Proning in ARDS

Proning patients who suffer from ARDS is a hallmark of treatment, but many do not know the modality by which it helps. Here, I go over the forces that worsen our VQ matching and hypoxemia when supine and how flipping a patient to the prone position helps alleviate that.
If you enjoyed this video, check out more like it on our KZbin channel "Count Backwards from 10" and hit that Subscribe button!
Check out our website at www.countbackw... for more great digital chalk talks!
Follow us on Instagram ( / countbackwardsfrom10 ) for new daily content!
Don’t see a topic you’re looking for, have a question you want explained simply in 10 minutes or less, or interested in getting involved? Head to our “Contact Us” page at www.countbackwardsfrom10.com and you’ll hear back from us before you even get to 0!

[@coribellanoche]

As a veteran neonatologist I am pleased to see that the adult world has taken a page out of the play book from the NICU as we have been "proning" our patients with varying respiratory challenges for thirty years. Greetings David, from Rapid City, SD

[@davidconvissar7055]

Haha this is awesome! You may know my uncle, Steve Benn!

[@coribellanoche]

@@davidconvissar7055 You dork, it is me, your uncle (Coribellanoche.) I have been following your videos - all are well done. I am proud to see how far you have come. Incidentally, it has only been since COVID that "proning" has become a verb. That being said, you did not have to be a competitive weightlifter to "prone" our NICU patients - just sayin'

[@book67891]

I had a bad cold or flu last week and for 1.5 hours while I was trying to sleep on my back I was constantly coughing and I had a lot of gurgling and bubbling of fluid in my lungs. I've had that before so I was not alarmed but it was distressing to think I had the whole night ahead of me. I flipped over to sleep on my stomach and ALL of the bubbling and gurgling in my lungs went away and the coughing reduced to near zero. I was shocked at how dramatic the change was. I was basically able to sleep the rest of the night. I also slept on my stomach the 2nd night, though I had a little bit of coughing but I was eventually able to sleep most of the night. To sleep on my stomach I sleep with my head on the edge of the pillow so my face is angled slightly down and I prop up my shoulder with 3 folded towels and I also lift my hip on that same side with a crumpled up bedsheet. This reduces the amount of neck rotation needed to sleep on my stomach. Another trick is to add something to keep your head from sliding off the pillow. It's hard to describe but basically I use pillowcase with the T-shirt in the end of it that sticks out from under my pillow and that creates a stop (like a wedge) to prevent my head from sliding off the side of the pillow. I've worked out these tricks for sleeping on my stomach over the past 2 years because I find stomach sleeping helps me sleep a lot better. I'm 57 years old and turning my head to the side to sleep on my stomach is more difficult than a younger person, so these methods reduce the amount the head needs to be turned for stomach sleeping.

[@harpreetsingh-nx9rq]

beautiful way of presenting...👍

[@Jamesbradley001]

I just found your channel. Thank you for all of the quality information. This is especially helpful as I am currently working on a COVID ICU as an RN. Keep it up Dr. Convisar!

[@CountBackwardsFrom10]

Brendan, thank you so, so much for your kind comments! my only request is that if you like the content, to subscribe and pass it on to anyone you think it may help! :D I am so, so glad that this helped advance your practice a little bit and take better care of your patients!

[@elwasad5710]

thanks alot sir for the amazing content. but ive a little confusion that how is the chest wall rigid while back flexible , while in normal breathing we mostly increase chest size by mostly anterior expension.

[@shashinthamonteiro8107]

Informative Thank you doc

[@latestlatest4760]

Hi, a very clear video..thanks👍..one thing, though, why is the perfusion always go to the dorsal lung? Thank you

[@CountBackwardsFrom10]

Hi, so sorry for the late reply! First thank you so, so much for your kind comments! my only request is that if you like the content, to subscribe and pass it on to anyone you think it may help! :D So the only explanation I have been able to find is that from an evolutionary standpoint, we come from animals that walked on all 4s and so it is evolutionary beneficial for blood to flow to the parts of the lung with most ventilation, which, when walking on all 4s would be the dorsal aspect! I hope this helps!

[@mariamabelcolladoexposito8932]

Loved it!

[@physiomedicine]

I have a question please what happen to v , ventilation (not perfusion) when the patient is supine relative to when he is setting on chair , the ventilation will increase ? And the frc will decrease? Why the ventilation will increase?

[@vashkarkhan301]

Thanks for your explanation and always love your videos. But i have one query. What about the pressure exerted by the bed surface on the abdominal contents? Wont that restrict the chest expand? What tricks you are using to correct it. I am also anesthesiologist in bangladesh. I am asking to learn more from you and in this covid 19 situation this prone position is really helpful.

[@piermaurocastino9333]

you can refer to a nice talk on the subject in you tube , from Xavier Monnet... prone positioning and hemodynamics......

[@CountBackwardsFrom10]

Hi Vashkar! thank you so, so much for your kind comments! my only request is that if you like the content, to subscribe and pass it on to anyone you think it may help! :D So yes, it does decrease chest expansion. But, the anterior chest wall allows for less alveolar expansion than the dorsal aspect. As a result, if the back can expand more because it is not against the bed, and is not being squished by all of those forces, you can expand and recruit more alveoli! I hope this helps!

[@roshagawa]

in my experience: we tend to put pillows - depending on the habitus of the patient - on their chest and hips, leaving a space for the abdomen to 'hang down' so it hopefully impedes the ventilation less. if i've understood your question correctly.

[@LaFou06]

Thank you for this! But do you know if the risk for gastric reflux and subsequent aspiration is higher or lower (or same) in prone position? 🙏

[@CountBackwardsFrom10]

Ahh thank you! And thank you so much for reaching out! so reflux and aspiration risk is higher! This is why we stop feeds prior to proning!

[@lauraforouher309]

@@CountBackwardsFrom10 but considering patients with COVID-19 seem to have an average stay of between 10-20 days in the ICU, this would lead to malnutrition - we won't be able to close the gaps in feeding if we only feed when patient is in supine position

[@CountBackwardsFrom10]

@@lauraforouher309 That is correct. And many times in the ICU especially, those are tough calls to make, like a patient with a PE who needs anti coagulation, but also has a GI bleed. It's a call made by the practitioner based on what will be best, or least harmful for that patient.

[@piermaurocastino9333]

no one can say... but NG in place , keep stomach empty as possible , , proning makes easier to gastric reflux to move out of the mouth , and the patient has a seald ETT , and is often ventilated with pressures higher than normal......so aspiration should not be a major problem......

[@davidconvissar7055]

@@piermaurocastino9333 while these points are absolutely correct, microaspiration still occurs around sealed ett. This is not to say it's a major concern, but many proning protocols will hold feeds about an hour prior to flipping in order to minimize risk.

[@kiranjha6113]

hello sir, can you please let me know which software your'e using for making videos

[@shashinthamonteiro8107]

Hi People realize the usefulness of pronning after a year....

[@elwasad5710]

Banavasi H, Nguyen P, Osman H, Soubani AO. Management of ARDS - What Works and What Does Not. Am J Med Sci. 2021 Jul;362(1):13-23. doi: 10.1016/j.amjms.2020.12.019. Epub 2020 Dec 26. PMID: 34090669; PMCID: PMC7997862.