‘PRONING’ has become a very important part of the management of some of the most severely ill COVID-19 positive patients in hospitals. It is where a patient is turned to lie on their front (prone position) on an anti-trendelenburg (head raised) incline of around 30 degrees. (See ‘ICS Guidance for Prone Positioning of the Conscious COVID Patient 2020’ by the Intensive Care Society.)
THE TECHNICAL BIT (as I understand it).
The deep infection of the virus into the lungs causes inflammation of the lung tissue (pneumonia). The air sacs (alveoli) at the end of the breathing tubes in the lungs become inflamed and fill with fluid or pus. This is known as Acute Respiratory Distress Syndrome (ARDS). It causes a drastic reduction in lung function, to the extent that the patient is unable to breathe properly and needs to be given oxygen. If the amount of oxygen transported into the bloodstream is still insufficient to oxygenate the vital organs, it can lead to multiple organ failure and death.
WHY IS THERE A NEED FOR PRONING?
It has been long known that lying in the traditional supine position (on their back) can be detrimental to the lung function of hospital patients with breathing difficulties. This is because the majority of lung tissue is at the back of the body, so the ability of the lungs to expand on breathing in is impaired when lying supine. In COVID-19 cases, the abnormal build up of fluid pools at the back of the lungs, leading to greater interference with lung function.
HOW DOES PRONING WORK?
Proning has been used to successfully treat COVID-19 patients when it looked like there was no hope of recovery. (The case of Stacey Fresco in England is an example of this.) Proning reduces the pressure on the lungs and allows them to expand more. The fluid in the lungs can then drain downwards with gravity, allowing greater lung capacity, enabling the patient to breathe in more oxygen. The patient can remain in this position for 12 hours before being returned to the supine position. Alternating supine and prone positioning of the body in this way has been successfully used to maximise the effects of this treatment.
WHY ISN'T PRONING MORE COMMON?
To start with, it takes up to 6 people, and 30 minutes, to safely turn a COVID-19 patient onto the other side. This procedure takes badly needed frontline carers away from managing the numerous other patients that are suffering in this pandemic.
Secondly, there is more pressure on the patient’s heart when in the prone position. It has to work harder, and can lead to a potentially fatal heart attack.
ANOTHER POTENTIAL USE OF IBT
I’ve found an interesting ongoing trial called ‘Incline Positioning in COVID-19 Patients for Improvement in Oxygen Saturation (UPSAT)’, at Johns Hopkins University, in which 15 degree incline versus horizontal (flat) positionings are compared in the supine position. It is described as:
‘..a pilot study to examine the acute effects of inclined posture on oxyhemoglobin saturation and the feasibility of conducting randomized controlled clinical trial among patients with confirmed or suspected COVID-19-associated hypoxia.’