Prone Position Over Ventilator For Covid-19 ARDS

January 28, 2022

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Acute respiratory distress syndrome (ARDS) is a lung illness that causes a decrease in oxygen saturation and fluid buildup in the lungs. This is a common complication with severe Covid-19 infection. Lying in a face down position (prone), in which the chest is down and the back is up, may be a simple way to improve outcomes in ARDS. Early application of prone positioning lowered mortality rates in patients with severe ARDS. Research suggests that this positioning should be used regularly in the early management of ARDS. Prone positioning can be utilized at home for cough and mild shortness of breath, and in conditions such as influenza (flu).

This topic has received much attention during the Covid-19 plandemic, since invasive mechanical ventilation is conventionally utilized with the patient in a face up (supine) position, which is lying on the back. “Mechanical ventilation is the main supportive treatment for critically ill patients” infected with SARS-CoV-2, according to a February 2020 study published in Lancet Respiratory Medicine. Many patients put on ventilators, however, don’t make it. Is there a better option for these patients? In a JAMA study that included 5,700 patients hospitalized with Covid-19 in New York City between March 1, 2020 and April 4, 2020, mortality rates for those put on a ventilator ranged from 76.4% to 97.2%, depending on age.

Given the poor outcomes, some doctors now are trying to keep patients off ventilators as much as possible by using alternative measures. Having patients lie on their stomachs allows for better lung aeration. Prone ventilation may help patients who are not responding to conventional mechanical ventilation, as well as reducing mortality in acute respiratory distress syndrome.

In ARDS, fluid builds up in the lung and surfactant (helps lungs to fully expand), breaks down. Therefore, the lungs are unable to properly fill with air, causing shortness of breath (SOB). This can in turn lead to low oxygen in the blood, rapid breathing, and rattling sounds in the lungs. ARDS is a common complication among seriously ill Covid-19 patients, with one study suggesting that 100% SARS-CoV-2 patients who died were suffering with ARDS. A study published in the New England Journal of Medicine found that early utilization of prone positioning may improve outcomes in people with severe ARDS. This study included 466 patients with severe ARDS who were randomly assigned to receive prone-positioning at least 16 hours per day or to stay in the supine positioning. After 28 days, 32.8% in the supine group had died, compared to 16% in the prone group. After 90 days, the supine group had a death rate of 41%, compared to 23.6% in the prone group. Oxygen saturation is also better among patients in prone position compared to supine position. Lying face down can prevent ventilator induced lung injury.

In ARDS, the lung’s air sacs, or alveoli, become damaged. Fluid leaks through the damaged walls of the alveoli and collects. Fluid in the lung will increase its weight, which then forces out the gas from the dependent areas. In the supine position the dependent regions are at the back of the lung. The increased lung mass squeezes out the gas of the gravity-dependent lung regions. This is why the lung densities shift when moving from the supine to the prone position. This shift can occur in a matter of minutes after changing the patient’s position. Differences in the shape of the lungs also are important. Lungs are normally conical in shape, with the dependent side being the base and the non-dependent side being the top. When the patient is lying on their back, this is the shape.

The chest wall, however, has a barrel-shape, and because of this difference, the lung must expand its upper regions more than the lower regions, which leads to greater expansion of the non-dependent air sacs and a lesser expansion of the dependent ones. When a patient is in the prone position, the weight becomes much more evenly distributed, allowing for better breathing.

Other benefits with prone positioning include:

• Removing some of the weight of the heart from the dependent lung

• Quick, significant and persistent improvement in oxygenation in the ARDS patient with heart failure

• Removing some of the weight of the abdominal contents from the better ventilated bottom part of the lung

Prone positioning can also help with stress and strain on the lung. Stress refers to the tension in the fibrous skeleton when expanding force is applied. Strain is the volume increase caused by the applied force related to the resting volume of the lungs. Prone positioning also reduces lung inflammation in ARDS patients and may reduce the extent of lung injury caused by mechanical ventilation.

Research suggests that prone positioning should be used in the early management of severe ARDS, and not reserved as a rescue maneuver or last-ditch effort. Lying in the face down position should be used together with lung-
protective strategies to decrease the death rate. These sessions in this position should last 12 to 18 hours and should be started early, within 36 hours of diagnosis. A small study of patients with severe Covid-19 ARDS, who required mechanical ventilation in Wuhan, China, also disclosed that lying in the prone position for 24- hour periods was better for the lungs. Despite the many potential benefits, this technique remains underutilized.

One study has been planned to determine whether the use of prone positioning in awake self-ventilating patients with Covid-19 induced ARDS could improve oxygen exchange and reduce the need for mechanical ventilation. Previous research also suggests that awake breathing patients who are not intubated can benefit from prone positioning, which leads to improved oxygen saturation. It has been suggested that the physiological changes that occur with prone positioning may be even more favorable in spontaneously breathing patients than in those who are intubated. In the case of Covid-19, some experts believe that all patients who are awake and able to adjust their own position should lie face down for 2 to 4 hour sessions, two to four times a day.

Some hospitals have released patients with instructions for prone positioning at home for people with cough or trouble breathing. Patients who are struggling to breathe should seek emergency care. However, in cases of cough or mild shortness of breath being treated at home, guidelines from Elmhurst Hospital “recommend not spending a lot of time lying flat on your back.”
Instead, it suggests “laying on your stomach and in different positions will help your body to get air into all areas of your lung.” The guidelines recommend changing position every 30 minutes to two hours, including:

• Lying on belly

• Lying on right side

• Sitting up

• Lying on left side

CONCLUSION

Prone positioning seems to be a viable alternative to mechanical ventilation in SARS-CoV-2 ARDS. With hospitals being the new “kill zones” for Covid-19 infection, I am always looking for better alternative treatments. Prone positioning also from earlier studies seems to reduce the mortality rate by almost 50%, both in short and long-term outcomes in patients with ARDS. Another important thing to remember is patients who died from Covid-19 in hospitals, most likely, died from ARDS. It is essential to have this information in preparation that one would become sick with Covid infection. The whole game plan should be early treatment, and by all means, to stay out of the hospital. Prone positioning is an essential home treatment for mild Covid-19, colds, and influenza. If hospitalization is required for severe SARS-CoV-2, the patient, family member, or friend can request not to be placed on mechanical ventilation. Instead, they can suggest prone positioning. Greedy hospital administrators, however, may not like that treatment because there is no money in it. May Yahweh bless and keep well.

By Ed J.