Proning is one of the only evidence-based techniques to affect the mortality of ARDS patients. I've ...

1. Podcast 124 – The Logistics of Proning for ARDS
Proning is one of the only evidence-based techniques to affect the mortality of ARDS
patients. I've been wanting to do an episode on proning for a while. Serendipitously, Joseph Tonna
recently published a piece on the topic in the ACEP Critical Care Section Newsletter. Dr. Tonna is a
fellow in Anesthesia Critical Care at the University of Washington. He recently did a rotation on a
refractory ARDs unit (read about all of his experiences below) and learned the way they prone. We
discuss it on the podcast today.
Article on the Physiology of Proning
Eur Resp J 2002;20(4):1017
LITFL's CCC Entry on Proning
Lots of good stuff here
Video on Proning from the Guerin Study
Here is the Dr. Tonna's Original Piece:
Prone Positioning: An experience of actually doing it
by Joseph E. Tonna, MD, Associate Newsletter Editor. This piece was originally published in the

2. ACEP Critical Care Section Newsletter
Most intensivists have read Guérin's 2013 NEJM study on the mortality benefit of prone
positioning. Previous studies [1,2] have established that dorsal consolidations improve when the
patient is placed prone. Taken together, the practice of prone positioning in select patients makes
sense. Despite this, I haven't found that it is done as often as one might infer from the robustness of
its benefit in this study or others. In my experience, while we are likely to notice the profound dorsal
pulmonary consolidations on our patient's CT scans, we don't take the next step and actually prone
the patient until we have already progressed further down the path towards worsening hypoxemia-
-often only when the pO2/FiO2 ratio is well below 150 on upwards of 70% FiO2. At this stage, we
begin to consider the patient "refractory" and allow ourselves to begin the intellectual path of
discussing the evidence for and risk/benefit or cost/benefit of therapies like inhaled nitric oxide
(iNO), epoprostenol, prone positioning, high frequency ventilation, paralysis or extracorporeal
membrane oxygenation (ECMO). The evidence for many of these therapies is thin at best, and given
how infrequently we reach these states of worsening refractory hypoxemia, and gain personal
experience with implementing them, many newly trained intensivists will finish training having
managed no more than a handful of patients on these therapies. As we all know, increased volume
leads to increased comfort and competence; so as part of my fellowship training, I wanted to know
what it looked like to routinely implement these therapies. Did they work? What did this process
actually look like?
Prior to turning a patient prone, the medical team places pillows on the chest, the thighs, and the
feet. Sheets are used to wrap the patient in preparation for proning.
I had the opportunity recently to train at Legacy Emanuel Medical Center in Portland, OR at the
Randall & Emanuel Severe Cardiopulmonary Failure and ECMO (RESCUE) Center under two

3. talented surgical intensivists, Drs. Andrew Michaels and Sandra Wanek. Patients brought to this unit
have already failed conventional therapies for hypoxemic respiratory failure, and often already have
a P/F of <100 on 80-100% FiO2. These patients have not only failed excellent critical care, but most
have failed alternative therapies such as airway pressure release ventilation (APRV), iNO, or
paralysis. Among the therapies implemented the RESCUE center for this subset of patients, prone
positioning is routine.
Who to Prone?
Given the practical risks of proning, I wanted to find out exactly when, why, and how it was done. I
watched the process, participated in it and talked extensively with one of its champions at Legacy
Emmanuel, Christine Lasich, RN. Proning was done in a very simple and sensical way. It was
initiated if the patient had hypoxemia with a P/F of roughly <150 and the thoracic CT scan showed
significant dorsal consolidation. Without dorsal predominant consolidation, even with refractory
hypoxemia, the prone position was not felt to be beneficial.
How to Prone
The way in which the patient was proned was also simple yet effective. All proning at the RESCUE
center was done manually. The patient would have telemetry leads disconnected and have stacked
pillows placed on their chest, lower pelvis and shins in a way to elevate the head, allow the abdomen
to hang free and protect the knees and feet. The patient was then covered in a top sheet above the
pillows and bundled tightly. The flip would involve 3 people per side, with highly experienced people
at the chest and pelvis. Two respiratory therapists would be at the head, one managing the head,
airway and pillow, and another managing the tubing and providing backup. One nurse would
manage the IV lines if they absolutely couldn't be disconnected, though they most often were after
appropriate medication doses (By disconnecting the central lines, the proning movements could be
more brisk and complete without the risk of traumatic removal.) The arterial lines were almost
always unhooked. Most patients were also on ECMO and would have a dedicated nurse at each
cannula. The specialist at the foot of the bed would oversee the whole process and monitor the
bypass circuit. The pulse oximeter would be left until the last minute to monitor saturation and heart
rate. The process was announced overhead prior to flipping so that assistants could begin to free
themselves. One RT would ensure the ETT was taped and secured without hard plastic holders or
bite blocks to avoid oral trauma while the bedside nurse would disconnect the leads, bolus analgesia,
sedation and often paralytics, and ready the patient so that the assistants could step in, participate
in the "time out" and then help flip. As such, additional help was only needed for no more than 5
minutes but during this time, the room had no fewer than 8-9 people plus anyone needed for the
ECMO circuitry. It felt very safe and controlled.
Post-Proning Care
Once prone, meticulous care was given positioning the patient's face, eyes and endotracheal tube
such that pressure points were protected, oral trauma to the lips and gums was avoided, and the
eyes were lubricated and closed. Frequent assessments and adjustments were made of all these
parts to avoid pressure wounds. Given the aforementioned internal jugular ECMO cannulas, patients
were positioned face down in the bed rather than "head to side," and so these frequent assessments
were of utmost importance. The RT or nurse would ensure that at any given time s/he could pass the
endotracheal suction catheter without resistance. It was common in this face down position to have
significant facial and lingual edema, and on speaking with experienced providers and nurses, in most
patients without such cervical limitations, there are distinct advantages to a "head to side" position,
including easier oral care and less edema. Feeding was continued while prone as long as the

