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Proning COVID Patients

Morganne Colburn

Delaware Technical Community College

NUR 340 Nursing Research

Mary Ellen McKnight

October 2, 2022
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Proning COVID Patients

There are multiple strands of the corona virus, but the corona virus that initially began the

pandemic in 2019 (COVID or COVID-19) is caused by SARS-CoV-2. COVID is spread through

droplet particles such as sneezing or coughing. Most people who contract this virus experience

mild to moderate symptoms, but those with previous underlying medical conditions are more at

risk. Serious signs and symptoms can result in acute respiratory distress syndrome (ARDS),

which can cause oxygen depletion of the organs. Treatment may include antivirals, monoclonal

antibodies, multi-vitamins, hydration, steroids, oxygen therapy, and proper positioning. This

paper focuses on the process, benefits, and risks of proning patients with COVID.

Proning

Proning is a position where an individual lies face down. “Physical position affects the

distribution and volume of air in the lungs and can have direct effects on the expansion or

collapse of the delicate alveoli that permits the exchange of oxygen and carbon dioxide in the

blood” (Penn Medicine, 2021, para. 3). Reversely, the supine position, where an individual lies

on their back, can be detrimental to pulmonary function because the lungs are compressed,

causing the alveoli (air sacs) to collapse (atelectasis). This collapse decreases oxygenation which

results in ventilation/perfusion mismatch, meaning there are significantly high levels of carbon

dioxide in the blood (Penn Medicine, 2021). Patients rapidly deteriorate and their breathing is

compromised which can ultimately result in death.

Statement of the Problem

There are different therapies and treatments for COVID mentioned previously. However,

what are the benefits of proning for improved patient outcomes against COVID in relation to
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acute respiratory distress syndrome either able to self-prone or mechanically ventilated? Proning

can be initiated in both nonventilated and mechanically ventilated patients. It is easier with

nonventilated patients. Benefits of proning include better ventilation of the dorsal lung regions

that could result in alveolar collapse, improvement of ventilation/perfusion matching, and

improvement of mortality rates (Penn Medicine, 2020, para. 7).

Nurses have an abundance of responsibilities. Most COVID patients typically reside on

intensive care units or step-down units for a closer nurse to patient ratio for better monitoring. It

is important for patients to remain in a prone position for as long as they can tolerate. A nurse’s

responsibility starts prior to prone initiation. Nurses who understand the evidence-based

implications of proning must ensure that the process will be performed appropriately (Chadwick,

2010). Proning schedules are regulated by nursing staff. To facilitate proning it is best for nurses

to follow FLIP. Find and understand current facility policies; learn about evidence-based

practice and applying it; initiate protocol with the multidisciplinary team to develop a standard of

care; being a patient advocate (FLIP). Prior to pronation, it is important to consider proper

personal protective equipment for staff members, when the patient ate last (if not ventilated),

actual/potential skin breakdown, vital signs, moving telemetry electrodes once repositioned, and

correct placement of tubing in relation to direction of turning. After pronation, it is important that

the patient’s SpO2 is continuously monitored as well as any cohesive labs such as arterial blood

gases for a basis of improved respiratory status.

Nursing staff education is another important factor related to proning. As nursing leaders

and managers, educating nursing staff on the correct protocol through huddle, mandatory in-

service, printables, emails, and computer-based modules are steps in the right direction. Nurses

are able to ask best practice clinical questions, review evidence-based research, and implement
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interventions to improve patient outcomes. Proning can be used as a safe and effective tool to

improve respiratory conditions and prevent escalation of care.

Literature Review

This section of the paper will focus on the sources chosen for the foundation of the paper.

Each source focused on a different portion in relation to proning such as the how, when, and why

proning is beneficial in relation to COVID patients that could potentially develop ARDS.

Supine positioning is not beneficial to the human body because of the nature of the

position and its compressing of vital organs impeding optimum function to improve respiratory

status (Chadwick, 2010). The heart compresses up to 42% of the left lung and up to 16% of the

right lung. Gravity also pushes down on the contents of the abdomen, causing displacement of

the diaphragm upward. This displacement weakens diaphragmatic excursion and reduces lung

expansion. Also, the supine position the back portion of the chest wall has little contribution to

movement so expansion is less synchronous (Chadwick, 2021). The prone position creates ease

of compression on vital organs resulting in synchronous chest wall expansion.

