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Historically, the prone position was used almost exclusively in the ICU for patients suffering from refractory hypoxemia due to acute respiratory distress syndrome (ARDS). Amidst the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) pandemic, however, this technique has been increasingly utilized in settings outside of the ICU, particularly in the emergency department. With emerging evidence that patients diagnosed with COVID‐19 who are not intubated and mechanically ventilated may benefit from the prone position, this strategy should not be isolated to only those with critical illness. This is a review of the pertinent physiology and evidence supporting prone positioning along with a step‐by‐step guide meant to familiarize those who are not already comfortable with the maneuver. Placing a patient in the prone position helps to improve ventilation‐perfusion matching, dorsal lung recruitment, and ultimately gas exchange. Evidence also suggests there is improved oxygenation in both mechanically ventilated patients and those who are awake and spontaneously breathing, further reinforcing the utility of the prone position in non‐ICU settings. Given present concerns about resource limitations because of the pandemic, prone positioning has especially demonstrable value as a technique to delay or even prevent intubation. Patients who are able to self‐prone should be directed into the ''swimmer's position'' and then placed in reverse Trendelenburg position if further oxygenation is needed. If a mechanically ventilated patient is to be placed in the prone position, specific precautions should be taken to ensure the patient's safety and to prevent any unwanted sequelae of prone positioning.
BACKGROUND: Patients with coronavirus disease 2019 (COVID-19) often develop acute hypoxemic respiratory failure and receive invasive mechanical ventilation. Much remains unknown about their respiratory mechanics, including the trajectories of pulmonary compliance and P aO 2 /F IO 2 , the prognostic value of these parameters, and the effects of prone positioning. We described respiratory mechanics among subjects with COVID-19 who were intubated during the first month of hospitalization. METHODS: We included patients with COVID-19 who were mechanically ventilated between February and May 2020. Daily values of pulmonary compliance, P aO 2 , F IO 2 , and the use of prone positioning were abstracted from electronic medical records. The trends were analyzed separately over days 1-10 and days 1-35 of intubation, stratified by prone positioning use, survival, and initial P aO 2 /F IO 2 . RESULTS: Among 49 subjects on mechanical ventilation day 1, the mean compliance was 41 mL/cm H 2 O, decreasing to 25 mL/cm H 2 O by day 14, the median duration of mechanical ventilation. In contrast, the P aO 2 /F IO 2 on day 1 was similar to day 14. The overall mean compliance was greater among the non-survivors versus the survivors (27 mL/cm H 2 O vs 24 mL/cm H 2 O; P 5 .005), whereas P aO 2 /F IO 2 was higher among the survivors versus the non-survivors over days 1-10 (159 mm Hg vs 138 mm Hg; P 5 .002) and days 1-35 (175 mm Hg vs 153 mm Hg; P < .001). The subjects who underwent early prone positioning had lower compliance during days 1-10 (27 mL/cm H 2 O vs 33 mL/cm H 2 O; P < .001) and lower P aO 2 /F IO 2 values over days 1-10 (139.9 mm Hg vs 167.4 mm Hg; P < .001) versus those who did not undergo prone positioning. After day 21 of hospitalization, the average compliance of the subjects who had early prone positioning surpassed that of the subjects who did not have prone positioning. CONCLUSIONS: Respiratory mechanics of the subjects with COVID-19 who were on mechanical ventilation were characterized by persistently low respiratory system compliance and P aO 2 /F IO 2 , similar to ARDS due to other etiologies. The P aO 2 /F IO 2 was more tightly associated with mortality than with compliance.
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