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Posted by ULY CLINIC

24 Machi 2021 19:20:48


The guidance  is based on proper case management aspects intended for clinicians involved in the care of patients with suspected or confirmed COVID-19. It is not meant to replace clinical judgment or specialist consultation but rather to strengthen frontline clinical management and the public health response.




Prone positioning has been shown to improve oxygenation in spontaneously breathing, non- intubated non-Covid-19 patients with hypoxemic acute respiratory failure. Consequently, its potential value in the management of patients with Covid-19 pneumonia has been explored. A management strategy involving early intervention and awake proning with high-flow nasal cannula or non-invasive mechanical ventilation to prevent alveolar collapse resulted in lower intubation and mortality rates has been observed in different health care facilities. Some studies have demonstrated that application of self-proning with HFNC may help avoid intubation.

a. Physiological Effects Of Proning

The physiological benefits of prone positioning that should apply to all patients regardless of whether they are intubated or not, include:

• Improved Ventilation/Perfusion (VQ) matching and reduced hypoxemia (secondary to more homogeneous aeration of lung and ameliorating the ventral-dorsal trans- pulmonary pressure gradient – more uniform lung ventilation, better distribution of air flow and better matching of areas that receive
oxygen and appropriate blood flow).

• Reduced shunt (perfusion pattern remaining relatively constant while lung aeration becomes more homogenous – better matching of areas that have blood flow to receiving oxygen).

• Recruitment of the posterior lung segments due to reversal of atelectasis; Improved secretion clearance.

b. Different approaches to positional adjustment in COVID-19

Various approaches have been attempted.

• Complete pronation (with the patient lying on their abdomen, ideally for 16-18 hours per day) as in prone intubated patients would be optimal. However, this can be difficult in many patients e.g. with obesity.

• Another approach is to rotate positions, including lying on either side and sitting bolt upright which may be easier for many patients to tolerate. Some health care facilities encourage mobilization via walking of selected Covid-19 patients.

• Proning for a few hours with a return to supine position may lead only to transient improvements in oxygenation. Longer-lasting benefit might result from longer periods of pronation, or strategies involving ongoing rotation between several different positions. The key principle is to avoid spending much time in a flat, supine position.

• As one suggested approach, we suggest following the UK Intensive Care Society’s proning recommendations as outlined below.

• Awake pronation appears to be a safe, inexpensive, and versatile strategy which can be used at all levels across a variety of different healthcare settings.

c. Assist Patient To Prone Position

• Explain procedure/benefit
• Get consent from the patient
• Ensure oxygen therapy and basic respiratory support secure with adequate length on the tubing
• Pillows may be required to support the chest
• Reverse trendelenberg position may aid comfort
• Monitor oxygen saturations If drop then ensure O2 connected and working
• Sedation must not be administered to facilitate proning

Pictures of proper prone position

Click to expand pictures on the top of this chapter for various prone positions

d. What to check while proning?

Oxygen Saturations For 15 Minutes

SaO2 92-96% (88-92% if risk of hypercapnia respiratory failure) and nil obvious distress


Continue Proning Process

• Change positions every 1-2 hrs, aiming to achieve a prone time as long as possible
• When not prone aim to be sat at between 30-60 degrees’ upright
• Monitor oxygen saturations after every position change
• Titrate down oxygen requirements as able


If Deteriorating Oxygen Saturations:

• Ensure oxygen is connected to patient
• Increase inspired oxygen
• Change patients position
• Consider return to supine position Escalate to critical care if appropriate Discontinue if no improvement with change of position, Patient unable to tolerate position, looks tired and using accessory muscles

NB: For ICU intubated patients’ needs a closer monitoring

e. Contraindication Of Proning

Absolute contraindications

• Respiratory distress (RR 35, PaCO2 6.5, accessory muscle use)
• Immediate need for intubation
• Hemodynamic instability (SBP < 90mmHg) or arrhythmia
• Agitation or altered mental status
• Unstable spine/thoracic injury/recent abdominal surgery

Relative Contraindications

• Facial injury
• Neurological issues (e.g. frequent seizures)
• Morbid obesity
• Pregnancy (2/3rd trimesters)
• Pressure sores / ulcers


25 Machi 2021 06:49:46



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