Pulmonology Book



Aka: Proning, Prone Positioning
  1. Indications
    1. Prevention of Respiratory Failure
      1. Awake, cooperative patient self-performs position changes to maximize lung recruitment
      2. Ehrmann (2021) Lancet Respir Med 9(12):1387-95+PMID:34425070 [PubMed]
    2. Respiratory Failure (Intubated patient with, for example, ARDS or Severe Covid Pneumonia)
      1. Mechanical Ventilator FIO2 >0.6
      2. P/F Ratio <150
        1. where P/F Ratio = PaO2 / FIO2
        2. where PaO2 = arterial PO2 (from Arterial Blood Gas)
        3. where FIO2 = fraction of inspired oxygen (ranging from 0.3 for 30% to 1.0 for 100%)
  2. Physiology
    1. Lung recruitment improves in prone position (or on side or upright) compared with supine position
  3. Technique: Awake, Cooperative Patient
    1. Direct patient to roll to prone position and other positions for as long as they are comfortable
    2. Positions
      1. Prone position (peferred)
      2. Left lateral decubitus or right lateral decubitus positions
      3. Sitting Upright
  4. Technique: Intubated Patient
    1. Precautions
      1. Much more difficult in obese patients (unless on rotational bed)
      2. Perform procedures before Proning (patient access is difficult in prone position)
        1. Transthoracic Echocardiogram
        2. Central venous catheters
        3. Arterial catheters
        4. Portable XRays
      3. Expect the Oxygen Saturations to drop precipitously on initial position change
        1. In Covid19 patients, Oxygen Saturations would drop to 70% for first 15 minutes after change
    2. Approach
      1. Prone for 16 hours, supine for 8 hours per day
  5. References
    1. Gandhi (2021) World J Crit Care Med 10(5):183-93 +PMID:34616655 [PubMed]

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