Proning

Neonate with electrical impedance tomography electrodes

Proning is a medical procedure that involves positioning a patient so that they are lying on their abdomen. This practice is commonly used in intensive care units (ICUs) for patients who are experiencing severe respiratory distress, particularly those suffering from acute respiratory distress syndrome (ARDS) or COVID-19 related pneumonia. The primary goal of proning is to improve oxygenation and ventilation in patients who are mechanically ventilated.

Benefits of Proning

The process of proning has been shown to significantly improve the oxygenation in patients with severe respiratory failure. This improvement is primarily due to better ventilation-perfusion matching and the alleviation of dorsal lung compression by the heart and abdomen. When a patient is in the supine position (lying on their back), the dorsal (back) regions of the lungs can become compressed, leading to atelectasis (collapse of lung tissue) and reduced gas exchange. Proning helps redistribute body weight, reducing pressure on the lungs and allowing for better expansion and gas exchange.

Indications for Proning

Proning is most commonly indicated for patients with ARDS, a condition characterized by the rapid onset of widespread inflammation in the lungs. It is also indicated for patients with severe hypoxemia (low blood oxygen levels) who do not respond adequately to other treatments. During the COVID-19 pandemic, proning has been widely used for patients with severe respiratory symptoms caused by the virus, even in non-intubated patients, as part of an awake proning strategy to improve oxygenation before mechanical ventilation becomes necessary.

Procedure

The process of proning a patient requires a coordinated effort from a team of healthcare professionals to ensure it is done safely. The team typically includes nurses, respiratory therapists, and sometimes physicians. The patient's arms, legs, and head must be carefully positioned to prevent pressure ulcers, nerve damage, and to ensure the airway remains secure. The procedure involves several steps: 1. Preparing the patient by ensuring that all lines and tubes are secure and will not be dislodged during the turn. 2. Using adequate personnel to gently roll the patient onto their abdomen. 3. Positioning the patient's limbs and head correctly to prevent complications. 4. Monitoring the patient closely for any signs of distress or complications.

Complications

While proning is generally safe when performed correctly, there are potential complications, including pressure ulcers, facial edema, and dislodgement of endotracheal tubes or central venous catheters. Careful monitoring and preventive measures, such as using specialized beds and padding, are essential to minimize these risks.

Conclusion

Proning is a valuable intervention in the management of patients with severe respiratory failure, particularly in the context of ARDS and COVID-19. It requires a multidisciplinary approach to ensure it is performed safely and effectively. As research continues, the benefits and techniques of proning are likely to be further refined, improving outcomes for critically ill patients.