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.

ResusReview's Checklist

Proning Checklist

Article on the Physiology of Proning

Eur Resp J 2002;20(4):1017

Meta-Analysis of RCTs on Proning

Crit Care Med 2014;42(5):1252

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 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 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,