Does proning help COVID-19 patients to improve oxygen levels?

Doctors believe this position helps in improving the oxygen flow in critical patients, making them less likely to be intubated or require ventilator support.
proning position
proning position

CHENNAI: As the medical fraternity continue to figure out ways to prevent COVID-19 deaths, ‘Proning’ is one such technique, that has received acknowledgement from both government and private hospitals in Chennai.

What is proning? As the word suggests, it simply means to make a patient lie in the prone position, with chest and belly facing downwards. Doctors believe this position helps in improving the oxygen
flow in critical patients, making them less likely to be intubated or require ventilator support.

How does it help with COVID-19 patients?

As detailed by Lenore Reilly, nurse manager of Critical Care at JFK Medical Center, some 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,” Lenore says. “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.”

How many people does it take to prone a patient?

At JFK Medical Center, a proning team typically consists of six highly trained experts including:

  • Registered nurses (with either critical care or operating room expertise)
  • Respiratory therapists
  • Physical therapists/occupational therapists/patient care technicians
  • Anesthesia physicians

“This number can increase based on the individual needs of the patient,” says Lenore.

As described by both Nancy and Lenore, a registered nurse will lead the proning team at the head of the patient bed and provide clear directions regarding the step-by-step process. The lead registered nurse, along with an additional registered nurse or a respiratory therapist, will guide the patient’s head and airway. Joining them are two physical therapists (or other support staff) on each side of the patient to help manage movement of the arms, legs, intravenous (IV) access and other catheters (tubes).

What are the steps in the proning process?

“The patient will go through a series of manual turns that are done in a synchronized pattern,” says Lenore. The team leader will coordinate with the other team members in each of the motions that are necessary to get the patient to a prone position. “Anesthesia physicians are also available for airway (breathing) management,” she continues.

The patients will be moved laterally (sideways) followed by turning the patient on their side and finally onto their abdomen. Each position requires the patient’s heart rate, blood pressure and pulse oximetry (oxygenation level) to remain stable during each move. “The process takes time, patience and skill to make sure that the patient remains stable,” elaborates Nancy.

How often and how long is a patient proned?

Patients are placed in the prone position for 16 to 18 hours and then placed in the supine position (lying horizontally with the face and torso facing up) for 6 to 8 hours if the oxygen levels are able to tolerate it. “While the patient is either in the prone and/or supine position, specific lab and radiology studies will be ordered,” says Lenore. “The findings of these particular procedures will drive if the patient will continue with prone positioning daily.”

Can all patients benefit from proning?

All patients that may benefit from proning are evaluated by a critical care physician and/or pulmonologist to determine if a patient is a “good candidate” for proning, Lenore notes. However, a patient may be unqualified for proning if they have:

  • Spinal instability
  • Unstable fractures
  • Open wounds
  • Burns
  • Tracheal surgery
  • A baby in utero (over 24+ weeks pregnant)

“There may be additional complications that we have to look out for on a case-by-case basis, such as cardiac (heart) abnormalities or prior abdominal surgery, to determine if proning would be beneficial,” explains Nancy.

If a patient does qualify, though, he/she will undergo a thorough preparation stage, explains Nancy. “This process would include making sure that the eyes and skin will be protected during the time that they are prone,” she says. “In addition, the patients will need proper sedation and IV access.”

Are there risks to proning?

As stated by Lenore, 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)

“The synchronized movements are done very slowly and methodically so the entire proning team can safely monitor the patient to prevent the associated risks,” assures Nancy.

Health Secretary J Radhakrishnan said that lately, the government hospitals in the city have been following this. “We have been seeing good results in KMC and RGGGH and it is being done under the
supervision of senior allopathy doctors,” he told New Indian Express.

Explaining the process, Infectious Diseases Specialist Dr Subramanian Swaminathan of Gleneagles Global Health City, said that proning is an age-old technique, normally used on patients with severe respiratory illnesses.

He added that when a person is in a prone position, owing to gravity, air moves up to the air-sacks. “This helps in better distribution of oxygen to lungs and other parts of the body,” said Dr Swaminathan.

Since the progression of COVID is not catastrophic, this may result in some amount of improvement in patients in not requiring ventilator support. Proning is widely followed in other private hospitals too and doctors say it has given good results.

Dr Anantha Subramanian, Consultant Pulmonologist with Kauvery Hospital says that out of the 400 Covid-19 patients treated in the hospital, at least 60 to 70 per cent people were put in the prone position. “It was also tried on many patients aged above 60 and definitely they showed good improvement,” he said.

Dr Subramanian said that the candidates for proning are those who have an oxygen saturation of 94 or below, and people with hypoxia too. “People who have spinal issues, neurological weakness and those who are uncomfortable are kept away from this,” he added.

Recently, a statement from the Apollo Hospitals, too said that five patients who had severe breathing issues, including 65 and 72 year-olds, returned home safely after this mechanism was followed.

While anecdotal evidence of its efficacy come up, there are still no Randomised Control Trials for the success of proning on Covid-19 patients.

In a small cohort study published in the peer-reviewed Jama Internal Network Journal in the US, 25 patients, who required intubation, were studied for proning. In that, oxygen levels of 19 people improved above 95 per cent after one hour of prone position while oxygen levels of six patients did not improve.

Subsequently, out of the 19, seven required intubation and five out of the six, whose oxygen levels were low needed intubation. Totally, 12
were intubated out of the 25 finally, and three died in that.

In India, doctors from AIIMS in Jodhpur are conducting a larger study on proning, which is expected to go on till October.

Doctors, however, said that proning must not be solely relied on for improvement but other forms of treatment too must compliment it.

“Checking viral load in CT scan, steroids and usage of Tocilizumab is also part of the process,” said Dr Swaminathan.

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