Proning

We have been hearing all kinds of things about proning. What’s the big deal? Aren’t we just flipping people over? Well… yes! That’s exactly what we are doing. But here’s why its a bit more complicated than that.

We’ve already talked about the role of PTs in supporting and improving V/Q matching. Proning helps with that in a different way than what we’ve previously discussed. Basically what you need to know is that the lungs work on a negative pressure system. The pressure balance is a bit fragile and the pressure inside of the lungs must stay higher than the pressure on the outside of the lungs for the lungs to stay open. This is true not just for the lungs as a whole organ, but also for each tiny alveolus.

If the pressure on the inside of this tiny pocket becomes less than the pressure pushing in from the outside, the alveolus collapses. This can happen with destruction from ARDS, but it can also happen temporarily from laying in one position too long or from atelectasis or consolidation. The external pressure of the surface you are laying on slowly compresses the lung tissue in the dependent position (on the bottom of the body).

Proning allows for increased V/Q matching as less lung tissue is compressed in the prone position. The heart is located anteriorly, so there is less total lung tissue anteriorly than posteriorly. If we reduce the compression of the posterior segments, we improve expansion of the majority of the lung tissue and, therefore, improved oxygenation.

Just flipping over may seem really simple and obvious. But we need to consider the whole patient. Patients in the ICU are supine with a ventilator, multiple lines, multiple tubes, a catheter, and so many other things. These all have to be managed during the proning process. However, the results can be really great, especially in patients with COVID-19.

Recent research has show that proning significantly improves mortality in patients with COVID-19 who have been intubated due to ARDS and are in the ICU. And I’m not talking, reduced by a little. I’m talking CUT IT IN HALF! Mortality from ARDS in the ICU at 24 days was reduced from 33% to 16% and at 90 days was reduced from 41% to 24%! This is no joke. This is a serious factor in improving outcomes for the most critically ill patients.

I’ve compiled some information from a video and three articles about proning to write this article. I am NOT part of a proning team, but this is just such an intriguing topic that I had to know more! So, I wanted to share with you what I learned. None of this is from my own experience except for where PTs can fit in to this team.

Now, about that team… You will need a few things set up and you will need to know the contraindications before getting started.

The Set-Up:

• All necessary lines and leads need to be in place and secured
  • Arterial line
  • Central line
  • Lateral chest tubes disconnected and secured
  • Drains secured with abdominal binder with bulbs on the back
  • Feeding tubes disconnected
  • Hemodialysis lines disconnected and secured
• All lines above the waist need to have their connected devices above the head of the bed and all lines below the waist need to have their connected devices below the foot of the bed.
• Protective dressings in place over boney prominences
• Patient has been suctioned recently
• EKG leads removed (they will be replaced on the back later)
• Patient’s gown removed
• FiO2 at 100%

Your team will need:

• Mepilex dressings
• Tubegrip/Tape/splinting material to secure lines/leads/tubing/catheters
• 3 bed sheets
• 6 pillows
• (Ideally) 7 people (1 RT/Pulmonologist/Very competent physician) and 6 of your closest friends. This can be done with fewer people but it makes it a bit more challenging.

Contraindications

• Anterior chest tube
• Hemodynamic instability
• Facial/Ocular Injuries
• Recent Sternotomy
• Abdominal Incisions
• Unstable Vertebral fractures
• Unstable Intracranial Pressure that is Unmonitored

Here’s a great video of what this process looks like! The proning process starts at 7:30. Feel free to fast-forward.

Look scary? YEP! That’s ok. You’re not alone. An RT typically leads the show because they have to maintain the endotracheal tube placement throughout the movement. Watch some videos, including the AMAZING one I have above and get some ideas of how this goes and what you can do.

Here’s some great parts for PTs to play in this process:

• Cervical spine stabilization: During proning, the cervical spine should not extend due to central line placement. PTs can assist in proning by stabilizing the cervical spine. Think of creating a cervical spine collar with your arms, from head to thoracic spine, to provide complete stabilization. Cervical spine positioning is also important to ensure proper management of intracranial pressure.
• Code response team: If you find a patient pulseless while prone, you have to start CPR. But how the heck do you do CPR when you can’t flip the patient on your own? According to ACLS, you do compression to the same rate and depth over the thoracic spine at the level of the inferior angle of the scapula. This continues as typical CPR until the proning team can supine the patient and continue standard CPR. (PLEASE REMEMBER: There is no such thing as an emergency in a pandemic. Protect yourself and don all proper PPE before entering the room to assist in a code.)
• Be a Roller: A roller is one of the 6 people on the proning team who roll the patient from supine to prone or back. Human movement is literally our job, so let’s do it.
• Line and lead arrangement: We do this anyway, right? We go in to see a patient and those things are just all over the place. Even in my settings, I’m working with Foleys, ports, and IV lines for antibiotics pretty much every day. We know how to arrange this to best serve the mobility task we are looking to perform.
• Positioning Post-Proning: Just like any other positioning program for off-loading, these proned patients need regular changes of position of many body parts every 2 hours. This includes utilizing “swimmer’s position,” head turns, and adding or removing pillows. Believe it or not, head turns require the full proning team!!! Peripheral nerve injuries can occur when patients are proned, so repositioning needs to happen frequently.

We can do this. We can take on this role. It is hard, clearly, as it takes 7 people to pull this off successfully, but you can be part of a really cool process that is nearly completely unique to what we have seen in the past and how we have functioned as a profession.

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Are you part of a proning team? What are some ways you do this differently or have found that make it easier? Tell me about it in the comments!

References

Ali, H. S., & Kamble, M. (2019). Prone positioning in ARDS: physiology, evidence and challenges. Qatar Medical Journal, 2019(2), 14. https://doi.org/10.5339/qmj.2019.qccc.14

Henderson, W. R., Griesdale, D. E., Dominelli, P., & Ronco, J. J. (2014). Does prone positioning improve oxygenation and reduce mortality in patients with acute respiratory distress syndrome?. Canadian respiratory journal, 21(4), 213–215. https://doi.org/10.1155/2014/472136

Lee, J., Kim, E., Song, I., Jung, S. A., Oh, H., Kim, J. (2016). Optimizing Prone CPR: Identifying the Vertebral Level Correlating With the Largest LV Cross Sectional Area Via CT Scan (Abstract for Presentation) American Society of Anesthesiology: Anesthesiology Annual Meeting. Retrieved from http://www.asaabstracts.com/strands/asaabstracts/abstract.htm?year=2016&index=4&absnum=4079.

Mount Sinai Health System Proning Team. (2020). Prone Positioning for the COVID-19 Patient. Retrieved from https://www.youtube.com/watch?v=ECdxhNFLwVo

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