Clinical
DIMENSION
The “Dolphin” Prone
Position in Awake COVID-
19 Patients
Downloaded from http://journals.lww.com/dccnjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 11/01/2021
Alberto Lucchini, RN; Dario Minotti, CCN-RN; Stefania Vanini, CCN-RN;
Flavia Pegoraro, CCN-RN; Luigi Iannuzzi, RN; Stefano Isgrò, MD
[DIMENS CRIT CARE NURS. 2021;40(6):311-314]
Prone positioning (PP) during invasive mechanical ventilazione
has been demonstrated to improve respiratory mechanics and
gas exchange. Prone positioning reduces mortality of most
severe acute respiratory distress syndrome patients.1-3 In
theory, these benefits should apply also to nonintubated
patients, in whom PP may improve oxygenation while
delaying or even avoiding the need for intubation. Reports
of the application of PP in spontaneously breathing,
nonintubated adult patients, before the COVID era, are
limited to few case reports.4-6 During the last 14 months,
PP has been largely used in all intensive care units (ICUs) to
treat patients with COVID-19 acute respiratory failure.3
Even the use of awake PP, outside ICUs, has been investigated
by several authors during the COVID-19 pandemic.7-9 Albeit
clear evidence on its impact of outcome is missing in awake
patients, PP is extensively used worldwide with several trials
ongoing. Although the respiratory benefits of PP in acute
respiratory distress syndrome have been accepted, the con-
current complications could be undervalued.10
González-Seguel and colleagues10 performed a scoping
review about PP complications, including 41 documents
from 121 eligible studies. They identified more than 40 indi-
vidual adverse events, and the highest pooled occurrence
rates were that of severe desaturation (37.9%), barotrauma
(30.5%), pressure sores (29.7%), ventilation-associated pneu-
monia (28.2%), facial edema (16.7%), arrhythmia (15.4%),
hypotension (10.2%), and peripheral nerve injuries (8.1%).
The reported mitigation strategies to reduce PP complications
include alternate face rotation, repositioning every 2 hours,
and the use of pillows under the chest and pelvis. The reported
DOI: 10.1097/DCC.0000000000000505
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
mitigation strategies suggest the use of a premaneuver
safety checklist. Thanks are due to the authors for sharing
their valuable experience with this issue. Even Bruni and col-
leagues11 recently described strategies to avoid complications
during PP in ICU patients, and they had proposed a checklist
to avoid PP complications. This checklist mainly deals with
the implementation of PP in patients with invasive ventila-
tion. Although the authors have reported some suggestions
for using PP in awake patients undergoing noninvasive ventila-
tion (NIV), some guidance could be added. Prone positioning
during helmet continuous positive airway pressure (CPAP) or
NIV requires some precautions, to avoid discomfort and skin
lesions. Awake patients during helmet CPAP may assume PP
with minimal assistance.12
APPROACH
Because of a high number of COVID-19 patients with
acute respiratory failure and of the shortage of ICU beds
and ventilators, in our hospital, we started positioning pa-
tients in helmet CPAP in general wards since the first days
of March 2020.13-15 We reported experience from our insti-
tution about patients treated with PP and helmet CPAP in
the general wards.7 Most patients were receiving CPAP, which
is a standard of care in our institution, whereas high-flow ox-
ygen were not available, and NIV is limited to a few high-
dependency units.16 Between March 20 and April 9, 2020,
we enrolled 56 patients. Prone positioning was feasible
(maintained for at least 3 hours) in 47 patients. Among
patients for whom positioning was feasible, most maintained
November/December 2021 311
Figure 1. Standard prone position in an awake patient with helmet continuous positive airway pressure. This is available in color online at www.
dccnjournal.com.

proning for the initial 3-hour period (median, 3 hours [In-
terquartile: 3-4]), and 25 patients maintained PP for longer
than 3 hours. No other relevant adverse effects or compli-
cations were observed. If patients asked to resume the
supine position before 3 hours, PP was considered un-
feasible and the reason was reported. Prone positioning
was unfeasible in 9 patients, reasons for which included
discomfort during positioning (n = 5), coughing (n = 1),
uncooperativeness of the patient (n = 1), and decrease in
oxygenation and worsening of respiratory mechanics.
One of the reasons for discomfort, reported by patients
undergoing PP and helmet CPAP in our hospital, was the dif-
ficulty to maintain a comfortable position, especially for the
vertebral column, when position was maintained for at least
3 hours. To increase patients' comfort, we adopted the “hel-
met bundle” in all patients with helmet CPAP.13 The use of
helmet without armpit braces is preferable, and another
important precaution is to prevent the rigid collar from
generating skin lesions by direct pressure and mechanical
stress to the neck. Unfortunately, the patient positioning

Figure 2. “Dolphin” prone position in an awake patient with helmet continuous positive airway pressure. This is available in color online at
www.dccnjournal.com.

