There has been publicity about how lying face-down (prone) may help people with COVID-19 to breathe more easily than when they are lying face-up.

Prone positioning of ventilated patients in intensive care units has been used since the start of the COVID pandemic. Guidelines now recommend that doctors try putting conscious hospital patients with COVID-19 who experience breathing difficulties onto their fronts, to see if it helps ease the pressure on their lungs. This is done with careful monitoring of blood oxygen levels to be sure it does not make things worse. People are helped to turn regularly so they are not constantly on their fronts.

Not everyone benefits from lying face-down. It’s not recommended for people with certain medical conditions or who have had recent abdominal surgery or spinal injury. Pregnant women and people who are very obese may also be unable to lie prone.

Where did the story come from?

An article by a medical student on the blogging platform Medium explained how hospitals around the world are using ‘proning’ – the practice of putting patients to lie on their fronts – to treat patients with breathing difficulties. There have been various journal publications on the use of prone positioning in COVID-19, both in intubated (ventilated) and non-intubated patients.

What is the basis for the claim?

A previous review (not specific to COVID-19) outlined the use of prone positioning in patients with the life-threatening condition of acute respiratory distress syndrome (ARDS). This is when the lungs become inflamed, fluid leaks into the air sacs (alveoli), and oxygen transfer into the surrounding blood capillaries is impaired, causing the patient to be very short of breath and have low blood oxygen. ARDS can have various causes, including infection, and is seen in people with severe COVID-19 infection.

When you lie flat on your back, in simplistic terms, the back of the lungs are compressed by various forces, including that from the rest of the lungs and tissues, your heart and diaphragm. On your front these various pressures are reduced, there is more lung capacity available and improved oxygenation. The review presented evidence from one trial where patients with ARDS were randomly assigned to be ventilated on their front (prone) or back (supine). Patients ventilated prone were more likely to survive than patients ventilated supine.

Prone positioning is already used in intensive care to manage ventilated patients with COVID-19. The evidence is increasing into the use of prone positioning for patients hospitalised with COVID who are not on a ventilator, with the hope that this may improve outcomes and reduce the need for intensive care admission. For example, one small, observational study in France found that most patients were able to tolerate prone positioning for several hours. However, only a quarter demonstrated improved oxygenation. The authors called for more trials to help identify patients who may benefit.

What do trusted sources say?

The UK Intensive Care Society has produced new guidance on prone positioning of conscious, unventilated patients hospitalised with suspected or confirmed COVID-19. It is recommended as a consideration for people who need basic respiratory support to maintain blood oxygenation, are able to communicate and position themselves independently and have no suspected airway issues. There are various contraindications to prone positioning, including any instability in the person’s cardiovascular or respiratory system.

The Intensive Care Society says: “Given its potential for improving oxygenation in COVID-19 patients we advocate that a trial of conscious prone positioning be performed on all suitable patients on the ward.”

Analysis by EIU healthcare, supported by RB

 

Reading list

  1. Henderson WR et al. Does prone positioning improve oxygenation and reduce mortality in patients with acute respiratory distress syndrome? Can Respir J. 2014;21(4):213‐215. doi:10.1155/2014/472136
  2. Guérin, C., Reignier, J., Richard, JC. Et al. PROSEVA Study Group. Prone Positioning in Severe Acute Respiratory Distress Syndrome. N Engl J Med (2013); 368: 2159–2168.
  3. Elharrar X, Trigui Y, Dols A, et al. Use of Prone Positioning in Nonintubated Patients With COVID-19 and Hypoxemic Acute Respiratory Failure. JAMA. Published online May 15, 2020. doi:10.1001/jama.2020.8255
  4. Intensive Care Society. ICS Guidance for Prone Positioning of the Conscious COVID Patient 2020. (Accessed 8 June 2020)