4. patient's feeding tube was post pyloric. If not, feeds were held but the total daily goals were
achieved by doubling the feeding rate while supine. I found this ensured the patients continued to
receive adequate nutrition.
The face is padded with a cut-out for the endotracheal tube so that patients can maintain the face-
down position to optimize the function of internal jugular ECMO cannulae.

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was carried out in units of between 4 and 16 hours, with ABGs obtained prior to, 30 minutes after,
and then at 4 hour intervals along the way to assess for trending improvement or zenith. ABGs were
then repeated 30 minutes or so after supination and with these data points, trends could be drawn to
see each patient's optimal duration of prone position. Some patients with dorsal consolidation didn't
show any improvement in their PaO2 after proning. I had been used to the 16h prone/8h supine
approach, without adjustment for changes in PaO2 during the day, and I was surprised to see that
while some patients achieved peak PaO2 late while prone, or peaked early and maintained elevated
PaO2 while prone, others peaked and started to fall by 4 to 6 hours, only to then have a rise in their
PaO2 upon supination.
http://supplychain.broad.msu.edu/
Patients at the RESCUE Center also had initiation of proning whenever or continued as long as the
patient demonstrated the 'inclusion' criteria already mentioned, sometimes two weeks into their
disease course. While many might critique this tailored approach to dynamic PaO2 changes as akin
to the "better PaO2, but higher mortality" of the control arm of the ARDSNet study, it also harkens
to a policy of "intervention, assessment, repeat" that defines not only good critical care but good
medicine. While the Guérin study showed that 16h of prone positioning early in the course was
beneficial, it is not known if intermittent prone positioning (IPP, as it is known) is better or worse. In
the face of empiric data suggesting a benefit and no data to suggest harm, the providers at the
RESCUE center argue that this is simply practical and attentive critical care [3]. While individual
interventions are difficult to isolate among bundled care, the incredible outcomes support them.
Conclusion

6. Over my month I was able to participate in the care of multiple patients transferred for refractory
hypoxemia, who through aggressive yet thoughtful interventions were able to be rescued from
critical condition to a neurologically intact survival. Utilization of prone positioning aggressively and
often was a key component of this care. It made physiologic sense, and had been practiced so often
that the process was regimented and efficient among the staff. The number of staff required for the
actual flip was far more than I had otherwise seen, but the process was also more regimented and, I
thought, safer. I saw daily the benefit of prone positioning and came to ask myself why it wasn't
done earlier and more often, before patients reached "refractory" states of hypoxemia. While many
would argue that without refractory hypoxemia, the risks of prone positioning, especially among
unfamiliar providers exceeds any benefit. It's hard to dispute that it may not be safe to have
unpracticed providers proning patients, I think it's also easy to believe that alveolar recruitment
with improved oxygenation and ventilation leads to lower FiO2s, lower ventilatory pressures, and
less atelectrauma, and fewer invocation of less proven, higher risk therapies. Like all new or
unfamiliar practices, there are risks, yet the marked improvement in oxygenation and ventilation I
saw with routine early prone positioning suggested to me that this was a skill worth learning so that
I too could implement it safely and effectively to the benefit of my patients.
REFERENCES:
1. Gattinoni L, Pelosi P, Vitale G, et al. Body position changes redistribute lung computed-
tomographic density in patients with acute respiratory failure. Anesthesiology. 1991;74(1):15-23.
2. Protti A, Chiumello D, Cressoni M, et al. Relationship between gas exchange response to prone
position and lung recruitability during acute respiratory failure. Intensive Care Med.
2009;35(6):1011-7.
3. Michaels AJ, Wanek SM, Dreifuss BA, et al. A protocolized approach to pulmonary failure and the
role of intermittent prone positioning. J Trauma Acute Care Surg. 2002;52(6):1037-47.
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