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Lippincott Nursing Pocket Card - May 2020

Prone Positioning: Non-Intubated Patient with COVID-19 ARDS

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Benefits of Prone Positioning

Based on the progress made in mechanically ventilated patients, it has been theorized that adopting the prone position for conscious, non-intubated patients with COVID-19 ARDS may help improve oxygenation, reduce the need for invasive ventilation and potentially decrease mortality. The potential physiologic benefits include:

  • Improved ventilation (V)/perfusion (Q) matching and reduced hypoxemia
  • Reduced shunt
  • Recruitment of the posterior lung segments due to reversal of atelectasis
  • Improved clearance of secretions

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Criteria and Contraindications

Criteria for Prone Positioning

For the conscious patient who is not receiving mechanical ventilation, consider these criteria for prone positioning:
  • Suspected or confirmed COVID-19 infection
  • FiO2 greater than or equal to 28% or requiring basic respiratory support to achieve SaO2 92 to 96% (88 to 92% if risk of hypercapnic respiratory failure)
  • Ability to communicate and cooperate with the procedure
  • Ability to rotate to front and adjust position independently
  • Absence of anticipated airway issues

Contraindications

Evaluate patient for the following absolute and relative contraindications:

Absolute contraindications
  • Respiratory distress
  • Immediate need for intubation
  • Hemodynamic instability (SBP less than 90 mmHg) or arrhythmia
  • Agitation or altered mental status
  • Unstable spine/thoracic injury/recent abdominal surgery
 
Relative Contraindications:
  • Facial injury
  • Neurological issues (e.g. frequent seizures)
  • Morbid obesity
  • Pregnancy (2nd/3rd trimesters)
  • Pressure injuries

Procedure

  1. Assist patient to prone position.
  • Explain the procedure.
  • Ensure oxygen therapy and basic respiratory support; make sure there is adequate length of tubing.
  • Use pillows, as needed, to support the chest.
  • Reverse Trendelenburg position may aid comfort.
  • Monitor oxygen saturation.
  • Don’t administer sedation to facilitate prone positioning.
  1. Monitor oxygen saturation for 15 minutes.
  • Goal is SaO2 92 to 96%; 88 to 92% if risk of hypercapnic respiratory failure
  1. Continue prone positioning.
  • Change position every 1 to 2 hours with the goal of keeping the patient prone as long as possible.
  • Use timed position changes; ask the patient to switch positions as follows:
    • 30 minutes to 2 hours lying fully prone (bed flat)
    • 30 minutes to 2 hours lying on right side (bed flat)
    • 30 minutes to 2 hours sitting up (30 to 60 degrees) by adjusting head of the bed
    • 30 minutes to 2 hours lying on left side (bed flat)
    • 30 minutes to 2 hours lying prone again
    • Continue to repeat the cycle.
  • Monitor oxygen saturations 15 minutes after each position change to ensure oxygen saturation has not decreased.
  • Continue to monitor oxygen saturations as per the National Early Warning Score (NEWS).
  • When not prone, position patient supine, upright 30 to 60 degrees.
  • Titrate oxygen therapy according to patient requirements, as ordered.

If Prone Positioning is Not Tolerated

If oxygen saturations deteriorate, take the following steps:

  • Ensure oxygen is connected to patient.
  • Increase FiO2 (per facility policy or prescriber’s order).
  • Change patient position; consider return to supine position.
  • Escalate to critical care, as appropriate.
 
Discontinue prone positioning if:
  • No improvement is seen with change of position.
  • The patient is unable to tolerate position.
  • Respiratory rate increases to 35 breaths/minute or higher, the patient tires, or uses accessory muscles.
Reference:

Bamford, P., Bentley, A., Dean, J., Whitmore, D. & Wilson-Baig, N. (2020). ICS Guidance for Prone Positioning of the Conscious COVID Patient 2020. Retrieved from https://emcrit.org/wp-content/uploads/2020/04/2020-04-12-Guidance-for-conscious-proning.pdf

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