Awake Proning: Current Evidence and Practical Considerations

Abstract

Prone positioning has been shown to improve oxygenation for decades. However, proning in awake, non-intubated patients gained acceptance in the last few months since the onset of coronavirus (COVID-19) pandemic. To overcome the shortage of ventilators, to decrease the overwhelming burden on intensive care beds in the pandemic era, and also as invasive ventilation was associated with poor outcomes, proning of awake, spontaneously breathing patients gathered momentum. Being an intervention with minimal risk and requiring minimum assistance, it is now a globally accepted therapy to improve oxygenation in acute hypoxemic respiratory failure in COVID-19 patients. We thus reviewed the literature of awake proning in non-intubated patients and described a safe protocol to practice the same. How to cite this article: Sodhi K, Chanchalani G. Awake Proning: Current Evidence and Practical Considerations. Indian J Crit Care Med 2020;24(12):1236-1241.

Keywords: Acute respiratory distress syndrome; Awake proning; Awake self-proning; COVID pneumonia; COVID-19.

Figs 1A and B

Schematic representation of the lung in the supine (A) and prone (B) position. (The red circle is the heart, the red lines are the blood vessels, and the circles are the alveoli.) (A) In supine position, there is more collapse of the alveoli posteriorly, with overdistention of the ventral alveoli. Perfusion is more in the posterior regions, causing V:Q mismatch. (B) In a prone position, there is the recruitment of the dorsal alveoli and improved V:Q ratio

Flowchart 1

Steps to follow when we awake prone a conscious patient