-
Intensive Care Medicine Dec 2020In ARDS patients, the change from supine to prone position generates a more even distribution of the gas-tissue ratios along the dependent-nondependent axis and a more... (Review)
Review
In ARDS patients, the change from supine to prone position generates a more even distribution of the gas-tissue ratios along the dependent-nondependent axis and a more homogeneous distribution of lung stress and strain. The change to prone position is generally accompanied by a marked improvement in arterial blood gases, which is mainly due to a better overall ventilation/perfusion matching. Improvement in oxygenation and reduction in mortality are the main reasons to implement prone position in patients with ARDS. The main reason explaining a decreased mortality is less overdistension in non-dependent lung regions and less cyclical opening and closing in dependent lung regions. The only absolute contraindication for implementing prone position is an unstable spinal fracture. The maneuver to change from supine to prone and vice versa requires a skilled team of 4-5 caregivers. The most frequent adverse events are pressure sores and facial edema. Recently, the use of prone position has been extended to non-intubated spontaneously breathing patients affected with COVID-19 ARDS. The effects of this intervention on outcomes are still uncertain.
Topics: Humans; Lung Compliance; Prone Position; Respiratory Distress Syndrome; Respiratory Mechanics
PubMed: 33169218
DOI: 10.1007/s00134-020-06306-w -
Chest Jan 2017Prone positioning was first proposed in the 1970s as a method to improve gas exchange in ARDS. Subsequent observations of dramatic improvement in oxygenation with simple... (Review)
Review
Prone positioning was first proposed in the 1970s as a method to improve gas exchange in ARDS. Subsequent observations of dramatic improvement in oxygenation with simple patient rotation motivated the next several decades of research. This work elucidated the physiological mechanisms underlying changes in gas exchange and respiratory mechanics with prone ventilation. However, translating physiological improvements into a clinical benefit has proved challenging; several contemporary trials showed no major clinical benefits with prone positioning. By optimizing patient selection and treatment protocols, the recent Proning Severe ARDS Patients (PROSEVA) trial demonstrated a significant mortality benefit with prone ventilation. This trial, and subsequent meta-analyses, support the role of prone positioning as an effective therapy to reduce mortality in severe ARDS, particularly when applied early with other lung-protective strategies. This review discusses the physiological principles, clinical evidence, and practical application of prone ventilation in ARDS.
Topics: Humans; Prone Position; Pulmonary Gas Exchange; Respiratory Distress Syndrome; Respiratory Mechanics; Treatment Outcome
PubMed: 27400909
DOI: 10.1016/j.chest.2016.06.032 -
Chest Feb 2023Prone positioning is an immediately accessible, readily implementable intervention that was proposed initially as a method for improvement in gas exchange > 50 years... (Meta-Analysis)
Meta-Analysis Review
Prone positioning is an immediately accessible, readily implementable intervention that was proposed initially as a method for improvement in gas exchange > 50 years ago. Initially implemented clinically as an empiric therapy for refractory hypoxemia, multiple clinical trials were performed on the use of prone positioning in various respiratory conditions, cumulating in the landmark Proning Severe ARDS Patients trial, which demonstrated mortality benefit in patients with severe ARDS. After this trial and the corresponding meta-analysis, expert consensus and societal guidelines recommended the use of prone positioning for the management of severe ARDS. The ongoing COVID-19 pandemic has brought prone positioning to the forefront of medicine, including widespread implementation of prone positioning in awake, spontaneously breathing, nonintubated patients with acute hypoxemic respiratory failure. Multiple clinical trials now have been performed to investigate the safety and effectiveness of prone positioning in these patients and have enhanced our understanding of the effects of the prone position in respiratory failure. In this review, we discuss the physiologic features, clinical outcome data, practical considerations, and lingering questions of prone positioning.
