Union govt guideline says timely proning and maintaining good ventilation could save many lives.

A man has a pulse oximeter on his finger as his hands are placed on his thighImage for representation, Picxy.com/Jo7gtz
Coronavirus Coronavirus Saturday, May 01, 2021 - 13:19

At a time when much of India including Delhi and Uttar Pradesh are experiencing a massive medical oxygen shortage in this second wave of COVID-19 crisis, many doctors are advising patients, who are in home isolation, to lie on their stomachs - known as proning - to help improve oxygen levels. While it may help some patients restore healthy blood oxygen levels (SpO2 or blood oxygen saturation), more crucially it can help buy time for critical patients until adequate medical attention can be arranged, doctors told TNM.

According to the Union government guidelines, proning is the process of turning a patient with precise, safe motions, from their back onto their abdomen (stomach), so the individual is lying face down. Timely proning and maintaining good ventilation could save many lives, it says.

Dr Rajavardhan R, Consultant Intensivist at Manipal Hospital Whitefield in Bengaluru said, “Proning definitely helps in improving the oxygen levels. It improves ventilation and perfusion (circulation of blood through tissues). That means when more air is going in the lung, there will be more blood going to the tissues. This can be a low-risk, low-cost manoeuvre which can help patients with COVID-19 pneumonia delay or reduce the need for intensive care.”

But he cautioned that for critical patients, it’s not a cure. “Once they turn back, it will go back to the same levels. It's a measure taken so that it gives some time for medicines to act in critical care conditions. He said all hospitals are following this in the emergency, ICU and wards.”

He suggested that patients should not depend on proning alone if there is medical help available. “Some people might get false confidence looking at the numbers and might turn up late to the hospital,” he warned.

Dr Prashanth NS, a medical doctor and public health researcher at the Institute of Public Health, Bengaluru, too said, “Awake prone position is a well known and safe measure that can be advised for COVID-19 patients who are isolating at home, especially if their oxygen saturation begins to fall towards 90%”.

“By putting ourselves in a prone position, we change the configuration and pressure within the chest cavity such that the air we breathe can more efficiently come in contact with lung areas that are not affected by the fluid and inflammation. Wherever it is feasible without disrupting the patient, this can be undertaken periodically by the patient at home,” he explained.

He opined that proning can work best if there is tele-support with qualified medical volunteers who can guide patients. He said evidence-based crowdsourced COVID-19 resources such as indiacovidsos.org has instructions in multiple Indian languages.

LIke Dr Dr Rajavardhan, Dr Prashanth said patients with falling saturation require oxygen support. “If there is too much fluid and inflammation in lungs there is no way that exercises can help. Awake proning works only in cases where there is moderate involvement of the lungs,” he said.

The Union government guidelines say, “Proning is required only when the patient feels difficulty in breathing and the SpO2 decreases below 94 (less than 94). Regular monitoring of SpO2, along with other signs like temperature, blood pressure and blood sugar, is important during home isolation.”

It added, “Missing out on hypoxia (compromised oxygen circulation) may lead to worsening of complications. Timely proning and maintaining good ventilation could save many lives.”

Union govt recommended pillow positions

One pillow below the neck

One or two pillows below the chest through upper thighs

Two pillows below the shins

The guideline says that one should alternate their lying position (lying on either side and sitting up) and it is best not to spend more than 30 minutes in each position.

Who can’t prone

Proning is to be avoided in times of pregnancy, deep venous thrombosis (treated in less than 48 hours), major cardiac conditions and for patients with unstable spine, femur or having pelvic fractures.

History of proning as medical intervention

According to Wired, Dr Robert Brown and nurse Margaret Piehl in the US had co-authored a paper in 1976 where they noted that proning had benefited five patients with “potentially deadly fluid build-up in the lungs”. Since then proning has been widely used by doctors all over the world to treat patients with respiratory distress.

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