What is the recommended approach for proning COVID-19 patients with severe Acute Respiratory Distress Syndrome (ARDS)?

From the Guidelines

The recommended approach for proning COVID-19 patients with severe Acute Respiratory Distress Syndrome (ARDS) is to place them in a prone position for at least 12, preferably 16 hours, as this has been shown to improve oxygenation and reduce mortality in severe ARDS patients when implemented early and for sufficient duration as part of a comprehensive respiratory support strategy. This intervention should be implemented early in patients with severe ARDS (defined as PaO2/FiO2 ratio < 150 mmHg) who require mechanical ventilation, as recommended by the most recent guideline on positioning and early mobilisation in the critically ill by an expert panel 1.

Key Considerations for Proning

• Before proning, ensure adequate sedation and possibly neuromuscular blockade to prevent self-extubation and maintain patient comfort.
• A team of healthcare providers should carefully coordinate the turning process using proper body mechanics to prevent complications like pressure injuries, endotracheal tube displacement, and line dislodgement.
• Continuous monitoring of oxygen saturation, hemodynamic parameters, and ventilator synchrony is essential during prone positioning.
• Proning works by improving ventilation-perfusion matching, recruiting dorsal lung regions, enhancing secretion clearance, and reducing ventilator-induced lung injury.

Benefits and Risks of Proning

• The benefits of proning include improved oxygenation and reduced mortality in severe ARDS patients.
• The risks of proning include pressure injuries, endotracheal tube displacement, and line dislodgement, which can be mitigated with proper technique and monitoring.
• Contraindications to prone positioning include the presence of an open abdominal wound, unstable pelvic fracture, spinal lesions and instability, and brain injury without monitoring of intracranial pressure, as noted in previous studies 1.

Implementation of Proning

• The implementation of proning should be individualized based on the patient's condition and response to the intervention.
• The duration of proning should be at least 12 hours, preferably 16 hours, as recommended by the guideline 1.
• The patient should be closely monitored during proning, and the intervention should be discontinued if there is no improvement in oxygenation or if complications arise.

From the Research

Recommended Approach for Proning COVID-19 Patients

The recommended approach for proning COVID-19 patients with severe Acute Respiratory Distress Syndrome (ARDS) involves several key considerations:

• Intermittent Prone Positioning (IPP): IPP has been shown to decrease mortality in patients with ARDS 2. Patients with severe ARDS can benefit from IPP, which involves placing them in a prone position for 16 hours each day.
• Patient Selection: Patients with severe ARDS, defined as a PaO2:FiO2 ratio (PFr) ≤ 150 on FiO2 ≥ 0.6 and PEEP ≥ 5 cm H2O, can benefit from proning 2.
• Proning Technique: Proning can be done using available materials without requiring additional work from the bedside team 2. The patient is placed prone for 16 hours each day, and the PFr is monitored to determine the effectiveness of the intervention.
• Oxygenation Improvement: Proning has been shown to improve oxygenation in COVID-19 patients with ARDS, with an increase in PFr and a decrease in FiO2 3, 4, 5.
• Hemodynamic Response: The use of high positive end-expiratory pressure (PEEP) and prone positioning can improve arterial oxygenation, but may also decrease cardiac output 5.
• Awake Proning: Awake proning can be effective in improving oxygenation in patients with COVID-19-related acute hypoxemic respiratory failure, and can be well-tolerated by patients 4, 6.

Key Findings

• Proning can improve oxygenation in COVID-19 patients with ARDS, with an increase in PFr and a decrease in FiO2 3, 4, 5.
• IPP can decrease mortality in patients with ARDS 2.
• Awake proning can be effective in improving oxygenation in patients with COVID-19-related acute hypoxemic respiratory failure, and can be well-tolerated by patients 4, 6.
• The use of high PEEP and prone positioning can improve arterial oxygenation, but may also decrease cardiac output 5.

Proning Sessions

• 129 proning sessions were identified in 34 consecutively prone patients, with an improvement in the PF ratio and a reduction in FiO2 3.
• 50 patients were enrolled in a study on awake proning, with a significant improvement in oxygenation and a substantial increase in mean PFr 4.
• 9 adult patients were studied to assess the hemodynamic effects of PEEP and prone position during COVID-19 respiratory failure, with an improvement in PaO2/FiO2 ratio and a decrease in pulmonary shunt fraction 5.
• 50 patients were included in a pilot study on early self-proning in awake, non-intubated patients in the emergency department, with an improvement in SpO2 after 5 minutes of proning 6.