Neal Wiggermann, Jie Zhou, and Dee Kumpar (2020) focus on different equipment that

can be used to prone ventilated patients as well as effective methods for repositioning. Between

analytical research and expert consultation, the authors identify three categories: manual;

mechanical; and specialized. Manual positioning typically requires the most staff members and

draw sheets for manipulation. Mechanical lifting, to ensure manipulation, also requires several

staff. Both types can require at least four staff members, but preferably six to ensure patient

safety and to decrease risk of musculoskeletal injury to staff. Such manual positioning increases

chances of vascular or endotracheal loss of access. A specialized bed, the RotoProne almost
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looks like a butterfly cocoon with sensors and cushion. It includes digital meters, touch screen

controls, and a tube management system for invasive lines that helps prevent tangles and

separation. Alarms can also be enabled for staff reminders. There is also a safety feature that

allows the bed to return the patient to a supine position in less than 40 seconds for CPR in

emergent situations. Each category has benefits and risks due to staffing, exposure, weight, cost,

and equipment availability.

Fulya Yilmaz and Koray Bas (2021), detail a case study of a nonventilated sixty-eight-

year-old male with COVID-19 who was able to initiate early proning, avoiding the development

of ARDS. This patient did not have a significant past medical history. His chest CT showed

opacities and areas of consolidation consistent with COVID pneumonia. He was swabbed for

SARS-Cov-2 that resulted positive. His oxygenation rapidly deteriorated and he was started on

anticoagulants, plasma, oxygen, and antiviral therapies. His initial arterial blood gas only showed

a lower partial arterial oxygen pressure (PaO2). Due to his deterioration, he was transferred to

ICU for close monitoring. His admission lasted 19 days.

During his admission he was encouraged to self-prone as much as he could tolerate

throughout the day. The patient’s oxygenation improved with each session of awake self-proning

confirmed by increased oxygen saturation and arterial blood gas samples. On day 17the patient

was weaned off supplemental oxygen and discharge two days later.

A retrospective review of 44 patients was conducted where 138 prone sessions occurred

(Gleissman et al. 2021). The study serves as an indication of random trials to determine the effect

prone positioning has on severe COVID-19 ARDS. This study took place from March 17 to May

19th of 2020. Respiratory parameters included: one hour before proning, one hour after prone

initiation; one hour before returning to supine; and one hour after returning to supine.
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Characteristics regarding the patients, such as age, gender, and comorbidities, were also included

in the study.

After conduction of the study, 82% of the mechanically ventilated COVID-19 ARDS

patients had a successful increase in PaO2 and FiO2. Partial pressure of oxygen (PaO2)

measured the amount of oxygen pressure in arterial blood which reflected how well oxygen is

able to move from the lungs to the blood. Fraction of inspired oxygen is the concentration of

oxygen (FiO2) in the gas mixture related to the content an individual inhales in relation to gas

exchange at the alveolar level. Both values depend on each other for adequate tissue perfusion.

Improvement in oxygenation occurred independently of changes in ventilation pressures and

volumes. Proning was also found to be hemodynamically tolerable for the patients. Lung

stiffness related to the severity of ARDS also decreased. The first three prone sessions for each

patient also showed the most benefit.

Lastly, “Proning During COVID-19” was an article used to conduct research in this

paper from Penn Medicine. This article breaks down all of the “need to know” regarding prone

positioning such as what proning is, why prone a patient, why supine can be an issue, why

proning helps ARDS patients, and the potential aid proning can have in preventing mechanical

ventilation, To reiterate, proning benefits patients by causing an even distribution of ventilator

volumes and pressures throughout each lung to cause a reduction of lung injury. A huge part of

implementing a protocol for prone positioning must also include strategies such as educational

outreach, collaboration, teamwork, continuous monitoring, and appropriate staff ratios. Some

facilities have even created “prone teams” that solely focus on repositioning and monitoring

patients that require it either ventilated or nonventilated. ARDS is a syndrome that has been
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around for a very long time and some patients were proned as well, however because the COVID

pandemic was so devastating and continues to be in some cases

Analysis

In Chadwick’s article, she supports initiating and maintaining prone positioning for

patients using F.L.I.P. This article focuses more on the roles and responsibilities of nurses for

initiation, continuation, and cessation of prone positioning. She supports her article with a few

figures of sample sized studies that include criteria for initiation and cessation as well as

weaknesses and complications. The main reason behind initiation is acute respiratory distress

syndrome resulting in extreme lack of oxygenation. Continuing positioning includes the

tolerance of the patient either ventilated or not for the position considering optimal proning

occurs for hours at a time. Premature discontinuation of positioning can result in regression and

needs to be carefully evaluated as an interdisciplinary team. Some reasons behind cessation

could be skin breakdown, hemodynamic instability, accidental loss of vascular or endotracheal

access, contractures, or nerve injury. Thorough and frequent patient assessments can prevent

most complications that could arise. This research study was beneficial because it focused more

on roles and responsibilities of staff so that proning could be safely and effectively carried out on

patients.

