Trending Clinical Topic: Prone Positioning in COVID-19

Ryan Syrek


October 09, 2020

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As those treating patients with severe COVID-19 attempt to determine best practices, new findings and controversies about the prone position resulted in this week's top trending clinical topic. In March, the first international guidelines on the management of critically ill patients with COVID-19 were released. The use of prone ventilation was one of the essential recommendations. Specifically, the guidelines stated: "For mechanically ventilated adults with COVID-19 and moderate to severe acute respiratory distress syndrome (ARDS), we suggest prone ventilation for 12 to 16 hours over no prone ventilation."

Now, nearly 6 months later, new research has found that among patients with COVID-19 who undergo mechanical ventilation, lying in the prone position has been associated with lasting nerve damage. The case series describes the specific peripheral nerve injuries associated with this type of positioning (see Infographic below). Researchers suggest that prone positioning is not necessarily the sole cause of peripheral damage in these patients but probably plays a significant role. Long-term recovery of such nerve injuries depends on severity and can be a long process, taking between a year and 18 months.

When it comes to awake proning, or positioning patients with COVID-19 on their stomachs to increase oxygenation, experts remain divided. At the virtual COVID-19: What's Next conference, organized by the Society of Critical Care Medicine, Nicholas Bosch, MD, a pulmonologist at Boston Medical Center, said the practice "has the potential for real harm."

Guidelines from the Intensive Care Society in the United Kingdom advocate awake proning in COVID-19, and individual hospitals, such as Brigham and Women's in Boston, have supported the practice in their protocols. However, research has shown that prone positioning can lead to pressure ulcers, tube dislodgment, arrhythmia, and general discomfort. It can also cause unnecessary delays for patients with COVID-19 who may need quick access to mechanical ventilation.

Still, some argue that awake proning remains a valuable tool. Meghan Lane-Fall, MD, MSHP, associate professor of anesthesiology, critical care, and epidemiology at the Perelman School of Medicine in Philadelphia, said that although patients have not liked proning, they have preferred trying it before intubation. "There's a dark road you go down if you end up on a breathing tube. We've seen people come out losing 30 to 40 pounds of good, lean muscle mass," she said.

As best practices for the treatment of awake and intubated patients with severe COVID-19 continue to evolve, the role of prone positioning is likely to remain a top trending clinical topic.

Read more about the treatment of patients with COVID-19.


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