Awake Proning: A Necessary Evil During the COVID-19 Pandemic

Abstract

The spread of COVID-19 has been exponential throughout the globe. Though only a small percentage of infected individuals reach the critical stage of the disease, i.e., acute respiratory distress syndrome (ARDS), this percentage represents a significant number of patients that can overwhelm the healthcare system. Patients presenting with ARDS need mechanical ventilation, as their lungs are unable to oxygenate blood on their own due to fluid accumulation. One way to manage this excess pressure of fluid build-up around the lung tissues is to relieve the dorsal alveoli by prompting the patient to lie face down on the stomach; this is called awake proning. It is a procedure that is directed towards the recruitment of lung parenchyma when infected with pneumonia or when the condition has worsened into ARDS. This helps in relieving the pressure from the dorsal lung surface that has markedly higher perfusion than the ventral surface. Awake proning delays the use of mechanical ventilation and facilitates the patients with severe ARDS or severe pneumonia in maintaining the supply of oxygen to the body tissues. Since medical institutes are overburdened and limited ventilators are available, awake proning can reduce not only the burden on hospitals but also decrease the need for ventilators.

Awake Prone Positioning in the Management of COVID-19 Pneumonia: A Systematic Review

“…Out of 36, 17 were original articles, 6 – 22 nine case series, 23 – 31 and 10 case reports. 32 – 41 In addition, there were seven protocols, 42 – 48 seven reviews, 49 – 55 two commentaries, 21 , 56 and four editorial. 57 – 60 The 17 original articles were included in the qualitative assessment of risk of bias.…”

Nurse-led implementation of awake prone positioning

“…13,14 Patients may also experience increased anxiety and discomfort during APP. 4 With or without mechanical ventilation, the therapeutic benefits of PP or APP for patients with ARDS can be understood through disease pathophysiology and the impact of postural changes in relation to optimizing oxygenation. As viral pneumonia progresses, injury to lung tissue disrupts normal blood flow and elicits the release of proinflammatory cytokines.…”

“…6 Given combined benefits and improved oxygenation, engaging patients in APP serves as a low-risk intervention, supporting the management of patients on the medical floor while helping reduce the risk of intubation. [4][5][6]17 In May 2020, nonventilated patients with COVID-19 ARDS were admitted to a designated 22-bed acute care medical unit at a 596-bed Level I trauma center and community teaching hospital in southcentral Pennsylvania. This COVID-19 medical unit adopted a cluster care model to limit viral exposure and prevent overexertion in patients with hypoxemia.…”

“…Shallow respirations pose a further risk for atelectasis. Ventral weight in the supine position compresses the lungs, causing atelectasis of the dorsal lung and hyperventilation of the ventral lung 4-6. Dorsal alveoli become preferentially perfused secondary to the gravitational gradient in vascular pressures, leading to high perfusion with poor ventilation, further disrupting blood oxygenation 4,5,16…”

“…PP may also facilitate postural drainage and secretion clearance 6. Given combined benefits and improved oxygenation, engaging patients in APP serves as a low-risk intervention, supporting the management of patients on the medical floor while helping reduce the risk of intubation 4-6,17…”