312 Dimensions of Critical Care Nursing Vol. 40 / No. 6

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

on the hospital beds, to guarantee the right functioning of
helmet CPAP, required the use of pillows under the chest.
As shown in Figure 1, when a patient is in PP with helmet
CPAP, the patient's back takes on a concave curvature. This
“not physiological” position could be one of the reasons of
patients' discomfort when we tried to maintain position for
a long time. For this reason, during the third COVID-19
wave (February to April 2021), we used a new approach
to place awake patients with helmet CPAP in PP. The nurses
encouraged patients to reverse their position on the bed,
placing their head in the “bed foot area.” In this way, the
joint of the bed, normally dedicated to the inclination of
the lower limbs, was used to achieve a comfortable chest
position. The inclination of the footrest made possible to
avoid use of additional pillows. Above all, using this new
strategy, the patients' spine was able to maintain a neutral
and natural position. As shown in Figure 2, the addition
of a slight Trendelenburg bed inclination helps in achieving
optimal patient positioning.
Another positive aspect of this new technique con-
cerns the patient's visual area. During normal PP, patients
undergoing helmet CPAP had limited vision, and often,
they could only see the wall in front of them. With the
head positioned on the bed foot area, the patients in the
prone position had a better view, being able to observe
the entrance to the hospital room, in the general wards.
We have treated more than 50 patients outside the ICU.
Unfortunately, its simplicity and the immediate comfort
communicated by the patients did not allow us to collect
comparison data with the old technique. All the nurses
and patients to whom it was proposed no longer wanted
to apply the conventional technique.
CONCLUSIONS
In conclusion, we show that “the dolphin prone position-
ing” is feasible outside the critical care environment in most
patients, is safe, and might improve patients' comfort in
COVID-19, making it an alternative or adjunct to standard
PP to maintain safe oxygenation. It is our intention to de-
sign a study to compare 2 techniques. We think this small
report could help nurses to perform PP in awake patients
undergoing helmet CPAP or NIV.
References
1. Taccone P, Pesenti A, Latini R, et al. Prone positioning in patients
with moderate and severe acute respiratory distress syndrome: a
randomized controlled trial. JAMA. 2009;302:1977-1984. doi:
10.1001/jama.2009.1614.
2. Guérin C, Reignier J, Richard J-C, et al. Prone positioning in se-
vere acute respiratory distress syndrome. N Engl J Med. 2013;
368:2159-2168. doi:10.1056/NEJMoa1214103.
3. Guérin C, Albert RK, Beitler J, et al. Prone position in ARDS pa-
tients: why, when, how and for whom. Intensive Care Med. 2020;
46:2385-2396. doi:10.1007/s00134-020-06306-w.
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
4. Feltracco P, Serra E, Barbieri S, et al. Non-invasive ventilation in
prone position for refractory hypoxemia after bilateral lung trans-
plantation. Clin Transplant. 2009;23(5):748-750.
5. Valter C, Christensen AM, Tollund C, Schønemann NK. Re-
sponse to the prone position in spontaneously breathing patients
with hypoxemic respiratory failure. Acta Anaesthesiol Scand.
2003;47:416-418.
6. Scaravilli V, Grasselli G, Castagna L, et al. Prone positioning im-
proves oxygenation in spontaneously breathing non-intubated
patients with hypoxemic acute respiratory failure: a retrospective
study. J Crit Care. 2015;30:1390-1394. doi:10.1016/j.jcrc.2015.
07.008.
7. Coppo A, Bellani G, Winterton D, et al. Feasibility and physiolog-
