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prone position

Lying on the abdomen or stomach (face down). Indications: - sleeping in prone position lowers systolic blood pressure in men as much as 15 mm Hg [2] - prone positioning may help to aerate lung regions dependent in a supine position during mechanical ventilation in patients with ARDS [3] - prone positioning may help COVID-19 patients who require oxygen improve oxygenation & avoid intubation [6,7,9] - prone positioning in mildly hypoxemic hospitalized Covid-19 patients requiring oxygen of no benefit possibly because of low adherence [10,11] - prone positioning in awake Covid-19 patients requring oxygen - reduces intubation risk & hospital stay [12] - not beneficial [13]; benefit not comfirmed, but could not be excluded [14] Procedure: - minimum suggested duration of prone position is 12 hours a day [5] Mechanism of action: ARDS - recruitment in dorsal lung regions [5] - increasing end-expiratory lung volume - increasing chest wall elastane - decreasing alveolar shunt - improving tidal volume - improves ventilation-perfusion mismatch [8] - prone position can only reduce mortality due to ARDS when patients are - ventilated with low tidal volume - started within 48 hours - patients have severe hypoxia [5]

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References

  1. Stedman's Medical Dictionary 26th ed, Williams & Wilkins, Baltimore, 1995
  2. Tabara Y, American Heart Association Conference, Chicago, 2004
  3. Guerin C et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013 Jun 6; 368:2159 PMID: 23688302 Free Article
  4. Caputo N, Strayer RJ, Levitan R Early Self-Proning in Awake Non-intubated Patients in the Emergency Department: A single ED;s Experimen during the COVID-19 Pandemic. Academic Emergency Medicine. April 22 2020 PMID: 32320506 https://onlinelibrary.wiley.com/doi/epdf/10.1111/acem.13994
  5. Ghelichkhani P, Esmaeili M. Prone Position in Management of COVID-19 Patients; a Commentary. Arch Acad Emerg Med. 2020 Apr 11;8(1):e48. eCollection 2020. PMID: 32309812 Free PMC Article
  6. Davenport L COVID-19: Jury Out Over Prone Position in Nonintubated Patients. Medscape - May 22, 2020. https://www.medscape.com/viewarticle/931029
  7. Elharrar X, Trigui Y, Dols AM et al. Use of prone positioning in nonintubated patients with COVID-19 and hypoxemic acute respiratory failure. JAMA 2020 May 15; PMID: 32412581 Free PMC article. https://jamanetwork.com/journals/jama/fullarticle/2766292 - Sartini C, Tresoldi M, Scarpellini P et al. Respiratory parameters in patients with COVID-19 after using noninvasive ventilation in the prone position outside the intensive care unit. JAMA 2020 May 15; PMID: 32412606 Free PMC article. https://jamanetwork.com/journals/jama/fullarticle/2766291
  8. Thompson AE, Ranard BL, Wei Y et al Prone Positioning in Awake, Nonintubated Patients With COVID-19 Hypoxemic Respiratory Failure. JAMA Intern Med. Published online June 17, 2020. PMID: 32584946 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2767575 - Sarma A, Calfee CS Prone Positioning in Awake, Nonintubated Patients With COVID-19. Necessity Is the Mother of Invention. JAMA Intern Med. Published online June 17, 2020. PMID: 32584940 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2767574
  9. Reuters Staff Prone Positioning Might Help More COVID-19 Patients Medscape - Nov 20, 2020 https://www.medscape.com/viewarticle/941334 - Venus K, Munshi L, Fralick M. Prone positioning for patients with hypoxic respiratory failure related to COVID-19. CMAJ 2020, Nov 11 PMID: 33177104 Free article https://www.cmaj.ca/content/cmaj/early/2020/11/11/cmaj.201201.full.pdf
  10. Fralick M et al. Prone positioning of patients with moderate hypoxaemia due to covid-19: Multicentre pragmatic randomised trial (COVID-PRONE). BMJ 2022 Mar 23; 376:e068585 PMID: 35321918 PMCID: PMC8941343 Free PMC article https://www.bmj.com/content/376/bmj-2021-068585
  11. Johnson SA et al Patient-directed Prone Positioning in Awake Patients with COVID-19 Requiring Hospitalization (PAPR). Ann Am Thorac Soc. 2021 Aug;18(8):1424-1426 PMID: 33596394 PMCID: PMC8513661 Free PMC article https://www.atsjournals.org/doi/10.1513/AnnalsATS.202011-1466RL
  12. Ibarra-estrada M, Vargas-Obieta A, Marin-Rosales M et al 19: PRONE POSITIONING IN AWAKE PATIENTS WITH COVID-19-ASSOCIATED RESPIRATORY FAILURE: THE PROCARF TRIAL. Critical Care Medicine: January 2022 - Volume 50 - Issue 1 - p 10 https://journals.lww.com/ccmjournal/Fulltext/2022/01001/19__PRONE_POSITIONING_IN_AWAKE_PATIENTS_WITH.21.aspx - Ibarra-Estrada M, Li J, Pavlov I et al Factors for success of awake prone positioning in patients with COVID-19-induced acute hypoxemic respiratory failure: analysis of a randomized controlled trial. Crit Care. 2022 Mar 28;26(1):84 PMID: 35346319 PMCID: PMC8958810 Free PMC article
  13. Qian ET et al. Assessment of awake prone positioning in hospitalized adults with COVID-19: A nonrandomized controlled trial. JAMA Intern Med 2022 Jun; 182:612. PMID: 35435937 PMCID: PMC9016608 Free PMC article https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2791385
  14. Alhazzani W et al. Effect of awake prone positioning on endotracheal intubation in patients with COVID-19 and acute respiratory failure: A randomized clinical trial. JAMA 2022 Jun 7; 327:2104-2113 PMID: 35569448 PMCID: PMC9108999 Free PMC article https://jamanetwork.com/journals/jama/fullarticle/2792506