Proning

What is proning?

Proning is when healthcare providers move someone from lying on their back (supine position) to lying on their front, face-down (prone position). Healthcare providers use it to help people with certain serious respiratory conditions get more oxygen.

Healthcare providers usually prone people who are on mechanical ventilation (prone ventilation). Many providers work together to move them into the prone position.

More people are aware of proning now because of its use to treat people with COVID-19, but it’s not a new thing. Providers have used it for several decades. Studies suggest it can significantly reduce mortality (death) rates in certain people with severe respiratory illness on mechanical ventilation if done early.

What conditions does proning treat?

Providers use proning to help get more oxygen to people with severe respiratory conditions who aren’t getting enough (hypoxia). Most commonly, it’s used in acute respiratory distress syndrome (ARDS). ARDS causes fluid to collect in your alveoli, the small air sacs in your lungs. This makes it hard to breathe. ARDS is a serious complication of many respiratory illnesses, including COVID-19 and pneumonia.

Why does proning improve oxygen levels (oxygenation)?

The reason proning works is largely because our bodies aren’t symmetrical. Proning does two things to get more oxygen to your body. It:

• Decreases the amount of weight and compression on your lungs, allowing more air to get to your alveoli (improved ventilation).
• Improves your lung efficiency by getting oxygen to the parts of your lungs that get the most blood flow (improved gas exchange).

Improved ventilation

Because of the way human bodies are shaped, you have more lung tissue toward your back than your chest. When you’re lying on your back, excess fluid presses on your alveoli, preventing them from completely filling with air. Your heart and abdominal organs at the front of your body also put pressure on your lungs when you’re lying on your back.

When you’re lying on your belly in the prone position, the weight of your heart and abdominal organs rests on your chest instead of your lungs. Fluid in your lungs compresses a smaller area of lung tissue. This leaves the larger area of your lungs at your back available to hold air.

Improved gas exchange

During ARDS, there’s a mismatch between the amount of oxygen that’s getting into your lungs (ventilation) and the amount that’s getting into your bloodstream (perfusion). Your blood carries oxygen from your lungs to the rest of your body. Ideally, you’d have the same amount of ventilation and perfusion.

Meanwhile, the back part of your lungs gets better blood flow than the front, no matter what position you’re in. When you’re in the prone position, not only are you opening up more alveoli so you can get more oxygen to your lungs, you’re getting the oxygen to the part of your lungs that has better blood flow. This makes breathing more efficient, with ventilation and perfusion more closely matched.

How do providers move you to the prone position?

Several providers work together to safely move you into a prone position. There might be two to three providers on either side of the bed, led by a respiratory therapist at the head of the bed. They’ll coordinate together any time they’re moving you, on the respiratory therapist’s count of three. This ensures they’re moving you as safely as possible.

One or more providers will:

1. Make sure any wires and tubes are secured safely so they don’t get tangled during proning. Sometimes they’ll remove EKG leads (sticky patches on your skin that detect your heart’s electrical activity). The respiratory therapist will hold your neck and the tube going into your mouth before anyone moves you.
2. Roll you partially onto one side, then the other, to get a sheet underneath you.
3. Lay a sheet, pillows and another sheet on top of you — over your chest, arms and legs.
4. Roll the edges of the sheets on each side of the bed together to securely grip them.
5. Move you all the way to one side of the bed and close to the head of the bed.
6. Roll you up onto one side.
7. Check any lines and tubes to make sure they’re still in the correct position.
8. Turn you onto your stomach, now on top of the pillows and sheets.
9. Put a pillow under your neck and head.
10. Reattach any leads.

These are the general steps providers use to get someone into the prone position, but different hospitals might do it slightly differently. Sometimes, they’ll also use special equipment to help.

How long will I need to be in the prone position?

Providers can see improvement in your oxygen levels in as little as one hour, but they’ll usually keep you prone for 12 to 18 hours to see if you improve. If you do, they’ll keep you in the prone position for at least 16 hours per session and return you to a supine position in between.

What are the potential benefits of proning?

In addition to improving your oxygen levels, proning can also:

• Open up the blood vessels in your lungs and allow your heart to pump better.
• Help your lungs drain mucus better.

Improving your oxygen levels might also allow you to come off a ventilator or oxygen treatment sooner. All of these factors reduce your risk of dying from serious respiratory issues.

How successful is proning?

Studies suggest lying in the prone position for at least 12 hours a day significantly decreases mortality rates in people with ARDS. In a study from 2013, people receiving mechanical ventilation who were prone for at least 16 hours a day showed a significant reduction in mortality compared to people who were in the supine position.

What are the risks or side effects of proning?

Your healthcare providers get you into a prone position in a specific way to reduce your risk of complications or injuries. But there are still some risks, including:

• Accidental removal of your endotracheal tube (tube that helps you breathe through the ventilator).
• Loss of tubes that deliver fluids and medicines to your veins (venous catheter).
• Problems with your blood pressure or heart, including hemodynamic instability, low blood pressure or irregular heart rate (arrhythmia).
• Temporary decreases in oxygen levels.
• Blockage of your airways.

These risks go down significantly in healthcare centers that have more than five years of experience proning.

Does proning reduce mortality in COVID-19?

Yes. Studies suggest that people who are hospitalized with COVID-19 are both more likely to survive and less likely to need mechanical ventilation (a ventilator) when they’re put in the prone position for at least 12 hours per day.

What is awake proning?

Rarely, a provider will recommend that someone with a less serious respiratory condition move themselves into the prone position (awake proning). This might improve their breathing and prevent them from needing a ventilator. If your provider recommends this, they’ll help you safely move into the prone position.

A note from Cleveland Clinic

It can be scary to watch someone you love experience serious illness in the hospital — or go through it yourself. Wires, tubes and beeping machines can feel overwhelming in an already stressful time. You might not always know why healthcare providers select a specific treatment or do something in a certain way.

Proning is a tool providers can use to help other treatments be more successful. Providers turn you face-down on your belly to help increase the amount of oxygen that gets to your lungs and the rest of your body. While no treatment is guaranteed, studies support proning as a way to reduce mortality and time on a ventilator.