Maintain proning for only as much time as is easily tolerable
• One may prone for up to 16 hours a day, in multiple cycles, as felt comfortable.
• Keep track of any pressure sores or injuries, especially around the bony prominence.

What are the precautionary measures that need to be taken?

Note: Always first please speak to your doctor before trying the self proning technique.

• Avoid proning if pregnant
• Avoid proning for an hour after meals
• Maintain proning for only as many times as easily tolerable
• Keep a track of any pressure sores or injuries, especially, around bony prominences
• Avoid proning if you have major cardiac conditions
• Avoid proning if you have an unstable spine, femur or pelvic fractures

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)

When to Interrupt proning?

There is no specific recommendation for how long a patient should be self-proned. We suggest that awake, self-proning should be continued till the patient is comfortable, or has recovered and maintaining oxygen saturation >96% on room air, and has no respiratory distress/desaturation on exertion. 

In a sick patient, proning should be interrupted if there is evidence of increased work of breathing, use of accessory muscles of respiration, failure of improvement in oxygenation with proning/further desaturation, or hemodynamic instability/arrhythmias.

An improvement in oxygen saturation on awake proning should not be an assurance of the improvement in the disease condition. Vigilance should be kept for signs of respiratory distress or increased work of breathing, which are an indication to interrupt awake proning and the need for invasive ventilation. The decision to intubate and invasively ventilate should be based on clinical assessment of work of breathing and other clinical criteria. Delaying intubation, just due to improvement in oxygenation, can lead to catastrophic outcomes.

In conclusion, awake, non-intubated patients appear to greatly benefit from self‐proning and alternating positioning, with many being able to independently change positions without disrupting the flow of oxygen.

Sources:

ncbi.nlm.nih.gov

atsjournals.org

ajemjournal.com

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