Topics: Humans; Prone Position; COVID-19; Pandemics; Respiratory Insufficiency; Respiratory Distress Syndrome; Patient Positioning
PubMed: 36162482
DOI: 10.1016/j.chest.2022.09.020 -
Seminars in Respiratory and Critical... Feb 2019Prone positioning is nowadays considered as one of the most effective strategies for patients with severe acute respiratory distress syndrome (ARDS). The evolution of... (Review)
Review
Prone positioning is nowadays considered as one of the most effective strategies for patients with severe acute respiratory distress syndrome (ARDS). The evolution of the pathophysiological understanding surrounding the prone position closely follows the history of ARDS. At the beginning, the focus of the prone position was the improvement in oxygenation attributed to a perfusion redistribution. However, the mechanisms behind the prone position are more complex. Indeed, the positive effects on oxygenation and CO clearance of the prone position are to be ascribed to a more homogeneous inflation-ventilation, to the lung/thoracic shape mismatch, and to the change of chest wall elastance. In the past 20 years, five major trials have tried, starting from different theories, hypotheses, and designs, to demonstrate the effectiveness of the prone position, which finally found its definitive place among the different ARDS supportive therapies.
Topics: Carbon Dioxide; Humans; Oxygen; Patient Positioning; Prone Position; Respiratory Distress Syndrome
PubMed: 31060091
DOI: 10.1055/s-0039-1685180 -
JAMA Oct 2020
Topics: Humans; Moving and Lifting Patients; Patient Positioning; Prone Position; Respiratory Distress Syndrome
PubMed: 32821908
DOI: 10.1001/jama.2020.14901 -
Journal of Clinical Anesthesia Nov 2021To review the effects of prone position and supine position on oxygenation parameters in patients with Coronavirus Disease 2019 (COVID-19). (Meta-Analysis)
Meta-Analysis
STUDY OBJECTIVE
To review the effects of prone position and supine position on oxygenation parameters in patients with Coronavirus Disease 2019 (COVID-19).
DESIGN
Systematic review and meta-analysis of non-randomized trials.
PATIENTS
Databases of EMBASE, MEDLINE and CENTRAL were systematically searched from its inception until March 2021.
INTERVENTIONS
COVID-19 patients being positioned in the prone position either whilst awake or mechanically ventilated.
MEASUREMENTS
Primary outcomes were oxygenation parameters (PaO₂/FiO₂ ratio, PaCO₂, SpO₂). Secondary outcomes included the rate of intubation and mortality rate.
RESULTS
Thirty-five studies (n = 1712 patients) were included in this review. In comparison to the supine group, prone position significantly improved the PaO₂/FiO₂ ratio (study = 13, patients = 1002, Mean difference, MD 52.15, 95% CI 37.08 to 67.22; p < 0.00001) and SpO₂ (study = 11, patients = 998, MD 4.17, 95% CI 2.53 to 5.81; p ≤0.00001). Patients received prone position were associated with lower incidence of mortality (study = 5, patients = 688, Odd ratio, OR 0.44, 95% CI 0.24 to 0.80; p = 0.007). No significant difference was noted in the incidence of intubation rate (study = 5, patients = 626, OR 1.20, 95% CI 0.77 to 1.86; p = 0.42) between the supine and prone groups.
CONCLUSION
Our meta-analysis demonstrated that prone position improved PaO₂/FiO₂ ratio with better SpO₂ than supine position in COVID-19 patients. Given the limited number of studies with small sample size and substantial heterogeneity of measured outcomes, further studies are warranted to standardize the regime of prone position to improve the certainty of evidence. PROSPERO Registration: CRD42021234050.
Topics: COVID-19; Humans; Prone Position; Respiration, Artificial; SARS-CoV-2; Supine Position
PubMed: 34182261
DOI: 10.1016/j.jclinane.2021.110406 -
Sports Health Jul 2016Prone, supine, and side position exercises are employed to enhance core stability.
BACKGROUND
Prone, supine, and side position exercises are employed to enhance core stability.
HYPOTHESIS
Overall core muscle activity would be greater in prone position exercises compared with supine and side position exercises.
STUDY DESIGN
Controlled laboratory study.
