COVID-19: Intensive Care Society issues new guidelines on ‘proning’

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Following a national survey, the UK's Intensive Care Society has issued guidelines on "proning", a technique usually applied to unconscious patients on ventilation, which may be effective with some coronavirus patients. The guidance addresses an array of possible complications.

With ventilators in short supply, doctors are looking for more ways to help patients with coronavirus who are short of breath. The Daily Telegraph reports that a statement from the Intensive Care Society, along with the Faculty of Intensive Care Medicine, said it appears that simply lying on your front could aid some sufferers, and can even help to avoid using a ventilator at all in some cases.

Laying someone on their front, or “proning”, is a technique usually applied to unconscious patients who are using ventilators. But there is suggestion that it can also be effective for other people with coronavirus. “The Italians who are ahead of us said that proning even awake patients has an impact”, says Dr Alison Pittard, dean of the faculty of intensive care medicine at the Royal College of Anaesthetists.

The ICS says in the introductory remarks to its guidelines:

Over the last two decades randomised controlled trials have consistently demonstrated that oxygenation can be significantly improved in patients with acute respiratory distress syndrome (ARDS) when ventilated in the prone position. (Early trials of prone ventilation failed to demonstrate any impact on mortality, although these trials were conducted in an era prior to lung protective ventilation, often had patients proned for short periods and included patients with mild ARDS. As trial design evolved to include modern ventilation practices along with patients with more severe ARDS, evidence emerged that the early application of prolonged prone positioning may significantly decrease mortality compared to conventional supine ventilation.

This stance has been further supported by a recent meta-analysis that concludes mechanical ventilation in the prone position significantly reduces mortality in patients with moderate to severe ARDS when used early and for greater than 16 hours per day in patients receiving lung protective ventilation.  In addition, a Cochrane systematic review published in 2015 recommends that prone ventilation for 16 or more hours per day should be actively considered in patients with severe hypoxaemia within 48 hours of mechanical ventilation. This has also led to the inclusion of prone ventilation in the ARDS guidance published by the Intensive Care Society (ICS) and Faculty of Intensive Care Medicine (FICM). 

These recommendations would suggest the use of early prone ventilation for moderate to severe hypoxaemia and potentially an increase in the number of patients that should be considered for proning. The increase in use of the prone position in critical care may have been partially responsible for a spike in critical incidents reported to NHSi over recent years. At the end of 2017, NHSi approached the ICS/FICM Joint Standards Committee (JSC), keen to draw our attention to this increase in incidents and with the hope that the committee might identify a strategy to reduce the number of incidents moving forward. 

With this in mind the ICS/FICM JSC performed a national survey of its members to identify current practices across the UK and to identify whether there was a need for a national guidance on managing patients in the prone position. 

The survey confirmed that 80% of respondents would routinely prone a patient with refractory hypoxia, intimating that there has been widespread acceptance of prone ventilation as a treatment strategy in these circumstances. Interestingly the survey identified that only 30% of respondents worked within a unit that used a specific prone ventilation protocol/checklist to facilitate the procedure of turning a patient prone. Only 58% of units used a post-proning protocol or guidance regarding how to nurse patients in this often, unfamiliar position. Surveyed members reported personal experience with wide array of complications including; 

• Pressure sores (most cited injury) • Facial / periorbital oedema
• IV line / ETT displacement
• CVS instability 
• Ocular injury/corneal abrasions
• Brachial plexus injury
• Staff injury
• CRRT line flow problems 

Most of these complications are preventable and it is hoped that the adoption of the guidance set out within this document will help improve safety and reduce complications associated with the prone positioning of mechanically ventilated patients. This document also hopes to standardise the approach to managing a cardiac arrest in the prone position, and has some guidance on prone ventilation in ECMO patients as well as considerations for performing bronchoscopy in the prone position. Assuming adequate staffing and equipment is available, the intervention of prone positioning involves very low costs and provided additional patient complications and long-term injuries to staff do not occur, would almost certainly be a cost-effective intervention. 

The Telegraph writes that proning could help you breathe in two ways. Firstly, gravity will draw blood down into the front of your lungs where it can more easily pick up oxygen from the air. “It’s about trying to make sure the blood going through the lungs has the ability to get as much oxygen as possible”, says Pittard. Secondly, it can release your lungs from the weight of your heart, stomach and belly, which can help them to further expand and take in air.

For this reason, there is some suggestion that the technique can be especially effective for overweight and obese patients with big bellies that press down on their lungs when they lie flat. “If you’re overweight then your abdomen contents will be heavier and will have more impact on your breathing”, says Pittard.

However, the report says, proning is far from a miracle cure – and it's benefits don't apply to everyone. For example, says Dr James Dodd, a senior lecturer in respiratory medicine at the University of Bristol, it can have greater risk for overweight patients: “If someone has a big tummy then it works both ways”, he says. “If you’re obese and lying on your front, a big tummy can push your lungs and diaphragm up that way.” Similarly, proning is not recommended for pregnant women.

Ultimately, proning is not a universal treatment, says Pittard: “It depends on what the condition of the lungs is and you can't predict who it will work for until you try it.” If it is more comfortable for you, then give it a go. If it isn’t, then get up, have a potter round the house and lie propped up on pillows.

Guidance

Full report in The Daily Telegraph

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