Breathing in Prone Position for C-19
There has been a spate of material going around on social media about the role of Prone Position Breathing for COVID-19 induced hypoxia. Let us look at the facts and the myths.
Material on Social Media
There are detailed videos being circulated but for the sake of the print
“If there is difficulty in breathing, then lie on your stomach for 40 minutes, this position acts as a natural ventilator; Results up to 80% effective. The prone position technique is up to 80 percent effective in improving the condition when the oxygen level falls. Doctors advised COVID patients to try this technique if they have difficulty breathing.1”
Facts — A collection of articles
Physiology of prone position ventilation: When a person is supine, the weight of the ventral lungs, heart, and abdominal viscera increase dorsal pleural pressure. This compression reduces transpulmonary pressure in the dorsal lung regions. The increased mass of the edematous ARDS lung further increases the ventral-dorsal pleural pressure gradient and reduces regional ventilation of dependent dorsal regions. The ventral heart is estimated to contribute approximately an additional 3 to 5 cm of water pressure to the underlying lung tissue. In addition to the weight of the heart, intraabdominal pressure is preferentially transmitted through the diaphragm, further compressing dorsal regions. Although these factors tend to collapse dependent dorsal regions, the gravitational gradient in vascular pressures preferentially perfuses these regions, yielding a region of low ventilation and high perfusion, manifesting clinically as hypoxemia. Placing a person in the prone position reduces the pleural pressure gradient from nondependent to dependent regions, in part through gravitational effects and conformational shape matching of the lung to the chest cavity2.
Awake prone positioning may be a promising therapy for patients with hypoxemic respiratory failure (including those with COVID-19), the supporting evidence is limited to case reports and cohort studies3. Many questions remain unanswered when considering the use of awake prone positioning.
So, while there are plenty of studies2,3 to establish the use of prone positioning to improve4–11 oxygenation in patients with ARDS12–14 like in COVID-193,4,6, there seems to be no evidence to prove that someone who is in a safe range of oxygenation due to COVID-19 (above 94%) will benefit in such a manner as to prevent further deterioration or even delay medical attention all together.
Prone positioning improves ventilation15–19, but then medical attention must be sought, and pharmaceutical intervention must be applied if PO2 levels fall below 94%20.
1. Positions to Reduce Shortness of Breath — Mero Kuraa Entertainment and Information [Internet]. [cited 2020 Oct 5]. Available from: https://www.merokuraa.com/2020/09/shortness-of-breath-prone-position-may.html
2. Ali HS, Kamble M. Prone positioning in ARDS: physiology, evidence and challenges. Qatar Medical Journal [Internet]. 2020 Feb 6 [cited 2020 Oct 5];2019(2). Available from: /pmc/articles/PMC6851950/?report=abstract
3. Weatherald J, Solverson K, Zuege DJ, Loroff N, Fiest KM, Parhar KKS. Awake prone positioning for COVID-19 hypoxemic respiratory failure: A rapid review. Journal of Critical Care [Internet]. 2020 Aug [cited 2020 Oct 5]; Available from: /pmc/articles/PMC7450241/?report=abstract
4. Zang X, Wang Q, Zhou H, Liu S, Xue X, Zhang W, et al. Efficacy of early prone position for COVID-19 patients with severe hypoxia: a single-center prospective cohort study. Intensive Care Medicine. Springer; 2020.
5. Munshi L, del Sorbo L, Adhikari NKJ, Hodgson CL, Wunsch H, Meade MO, et al. Prone position for acute respiratory distress syndrome: A systematic review and meta-analysis. Vol. 14, Annals of the American Thoracic Society. American Thoracic Society; 2017. p. S280–8.
6. Gulart AA, Silva IJCS. Early prone position for COVID-19 patients with severe hypoxia: reduces the mortality but increases the intubation risk? Intensive Care Medicine. Springer; 2020.
7. Gaudry S, Tuffet S, Lukaszewicz A-C, Laplace C, Zucman N, Pocard M, et al. Prone positioning in acute respiratory distress syndrome after abdominal surgery: a multicenter retrospective study. Annals of Intensive Care [Internet]. 2017 Dec 24 [cited 2020 Oct 5];7(1):21. Available from: http://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-017-0235-z
8. Jochmans S, Mazerand S, Chelly J, Pourcine F, Sy O, Thieulot-Rolin N, et al. Duration of prone position sessions: a prospective cohort study. Annals of Intensive Care [Internet]. 2020 Dec 24 [cited 2020 Oct 5];10(1):66. Available from: https://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-020-00683-7
9. Munshi L, del Sorbo L, Adhikari NKJ, Hodgson CL, Wunsch H, Meade MO, et al. Prone position for acute respiratory distress syndrome: A systematic review and meta-analysis. Vol. 14, Annals of the American Thoracic Society. American Thoracic Society; 2017. p. S280–8.
10. Ding L, Wang L, Ma W, He H. Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study. Critical Care [Internet]. 2020 Dec 30 [cited 2020 Oct 5];24(1):28. Available from: https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-2738-5
11. Papazian L, Bregeon F, Gaillat F, Thirion X, Gainnier M, Gregoire R, et al. Respective and combined effects of prone position and inhaled nitric oxide in patients with acute respiratory distress syndrome. American Journal of Respiratory and Critical Care Medicine. 1998;157(2):580–5.
12. Kallet RH. A comprehensive review of prone position in ARDS. Vol. 60, Respiratory Care. American Association for Respiratory Care; 2015. p. 1660–87.
13. Langer M, Mascheroni D, Marcolin R, Gattinoni L. The prone position in ARDS patients. A clinical study. Chest. 1988;94(1):103–7.
14. Vieillard-Baron A, Charron C, Caille V, Belliard G, Page B, Jardin F. Prone positioning unloads the right ventricle in severe ARDS. Chest. 2007;132(5):1440–6.
15. Richter T, Bellani G, Harris RS, Melo MFV, Winkler T, Venegas JG, et al. Effect of prone position on regional shunt, aeration, and perfusion in experimental acute lung injury. American Journal of Respiratory and Critical Care Medicine. 2005 Aug 15;172(4):480–7.
16. Petersson J, Glenny RW. Gas exchange and ventilation-perfusion relationships in the lung. Vol. 44, European Respiratory Journal. European Respiratory Society; 2014. p. 1023–41.
17. Altemeier WA, McKinney S, Krueger M, Glenny RW. Effect of posture on regional gas exchange in pigs. Journal of Applied Physiology. 2004 Dec;97(6):2104–11.
18. MARTIN CJ, CLINE F, MARSHALL H. Lobar alveolar gas concentrations; effect of body position. The Journal of clinical investigation. 1953;32(7):617–21.
19. Albert RK, Keniston A, Baboi L, Ayzac L, Guérin C. Prone position-induced improvement in gas exchange does not predict improved survival in the acute respiratory distress syndrome. Vol. 189, American Journal of Respiratory and Critical Care Medicine. 2014. p. 494–6.
20. (No Title) [Internet]. [cited 2020 Oct 5]. Available from: https://www.mohfw.gov.in/pdf/ClinicalManagementProtocolforCOVID19.pdf
