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Review
. 2023 Oct;68(10):1449-1464.
doi: 10.4187/respcare.11227.

Prone Positioning for Patients With COVID-19-Induced Acute Hypoxemic Respiratory Failure: Flipping the Script

Jie Li  1 , Miguel Ibarra-Estrada  2 , Claude Guérin  3
Affiliations
Review

Prone Positioning for Patients With COVID-19-Induced Acute Hypoxemic Respiratory Failure: Flipping the Script

Jie Li et al. Respir Care. 2023 Oct.

Abstract

During the COVID-19 pandemic, prone positioning (PP) emerged as a widely used supportive therapy for patients with acute hypoxemic respiratory failure caused by COVID-19 infection. In particular, awake PP (APP)-the placement of non-intubated patients in the prone position-has gained popularity and hence is detailed first herein. This review discusses recent publications on the use of PP for non-intubated and intubated subjects with COVID-19, highlighting the physiological responses, clinical outcomes, influential factors affecting treatment success, and strategies to improve adherence with APP. The use of prolonged PP and the use of PP for patients undergoing extracorporeal membrane oxygenation are also presented.

Keywords: COVID-19; acute hypoxemic respiratory failure; awake prone positioning; prone positioning.

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Conflict of interest statement

Dr Li discloses relationships with Fisher & Paykel Healthcare, Aerogen, the Rice Foundation, the American Association for Respiratory Care, and Heyer. Dr Li is a section editor for Respiratory Care. The remaining authors have disclosed no conflicts of interest.

Figures

Fig. 1.
Fig. 1.
Physiologic responses to awake prone positioning (APP) as assessed by different bedside clinical tools. (A) Inspiratory effort measured by esophageal pressure swing, which decreased from 10.4 cm H2O to 4.5 cm H2O after 30 min of APP. (B) Lung consolidation tissue (arrow heads) disappearance after 1 d of APP as assessed by lung ultrasound. (C) Electrical impedance tomography showing homogenization of lung aeration after APP, especially at ventral lung regions (layers 1 and 2). (D) Computed tomography showing improving of aeration at both lung bases after 3 d of APP. Images are provided by Drs Li and Ibarra-Estrada from their unpublished studies. PeSw = esophageal pressure swing.
Fig. 2.
Fig. 2.
The effect of prone positioning (PP) in intubated patients. A: Dorsal lung regions with normal perfusion are collapsed (shunt) at supine, whereas ventral regions tend to present overdistention with limited perfusion (functional dead space). B: With PP, matching of ventilation/perfusion improves by inducing collapse of barely perfused ventral regions and recruitment of well-perfused dorsal units.
See this image and copyright information in PMC

References

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