ical effects of prone positioning in non-intubated patients with
acute respiratory failure due to COVID-19 (PRON-COVID): a
prospective cohort study. Lancet Respir Med. 2020;8:765-774.
doi:10.1016/S2213-2600(20)30268-X.
8. Thompson AE, Ranard BL, Wei Y, et al. Prone positioning in
awake, nonintubated patients with COVID-19 hypoxemic respi-
ratory failure. JAMA Intern Med. 2020;180:1537-1539. doi:10.
1001/jamainternmed.2020.3030.
9. Perez-Nieto OR, Escarraman-Martinez D, Guerrero-Gutierrez
MA, et al, APRONOX Group. Awake prone positioning and
oxygen therapy in patients with COVID-19: the APRONOX
study. Eur Respir J. 2021;15:2100265. doi:10.1183/13993003.
00265-2021.
10. González-Seguel F, Pinto-Concha JJ, Aranis N, Leppe J. Adverse
events of prone positioning in mechanically ventilated adults with
acute respiratory distress syndrome. Intensive Crit Care Nurs.
2021;66:103064.
11. Bruni A, Garofalo E, Longhini F. Avoiding complications during
prone position ventilation. Intensive Crit Care Nurs. 2021;66:
103064. doi:10.1016/j.iccn.2021.103064.
12. Longhini F, Bruni A, Garofalo E, et al. Helmet continuous posi-
tive airway pressure and prone positioning: a proposal for an
early management of COVID-19 patients. Pulmonology. 2020;
26(4):186-191. doi:10.1016/j.pulmoe.2020.04.014.
13. Lucchini A, Giani M, Isgrò S, Rona R, Foti G. The "helmet bun-
dle" in COVID-19 patients undergoing noninvasive ventilation.
Intensive Crit Care Nurs. 2020;58:102859. doi:10.1016/j.iccn.
2020.102859.
14. Coppadoro A, Benini A, Fruscio R, et al. Helmet CPAP to treat
hypoxic pneumonia outside the ICU: an observational study during
the COVID-19 outbreak. Crit Care. 2021;25:80. doi:10.1186/
s13054-021-03502-y.
15. Lucchini A, Giani M, Elli S, Villa S, Rona R, Foti G. Nursing Ac-
tivities Score is increased in COVID-19 patients. Intensive Crit
Care Nurs. 2020;59:102876. doi:10.1016/j.iccn.2020.102876.
16. Rezoagli E, Villa S, Gatti S, et al. Helmet and face mask for non-
invasive respiratory support in patients with acute hypoxemic
respiratory failure: a retrospective study. J Crit Care. 2021;65:
56-61. doi:10.1016/j.jcrc.2021.05.013.
ABOUT THE AUTHORS
Alberto Lucchini, RN, is a head nurse, General Intensive Care Unit,
Emergency Department, ASST Monza - San Gerardo Hospital; and
University of Milano-Bicocca, Italy.
Dario Minotti, CCN-RN, General Intensive Care Unit, Emergency
Department, ASST Monza - San Gerardo Hospital; and University of
Milano-Bicocca, Italy.
Stefania Vanini, CCN-RN, General Intensive Care Unit, Emergency
Department, ASST Monza - San Gerardo Hospital; and University of
Milano-Bicocca, Italy.
Flavia Pegoraro, CCN-RN, General Intensive Care Unit, Emergency
Department, ASST Monza - San Gerardo Hospital; and University of
Milano-Bicocca, Italy.
November/December 2021 313
Luigi Iannuzzi, RN, General Intensive Care Unit, Emergency Department,
ASST Monza - San Gerardo Hospital; and University of Milano-Bicocca,
Italy.
Stefano Isgrò, MD, Medical Emergency Team, Emergency Department,
ASST Monza - San Gerardo Hospital; and University of Milano-Bicocca,
Italy.
All authors have approved the final article that all those entitled to
authorship are listed as authors.
The authors have disclosed that they have no significant relationship with,
or financial interest in, any commercial companies pertaining to this article.
Address correspondence and reprint requests to: Alberto Lucchini, RN,
General Intensive Care Unit, San Gerardo Hospital – ASST Monza, Milan-
Bicocca University, Via Pergolesi 33, Monza (MB), Italy (alberto.lucchini@
unimib.it; a.lucchini@asst-monza.it).
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

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