In Wigglemann, Zhou, and Kumpar’s article, ideally the RotoProne is the most effective

method for proning due to the nature of the machine’s safety features for patient monitoring.

However, cost is a major factor with the RotoProne in relation to organization budgets. The

mechanical method may be the most suitable for patients and healthcare workers, because it

eliminates the horizontal and lifting motion associated with manual positioning. This research
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study was beneficial in laying out different methods of proning patients either ventilated or

nonventilated and the pros and cons of each method.

In Yilmaz and Bas’s article, the evidence to support the patient’s clinical improvement is

included in figures. There is a chest CT figure including the third, fifth, tenth, and seventeenth

day that shows resolution of the areas of opacities and consolidation. Also supporting the article

in another figure are the first, second, third, twelfth, and nineteenth day arterial blood gas results

which also confirm the patient achieves a state of homeostasis. The other therapies involved also

played a role in improvement overall. This research study was beneficial in focusing on awake

self-proning for the body of this research paper.

In Gleissman’s article a supplemental table and two figures are provided as a visual to

support the study. The supplemental table includes an average median of all patients included

through ventilatory, metabolic, and circulatory data from the first proning session. This table

suggests the most changes seen amongst the data occurred during prone positioning. The average

length of time per session was fourteen hours. Figure one features a line chart that includes the

average median data of the first five prone sessions in relation to PaO2 and FiO2. All five

sessions show the increase of both values. Figure two features a scatter plot of the PaO2 and

FiO2 prior to prone positioning versus the end of prone positioning. There is a significant

increase in both values from less than 120 mm Hg. This retrospective research study was

beneficial in focusing on mechanically ventilated patients and their improved outcomes due to

proning having an increased effect on PaO2 and FiO2.

In the article by Penn Medicine, there is a printable pamphlet half-way through the article

that outlines the criteria, contraindications, if an emergency ensues, what to do prior to proning, a

step-by-step on how to prone, and post-proning care. The pamphlet also has a small portion for
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how nurses should chart the process of proning and where to find said documentation through

EPIC. There are also some educational photos included in the pamphlet as well. This figure

would be very beneficial for nurses to keep handy in their clipboards or posted on various units.

At the end of the article there are also highlighted links to two different videos for awake self-

proning and the mechanisms and therapies for ARDS. This article was very helpful in gathering

a foundation of knowledge for the structure of this research paper.

Recommendations

Authors, Yilmaz and Bas’s article would have been much more effective in delivering

positive results if the supporting figures had been spaced out more to show underlying changes.

Especially the ABG results being so close together in days and then skipping to the twelfth day.

The other sources used in this research paper were all very helpful for analytical

purposes. There were not many flaws seen. Unfortunately, such a topic is difficult to obtain a

control group, because those patients would be at an increased risk for death and it would not be

ethically sound to pick and chose patients to prone or supine for vast results. Typically most

studies are done retrospectively. I felt that each source chosen was completely different focuses

of information which together provided a wealth of information regarding all education needed

for proning.

Conclusion

Essentially there are always risks and benefits to anything, but when it comes to

increasing patient outcomes and decreasing mortality rates, being able to aid patients combined

with other therapies to return their lungs to a synchronous unit, evidence-based practice must be

evaluated and implemented for quality care and monitoring.

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References

Chadwick, J. R. (2010). Prone positioning in trauma patients. Journal of Trauma Nursing, 17(4),

201–207. https://doi.org/10.1097/jtn.0b013e3181ff2813

Gleissman, H., Forsgren, A., Andersson, E., Lindqvist, E., Lipka Falck, A., Cronhjort, M.,

Dahlberg, M., & Günther, M. (2021). Prone positioning in mechanically ventilated patients

with severe acute respiratory distress syndrome and coronavirus disease 2019. Acta

Anaesthesiologica Scandinavica, 65(3), 360–363.

https://doi-org.libproxy.dtcc.edu/10.1111/aas.13741

Penn Medicine. Proning during COVID-19. (2020, March 10).

https://www.pennmedicine.org/updates/blogs/penn-physician-blog/2020/may/proning-

during-covid19#:~:text=Research%20has%20found%20that%20when,potentially%20an

%20improvement%20in%20mortality.

Wiggermann, N., Zhou, J., & Kumpar, D. (2020, August 16). Proning patients with Covid-19: A

review of equipment and methods. Human factors 62 (7), 1069-1076.

https://pubmed.ncbi.nlm.nih.gov/32845730/

Yılmaz, F., & Bas, K. (2021). Successful recovery from COVID-19 pneumonia with awake early

self-proning. Ain Shams Journal of Anesthesiology, 13(64), 1–4. https://doi-

org.libproxy.dtcc.edu/10.1186/s42077-021-00184-0
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