The first time a pulmonary physician asked me to prone his patient my reaction was, “You want me to do what?” Research has provided the evidence to support use of the procedure. It has become almost commonplace in the ICU as a therapy for the subset of patients with acute respiratory distress syndrome (ARDS). I recently spoke with a hospital-based educator colleague who told me there were seven patients with ARDS due to COVID-19 receiving pronation therapy on her unit.
There are three categories of ARDS: mild, moderate or severe. Severe ARDS is acute hypoxemia with a P/F ratio (PaO2 from blood gas/FiO2 as a decimal) of ≤100 mmHg with PEEP ≥ 5cmH20. These patients are most likely to benefit from turning to a prone position. The goal is to match ventilation and perfusion by decreasing the pressure on the lungs from the abdominal contents, the heart and supporting structures, and the added weight of the edematous lungs. The ideal length of pronation is between 12–20 hours if the patient is showing improvement in the P/F ratio and is hemodynamically stable.
Pronation therapy requires teamwork to achieve success safely and without complications. There have been different types of beds and equipment available to assist with pronation therapy. However, this can also be quite successful using some padding and an extra sheet. Ventilated patients may require neuromuscular blocking agents to maintain the position. Anecdotal information has suggested that non-ventilated patients on nasal cannula or high-flow oxygen may self-prone as tolerated for periods of time to prevent worsening of their condition, and they may show significant improvement even when lying prone for shorter periods of time.
Following are resources to help you understand the benefits of the procedure and see how pronation therapy can be done safely.
Resources to Support Your Practice
The following resources offer a variety of topics focused on safety and improved outcomes for your patients.