Potential physiological benefits of proning

Reviewed by Jessica Muñoz, Jessica Muñoz is a registered nurse and educator with 20 years of experience in critical care emergency nursing, specializing in patient care, education, and evidence-based practice. She holds multiple certifications and serves as a Patient Safety Coordinator.

Proning, a method employed by healthcare professionals, involves positioning an individual face-down on their abdomen. This technique enhances oxygen levels in cases of severe respiratory illness, particularly in ventilated patients. It requires a coordinated effort from multiple providers to transition the patient into the prone position safely.

Healthcare professionals commonly utilize prone ventilation for individuals undergoing mechanical ventilation. This technique often involves collaboration among multiple providers to transition patients into the prone position.

While proning has gained increased recognition due to its application in treating COVID-19 patients, it is not a recent development. Healthcare providers have employed this method for several decades. Research indicates that early implementation of proning can substantially decrease mortality rates in specific cases of severe respiratory illness among mechanically ventilated patients.

Potential benefits

Proning is effective primarily due to the asymmetry of our bodies. This technique achieves two key objectives in enhancing oxygenation:

• Reducing lung compression and weight, facilitates increased airflow to the alveoli, thereby improving ventilation.
• Enhancing lung efficiency by directing oxygen to regions of the lungs with higher blood perfusion, thus optimizing gas exchange.

Decreased atelectasis

Atelectasis is a condition characterized by the collapse or closure of a portion of the lung, resulting in reduced or absent air exchange in the affected area. Proning can help decrease atelectasis by promoting better lung ventilation and gas exchange. When a person is placed in the prone position, it reduces the pressure on the dependent parts of the lungs, allowing for improved airflow and preventing the collapse of lung tissue. Additionally, proning helps redistribute ventilation to areas of the lungs that may have been previously underutilized, thus reducing the risk of atelectasis.

Increase in FRC

Proning increases functional residual capacity (FRC) by redistributing lung volume, alleviating ventral pressure on the lungs, and optimizing ventilation-perfusion matching. This leads to better lung expansion, decreased compression, and improved efficiency of gas exchange, ultimately increasing FRC.

Optimization of V/Q matching

Proning helps optimize ventilation/perfusion (V/Q) matching by improving airflow to dependent lung regions and enhancing blood flow to well-ventilated areas. In the prone position, gravity aids in opening previously collapsed or poorly ventilated lung regions, allowing for better ventilation. Additionally, proning redistributes pressure on the lungs, reducing compression on the ventral aspect and facilitating more uniform ventilation. This improved ventilation pattern enables better matching with pulmonary blood flow, resulting in more efficient gas exchange. Overall, proning helps optimize V/Q matching by promoting a better distribution of ventilation and perfusion throughout the lungs.

Facilitates secretion drainage

Proning facilitates secretion drainage by promoting gravitational assistance in clearing secretions from the airways. When a person is in the prone position, gravity aids in moving secretions towards larger airways, making it easier for them to be expectorated or suctioned. Additionally, the change in position can help mobilize and redistribute mucus within the lungs, making it more accessible for clearance. Proning also allows for better ventilation of the posterior lung regions, which may help loosen and clear secretions that may have been stagnant in those areas.

Dorsoventral orientation of large airways

The dorsoventral orientation of large airways refers to their alignment along the front-to-back axis of the body. In the context of proning, this orientation can influence the drainage of secretions and ventilation patterns within the lungs. When a person is in the prone position (lying face down), gravity acts differently on the lungs compared to when they are supine (lying face up). In the prone position, the ventral (front) aspect of the lungs is more dependent, which may facilitate the drainage of secretions towards larger airways, aiding in clearance. Additionally, this orientation can help improve ventilation in dependent lung regions, potentially enhancing gas exchange and lung function.

How are patients positioned in the prone posture by healthcare providers?

A team of healthcare providers collaborates to safely transition patients into a prone position. Typically, there are two to three providers stationed on each side of the bed, with a respiratory therapist positioned at the head of the bed to oversee the process. They synchronize their movements under the respiratory therapist’s direction, ensuring a safe transition.

The procedure involves the following steps:

• Ensuring secure placement of wires and tubes to prevent entanglement during proning. This may involve removing EKG leads if necessary, with the respiratory therapist ensuring the stability of the patient’s neck and intubation tube.
• Gently rolling the patient onto one side, then the other, to facilitate the placement of a sheet underneath.
• Layering sheets and pillows over the patient’s chest, arms, and legs, and rolling the edges of the sheets together for a secure grip.
• Shifting the patient to one side of the bed, closer to the head.
• Rolling the patient onto their side, ensuring proper positioning of lines and tubes.
• Transitioning the patient onto their stomach, with pillows placed under the neck and head for support.
• Reattaching any removed leads or monitoring equipment.
• While these steps outline the general procedure, variations may exist among different healthcare facilities, and specialized equipment may be utilized in some cases.

Risks

The healthcare team positions the patient into a prone position using a specific method to minimize potential complications or injuries. However, there are still inherent risks, such as:

• Accidental dislodgement of the endotracheal tube, which aids breathing via the ventilator.
• Misplacement of tubes delivering fluids and medications through veins (venous catheter).
• Issues related to blood pressure or heart function, including hemodynamic instability, hypotension, or irregular heartbeat (arrhythmia).
• Temporary dips in oxygen saturation levels.
• Potential obstruction of the airways.
• These risks are notably reduced in healthcare facilities with more than five years of experience in proning techniques.

Work cited

• Professional, C. C. medical. (n.d.). Proning. Cleveland Clinic.https://my.clevelandclinic.org/health/treatments/25026-proning
• Case of the month #40 Ards (acute respiratory distress syndrome). What are potential physiological benefits of proning? . The Faculty of Intensive Care Medicine. (n.d.). https://ficm.ac.uk/index.php/documents/what-are-potential-physiological-benefits-of-proning