METHODS
Eighteen men and women between 23 and 45 years of age served as subjects. Surface electrodes were positioned over the upper and lower rectus abdominis, external and internal obliques, rectus femoris, latissimus dorsi, and lumbar paraspinals. Electromyography data were collected during 5 repetitions of 10 exercises, then normalized by maximum voluntary isometric contractions (MVIC). Differences in muscle activity were assessed using 1-way repeated-measures analysis of variance, while t tests with a Bonferroni correction were employed to assess pairwise comparisons.
RESULTS
Upper and lower rectus abdominis activity was generally significantly greater in the crunch, bent-knee sit-up, and prone position exercises compared with side position exercises. External oblique activity was significantly greater in the prone on ball with right hip extension, side crunch on ball, and side bridge (plank) on toes compared with the prone and side bridge (plank) on knees, the crunch, or the bent-knee sit-up positions. Internal oblique activity was significantly greater in the prone bridge (plank) on ball and prone on ball with left and right hip extension compared with the side crunch on ball and prone and side bridge (plank) on knees positions. Lumbar paraspinal activity was significantly greater in the 3 side position exercises compared with all remaining exercises. Latissimus dorsi activity was significantly greater in the prone on ball with left and right hip extension and prone bridge (plank) on ball and on toes compared with the crunch, bent-knee sit-up, and prone and side bridge (plank) on knees positions. Rectus femoris activity was significantly greater in the prone on ball with left hip extension, bent-knee sit-up, or prone bridge (plank) on toes compared with the remaining exercises.
CONCLUSION
Prone position exercises are good alternatives to supine position exercises for recruiting core musculature. Side position exercises are better for oblique and lumbar paraspinal recruitment.
CLINICAL RELEVANCE
Because high core muscle activity is associated with high spinal compressive loading, muscle activation patterns should be considered when prescribing trunk exercises to those in which high spinal compressive loading may be deleterious.
Topics: Abdominal Muscles; Adult; Back Muscles; Electromyography; Exercise; Female; Humans; Male; Middle Aged; Posture; Prone Position; Sports Equipment; Supine Position; Young Adult
PubMed: 27302152
DOI: 10.1177/1941738116653931 -
Intensive Care Medicine Jun 2024
Topics: Humans; Prone Position; Patient Positioning
PubMed: 38656358
DOI: 10.1007/s00134-024-07413-8 -
Respiratory Care May 2021
Topics: Humans; Lung; Noninvasive Ventilation; Patient Positioning; Prone Position; Respiratory Distress Syndrome
PubMed: 33931520
DOI: 10.4187/respcare.09131 -
Medicine, Science, and the Law Jul 2021Deaths occurring among agitated or violent individuals subjected to physical restraint have been attributed to positional asphyxia. Restraint in the prone position has... (Review)
Review
Deaths occurring among agitated or violent individuals subjected to physical restraint have been attributed to positional asphyxia. Restraint in the prone position has been shown to alter respiratory and cardiac physiology, although this is thought not to be to the degree that would cause asphyxia in a healthy, adult individual. This comprehensive review identifies and summarizes the current scientific literature on prone position and restraint, including experiments that assess physiology on individuals restrained in a prone position. Some of these experimental approaches have attempted to replicate situations in which prone restraint would be used. Overall, most findings revealed that individuals subjected to physical prone restraint experienced a decrease in ventilation and/or cardiac output (CO) in prone restraint. Metabolic acidosis is noted with increased physical activity, in restraint-associated cardiac arrest and simulated encounters. A decrease in ventilation and CO can significantly worsen acidosis and hemodynamics. Given these findings, deaths associated with prone physical restraint are not the direct result of asphyxia but are due to cardiac arrest secondary to metabolic acidosis compounded by inadequate ventilation and reduced CO. As such, the cause of death in these circumstances would be more aptly referred to as "prone restraint cardiac arrest" as opposed to "restraint asphyxia" or "positional asphyxia."
Topics: Acidosis; Cardiac Output; Cause of Death; Death, Sudden; Heart Arrest; Humans; Prone Position; Respiratory Physiological Phenomena; Restraint, Physical
PubMed: 33629624
DOI: 10.1177/0025802420988370