With the country facing an unprecedented medical crisis and our healthcare system collapsing under its weight, doctors have been recommending ways to manage COVID symptoms at home.
One such recommendation has been the technique called 'proning' or lying in the 'prone position', which is said to increase the oxygen levels in patients who either experience breathlessness or a dip in their oxygen level.
The Ministry of Health and Family Welfare (MoHFW), too, has released detailed guidelines on proning, as a self-care measure for COVID patients.
What is proving? How does it help COVID patients? When should you do it, and how to do it right?
FIT spoke to Dr Rajesh Kumar Pande, Senior Director & HOD, Critical Care, BLK-Max Super Speciality Hospital, and Dr Praveen Gupta, Director and Head of Department, Neurology, Fortis Memorial Research Institute, Gurugram, to break it down.
What is Prone Position?
First things first, what is 'proning'?
'Proning' is not an exercise, but more of a manoeuvre or as the name suggests, a 'position'.
“In this, the patient is made to lie down on their chest and stomach and take deep breaths.”Dr Praveen Gupta, Director and Head of Department, Neurology, Fortis Memorial Research Institute, Gurugram.
"This position helps in improving oxygen flow in patients who are critical, in turn ensuring that they are less likely to require ventilator support," he adds.
It Isn't a Particularly New Technique
Pande explained how 'proning' has been practised by medical professionals for years in non-COVID scenarios.
He told us about a study conducted in France 10 years ago that showed that patients with acute respiratory failure were helped with proning.
“The study showed that proning patients with moderate to acute respiratory distress syndrome (ARDS) who are on ventilators for at least 16 hours, significantly decreased mortality, especially when compared to other cases where everything else, except proning, was done.”Dr Rajesh Kumar Pande, Senior Director & HOD, Critical Care, BLK-Max Super Speciality Hospital
Since then proning in ventilated patients has become a norm, especially for those who have ARDS or severe respiratory failure.
How Proning Helps
Pande explained this with an analogy.
"Our lungs are like a collection of millions of little balloons that inflate and deflate with every breath," he says. The round shape of these alveoli is retained in a healthy person, even as they deflate.
"In severe respiratory failure, these get inflated when you breathe in, but instead of the balls retaining their shape, they collapse when you exhale."
This is a pulmonary problem that COVID patients face.
Moreover, "When a person is lying in the supine position (on their backs), the heart is pressing on the lungs. Because of this certain parts of the lungs are not able to fully inflate."
“But when we put the ventilated patients in the prone position, the weight of the heart falls on the breastbone and the chest wall, allowing the lungs to inflate fully, allowing better aeration.”Dr Rajesh Kumar Pande, Senior Director & HOD, Critical Care, BLK-Max Super Speciality Hospital
According to Pande, other ways in which proning helps patients with acute respiratory failure are:
- The homogenous distribution of ventilation and improvement of overall oxygenation
- Very good matching of ventilation (lung inflation) with perfusion (blood supply)
- Due to gravity, secretions in the lungs also come out reducing the risk of ventilator-associated pneumonia.
Proning in COVID
When it comes to COVID-related respiratory failure, Pande speaks of two types of cases, one is the type of patients who don't feel any outward symptoms or discomfort, a condition dubbed 'happy hypoxia'.
The other is the section that comprises patients who experience the classic symptoms of severe hypoxia, and classic respiratory failure.
"This is one of the more critical dangers of COVID, especially considering the fact that young patients with happy hypoxia can rapidly develop severe respiratory failure," he said. "This is how proning has come into the picture here," he added.
“As medical professionals, we are trying to find ways to prevent further deaths from COVID-19 and “proning” is one such technique.”Dr. Praveen Gupta, Director and Head of Department, Neurology, Fortis Memorial Research Institute, Gurugram
"In the initial stage, when the disease is not so severe, we ask patients to lie down in a prone position when they start experiencing difficulty breathing," Pande said.
He spoke of his patients who have benefitted from it.
“A lot of my own patients said that they felt much better when they practised this technique. People can even night prone with an oxygen mask.”Dr Rajesh Kumar Pande, Senior Director & HOD, Critical Care, BLK-Max Super Speciality Hospital
But It Has Limitations
Proning has not been scientifically tested in this situation. Rather, the benefits observed in the ventilator study have been extrapolated here.”Dr Rajesh Kumar Pande, Senior Director & HOD, Critical Care, BLK-Max Super Speciality Hospital
For this reason, it is difficult to say with absolute certainty that it works and the extent to which it is effective.
"The only thing we need is to scientifically back it up. But right now, to do a controlled study, in the current scenario would be very difficult," he says.
That being said, Pande spoke of how doctors around the world had noticed a significant difference in their patients when pratising proning.
“There is no adverse effect related to the position. However, we must keep in mind that proning is not the sole solution to improve oxygen level and it should be complemented with other necessary treatments.”Dr Praveen Gupta, Director and Head of Department, Neurology, Fortis Memorial Research Institute, Gurugram
Pande also said, “Proning should only be done when you feel breathless or if you find your oxygen level dropping”.
If you're experiencing any COVID symptoms or are self-quarantining, you can monitor your oxygen level using a pulse-oximeter.
How to Read an Oximeter Right
Pande explained, "Oxygen levels of 94 and above are considered acceptable in those who are breathing room air, containing 20 percent oxygen."
If you have COVID and are self-treating at home, it's important you know how to read the oximeter correctly.
Before that, though, it's important you have the right kind of oximeter.
Pande suggested buying a portable pulse-oximeter that shows both the heart rate and a graph (plethysmograph), over the finger probe that only give values.
What Can Cause Errors in Reading?
Pande enumerated obstructions that can cause inaccurate readings:
- In case of finger probes, if the finger is not profused well.
This can happen in people who have low blood pressure, as blood flow to the fingertips in such people will be relatively lower.
- Other obstructions such as nail paint, can also affect the reading.
- Another limitation of the device itself is that it may not be very accurate when it comes to showing lower values as it is with higher values.
(This was first published on FIT.)
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