Why do we want COVID-19 patients in a prone position?
There three main reasons to put a COVID-19 patient in a prone position are as follows:
- Improves gas exchange efficiency
- Increases perfusion and recruitment of dorsal lung
- Mobilizes secretions
Resource for Images of positioning recommendations: https://www.ficm.ac.uk/sites/default/files/prone_position_in_adult_critical_care_2019.pdf
Prone positioning is an intervention that medical teams have been using for pulmonary function. Why do they do this? Prone positioning is having somebody lay onto their belly. This improves gas exchange efficiency, increases the perfusion and recruitment of the dorsal lung and posterior inferior lobes, and mobilizes secretions. With their lungs full of fluid and with the weight of their heart, it is hard for these patients to expand their chest to breathe. By repositioning them, this can help to redistribute that perfusion and access the posterior lung. I highly recommend that you use the link provided above. It is through the ICS or the Intensive Care Society out of the UK. It provides a lot of information on why proning is important. More importantly, it has step by step pictures on how to safely prone position somebody who is sedated as it is a very complex process
There are two ways that we can prone somebody. One is when they are awake and one is when they are sedated.
- Patients above their baseline O2 needs
- Independently able to position themselves in prone
- Respiratory distress (accessory muscle use, RR over 35)
- Altered mental status
- Hemodynamic instability
- Physically unable (ex. morbid obesity, pregnancy, wounds)
- Goal to maintain 30 minutes - 2 hours as tolerated
- Can turn alternate into side-lying for comfort
- If unable to tolerate, recommend HOB elevated >30 vs. a flat bed in supine
Conscious proning is when somebody is awake. This is for somebody who is above their baseline for oxygen needs but is able to independently position themselves into prone. We would not want to do this in somebody whose respiratory rate is very high, over 35, or somebody who is using their accessory muscles and already struggling to breathe at baseline. If they are confused, delirious, have any altered mental status, or are hemodynamically unstable, this is also not appropriate. Somebody whose blood pressure already plummets when you roll them into side-lying is not a patient that you then want to be prone. Other contraindications are those that are morbid obesity, are pregnant, or those who have wounds. Some people with back pain also cannot tolerate this position. Lastly, if they are not able to reposition themselves, then this is not an appropriate intervention.
When you have somebody consciously prone, the goal is to maintain this for 30 minutes to two hours as they tolerate it. They can also alternate into side-lying for comfort. Again, this is a repositional strategy to mobilize the lungs. If they can tolerate 30 minutes on their belly, 30 minutes on their side, 30 minutes on their other side, and 30 minutes on their back, this is also helpful as a proning intervention. If somebody is not able to tolerate this or if it is contraindicated, we encourage them to keep the head of their bed elevated greater than 30 versus a flat supine position. This helps for both comfort and pulmonary function.
Proning is something that is used by the medical team, but this can also be helpful during our therapy interventions because this enables the patients to recover more comfortably. For those patients who are sitting up at the edge of the bed and it is taking them a long time to recover or they have a lot of anxiety, this can be a good tool to use during your therapy sessions. Just have them lay back down as you would normally do when somebody is not tolerating your session, but encourage them to lay on their belly. You do not have to be in the room for this. Before you leave, remind them that as they are able to throughout the day to roll onto their belly. The ultimate goal with this is to prolong or hopefully completely avoid intubation by maximizing the gas exchange and mobilizing those secretions in the lungs before the disease process progresses to the point of needing intubation.
Prone Positioning of the Sedated Patient
- Indication: Moderate to severe ARDS at least 12 hours after intubation, use of paralytics for vent synchrony
- “Swimmer’s Position”
- One arm abducted to 45-70 degree, elbow at 90
- The other arm down at the side
- Head facing toward the abducted arm, neck not extended
- Slight scapular elevation
- Chest supported
- Pillows padding chest, pelvis, and knees
- Goal: 16 hours/ day
- Alternate abduction of arms and rotation of neck every 2 hours for skin protection and prevention of plexopathy
- Complications to monitor:
- ETT dislodgment
- Brachial plexus injury
- CRRT line flow issues
- Facial edema
- Corneal abrasions
Prone positioning of a sedated patient is much more complicated, and this is indicated for moderate to severe ARDS patients, at least 12 hours of intubation, or when somebody is on paralytics. You do not want somebody who is already fighting the vent to now repositioned in a prone position because that is more difficult to regulate.
In that previous link, there are pictures of the swimmer's position that I am going to describe. You want these patients to have one arm abducted to 40 to 70 degrees with the elbow at 90. You do not want the arm elevated too high, but you want it bent up a little bit. The other arm will be down at the side. Their head should be facing towards the abducted arm with the neck not extended. You also want the neck neutral, or if needed, in slight flection with some slight scapular elevation or a slight shoulder shrug. They should have a pillow under their chest so that it is supported. This gives the shoulders a little bit of forward flexion.
In addition to the pillow at the chest, you also want pillows at the pelvis and knees. This is very important in males to ensure that the genitalia is not in a compromising position. The ultimate goal is to have a patient in a prone position for 16 hours a day. Like you would normally turn a patient who is on paralytics, you are going to want to rotate them and turn them every two hours. In this case, when they are in prone, you are going to alternate the abduction of the arms and rotate the neck to the opposite side every two hours. This is both for skin protection of the face but also to prevent a brachial plexopathy, which we are going to review.
Complications are wounds typically on the face. We have also seen some wounds from peripheral IVs that are resting on their arms or blood pressure cuffs resting in places that we are not as used to checking. There can be ETT dislodgement. We do not want to accidentally extubate somebody during proning or pull out their CRT lines. The resource from the ICS walks through multiple strategies to do this safely to avoid this. There can also be facial edema from their face being in a dependent position and corneal abrasion. It is encouraged that you use ointment on the eyes and/or tape them shut while you are doing this. This is generally a three to a five-person job as it is a complicated process because of their lines. If ECMO is involved, it becomes a much more complicated process. Of course, this is up to the medical team to dictate when it is appropriate for somebody. This is not up to us, but we can use our expertise to make sure that these patients are positioned correctly. In some hospitals, I also know that therapists have been utilized on prone teams to go around and to help turn these patients forward and backward because it does require so much manpower.