What is Proning and How Does it Help In Fighting With COVID-19?

The SARS-CoV-2 virus causes pneumonia, which is identified by fever, dyspnea, and acute respiratory symptoms and is known as COVID-19. This disease worsens in some patients, resulting in pulmonary edoema, multi-organ failure, and acute respiratory distress syndrome (ARDS).

The prevalence of ARDS among COVID-19 patients has been reported to be as high as 17%. Among the treatment methods for ARDS patients that have been introduced, the prone position can be used as an adjuvant therapy to improve ventilation in these patients.

What is Proning?

Proning is a medically accepted position for improving oxygenation that involves lying face down. It is especially beneficial in COVID-19 patients who require or do not require ventilator support. If a patient’s oxygen levels fall below 94 per cent (as measured at home with an oximeter), the patient can lie on their stomach; this position improves ventilation and allows for more comfortable breathing.

The position allows for greater expansion of the dorsal (back) lung regions, improved body movement, and improved secretion removal, which may eventually lead to improvements in oxygenation (breathing).

For decades, prone positioning has been shown to improve oxygenation. However, since the onset of the coronavirus (COVID-19) pandemic, proning in awake, non-intubated patients have gained acceptance. Proning of awake, spontaneously breathing patients gained traction as a means of overcoming a ventilator shortage, reducing the overwhelming burden on intensive care beds during the pandemic era, and also because invasive ventilation was associated with poor outcomes.

It is now a globally accepted therapy to improve oxygenation in COVID-19 patients with acute hypoxemic respiratory failure because it is a low-risk, low-assistance intervention. As a result, we reviewed the literature on awake proning in non-intubated patients and described a safe protocol for doing so.

Importance of Proning


Physical position influences the distribution and volume of air in the lungs, as well as the expansion of the lungs to allow for the exchange of oxygen and carbon dioxide in the blood.

Prone positioning has been used increasingly in the treatment of patients with Acute Respiratory Distress Syndrome (ARDS) in recent years, and it is now considered a simple and safe method of improving oxygenation. It is a medically accepted procedure that involves turning a patient from their back onto their abdomen with precise, safe motions so that the individual is lying face down to improve breathing.

Only when the patient’s breathing becomes difficult and his or her SpO2 drops below 94 per cent do proning become necessary. During home isolation, it is critical to monitor SpO2 as well as other vital signs such as temperature, blood pressure, and blood sugar on a regular basis. Missing out on Hypoxia (impaired oxygen circulation) may worsen complications.

Physiological effects of proning


The heart and abdominal organs compress the lungs in the supine position. In areas of collapsed lungs, gas exchange, or the process of exchanging carbon dioxide for oxygen, is reduced, resulting in low oxygen levels. Lung compression improves lung function less in the prone position.

The body has mechanisms in place to regulate blood flow to different parts of the lung. Prone positioning more evenly distributes blood and airflow, reducing the imbalance and improving gas exchange.

With improved lung function in the prone position, less ventilator support is required to maintain adequate oxygen levels. This may reduce the risk of ventilator-induced lung injury, which occurs as a result of overinflation and excessive stretching of specific lung segments.

In some patients, prone positioning may improve heart function. Blood returns to the chambers on the right side of the heart increase in the prone position, while constriction of the blood vessels of the lung decreases. This may help the heart pump more efficiently, resulting in better oxygen delivery to the body.

Secretions produced by the disease process in the lung may drain better because the mouth and nose are facing down in the prone position.

How does proning help with COVID-19 patients?

Proning improves oxygenation in patients with mild respiratory distress who do not require a ventilator or those who could progress to severe respiratory distress.

There is currently insufficient evidence to prove that proning reduces the need for ventilators in patients. “However, we can see that oxygenation is temporarily improved. This is why, during the COVID-19 pandemic, pronation has become part of the treatment plan.”

Some researchers have reported the use of prone positioning in non-intubated, spontaneously breathing patients receiving standard oxygen therapy, continuous positive airway pressure (CPAP), or non-invasive ventilation. In this setting, prone positioning appears to improve oxygenation and may reduce respiratory effort, which may be especially beneficial in patients at high risk of self-inflicted lung injury.

As a result, this position may postpone or avoid tracheal intubation and its associated risks (both linked to the procedure itself and to subsequent superinfections). In resource-constrained situations, reducing the need for intubation and subsequent ICU admission may also be beneficial. 

At the same time, there may be some risks associated with the change of position (e.g., vomiting, thromboembolism) or delayed intubation with this procedure.

Who requires self proning or awake proning? When should you do it?


In hospitalised intubated patients, proning techniques are used. Recently, self proning or awake proning has been suggested in COVID-19 patients to improve oxygenation.

Note: Self-pronation is a good way to increase oxygen levels at critical times when obtaining medical help may be difficult or to manage symptoms at home. However, keep in mind that it is only one of several methods that provide temporary relief and is not a suitable substitute for hospitalised care or oxygen support.

Not all patients who test positive for coronavirus and are placed on home care require proning. However, for those who are experiencing oxygen deprivation or are waiting for medical assistance, lying down on your stomach can be extremely beneficial.

Proning should be attempted, especially if oxygen levels begin to fall below 94 per cent and continue to fluctuate throughout the day due to a lack of external support.

To sleep in the prone position, one must use a lot of pillows and switch positions every half hour.

What are the precautionary measures that need to be taken?

Please consult your doctor before attempting the self-pronation technique.

  • If you are pregnant, avoid pronating.
  • Avoid pronation for an hour after eating.
  • Maintain pronation for only as many times as is comfortably tolerable.
  • Keep track of any pressure sores or injuries, particularly those near bony prominences.
  • If you have serious cardiac problems, you should avoid pronating.
  • If you have an unstable spine, femur, or pelvic fracture, avoid pronating.

Risks associated with proning include

  • Airway obstruction
  • Dislodgement of the endotracheal tube
  • Pressure-related skin injuries
  • Facial and airway edema (swelling)
  • Hypotension (low blood pressure)
  • Arrhythmias (irregular heartbeat/rate)

When to Interrupt proning?

There is no set time limit for how long a patient should be self-proned. We recommend that awake, self-pronation be continued until the patient is comfortable or has recovered and is maintaining oxygen saturation >96% on room air with no respiratory distress/desaturation on exertion.

Proning should be stopped in a sick patient if there is evidence of increased work of breathing, use of accessory muscles of respiration, failure of oxygenation improvement with proning/further desaturation, or hemodynamic instability/arrhythmias.

An increase in oxygen saturation during awake proning should not be interpreted as an improvement in the disease’s condition. Keep an eye out for signs of respiratory distress or increased work of breathing, which indicate the need to interrupt awake proning and use invasive ventilation. 

The decision to intubate and ventilate invasively should be based on a clinical assessment of work of breathing and other clinical criteria. Delaying intubation solely for the sake of improved oxygenation can have disastrous consequences.

Wrapping It Up

In conclusion, awake, non-intubated patients appear to benefit greatly from self pronation and alternating positioning, with many being able to change positions independently without disrupting the flow of oxygen.

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