Using the Prone Position Could Help to Combat the Development of Fast Hypoxia in Some Patients with COVID-19

Overview

Journal Acta Paediatr

Specialty Pediatrics

Date 2020 Jun 3

PMID 32484966

Citations 9

Authors

Sten G E Lindahl

Affiliations

Soon will be listed here.

Abstract

The world is facing an explosive COVID-19 pandemic. Some cases rapidly develop deteriorating lung function, which causes deep hypoxaemia and requires urgent treatment. Many centres have started treating patients in the prone position, and oxygenation has improved considerably in some cases. Questions have been raised regarding the mechanisms behind this. The mini review provides some insights into the role of supine and prone body positions and summarises the latest understanding of the responsible mechanisms. The scope for discussion is outside the neonatal period and entirely based on experimental and clinical experiences related to adults. The human respiratory system is a complex interplay of many different variables. Therefore, this mini review has prioritised previous and ongoing research to find explanations based on three scientific areas: gravity, lung structure and fractal geometry and vascular regulation. It concludes that gravity is one of the variables responsible for ventilation/perfusion matching but in concert with lung structure and fractal geometry, ventilation and regulation of lung vascular tone. Since ventilation distribution does not change between supine and prone positions, the higher expression of nitric oxide in dorsal lung vessels than in ventral vessels is likely to be the most important mechanism behind enhanced oxygenation in the prone position.

Citing Articles

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Neurological complications and infection mechanism of SARS-COV-2.

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Awake Prone Positioning in the Management of COVID-19 Pneumonia: A Systematic Review.

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References

Altemeier W, Robertson H, Glenny R . Pulmonary gas-exchange analysis by using simultaneous deposition of aerosolized and injected microspheres. J Appl Physiol (1985). 1998; 85(6):2344-51. DOI: 10.1152/jappl.1998.85.6.2344. View

Guerin C, Reignier J, Richard J, Beuret P, Gacouin A, Boulain T . Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013; 368(23):2159-68. DOI: 10.1056/NEJMoa1214103. View

Piehl M, Brown R . Use of extreme position changes in acute respiratory failure. Crit Care Med. 1976; 4(1):13-4. DOI: 10.1097/00003246-197601000-00003. View

DOUGLAS W, REHDER K, Beynen F, SESSLER A, Marsh H . Improved oxygenation in patients with acute respiratory failure: the prone position. Am Rev Respir Dis. 1977; 115(4):559-66. DOI: 10.1164/arrd.1977.115.4.559. View

Gattinoni L, Busana M, Giosa L, Macri M, Quintel M . Prone Positioning in Acute Respiratory Distress Syndrome. Semin Respir Crit Care Med. 2019; 40(1):94-100. DOI: 10.1055/s-0039-1685180. View

Glenny R, Robertson H . Fractal properties of pulmonary blood flow: characterization of spatial heterogeneity. J Appl Physiol (1985). 1990; 69(2):532-45. DOI: 10.1152/jappl.1990.69.2.532. View

Mure M, Martling C, Lindahl S . Dramatic effect on oxygenation in patients with severe acute lung insufficiency treated in the prone position. Crit Care Med. 1997; 25(9):1539-44. DOI: 10.1097/00003246-199709000-00022. View

Hughes J, GLAZIER J, MALONEY J, West J . Effect of lung volume on the distribution of pulmonary blood flow in man. Respir Physiol. 1968; 4(1):58-72. DOI: 10.1016/0034-5687(68)90007-8. View

Petersson J, Rohdin M, Sanchez-Crespo A, Nyren S, Jacobsson H, Larsson S . Paradoxical redistribution of pulmonary blood flow in prone and supine humans exposed to hypergravity. J Appl Physiol (1985). 2005; 100(1):240-8. DOI: 10.1152/japplphysiol.01430.2004. View

10.

Walther S, Domino K, Glenny R, Polissar N, Hlastala M . Pulmonary blood flow distribution has a hilar-to-peripheral gradient in awake, prone sheep. J Appl Physiol (1985). 1997; 82(2):678-85. DOI: 10.1152/jappl.1997.82.2.678. View

11.

Amis T, Jones H, Hughes J . Effect of posture on inter-regional distribution of pulmonary ventilation in man. Respir Physiol. 1984; 56(2):145-67. DOI: 10.1016/0034-5687(84)90100-2. View

12.

Nyren S, Radell P, Lindahl S, Mure M, Petersson J, Larsson S . Lung ventilation and perfusion in prone and supine postures with reference to anesthetized and mechanically ventilated healthy volunteers. Anesthesiology. 2010; 112(3):682-7. DOI: 10.1097/ALN.0b013e3181cf40c8. View

13.

Pelletier N, Robinson N, Kaiser L, Derksen F . Regional differences in endothelial function in horse lungs: possible role in blood flow distribution?. J Appl Physiol (1985). 1998; 85(2):537-42. DOI: 10.1152/jappl.1998.85.2.537. View

14.

Pelosi P, Croci M, Calappi E, Cerisara M, Mulazzi D, Vicardi P . The prone positioning during general anesthesia minimally affects respiratory mechanics while improving functional residual capacity and increasing oxygen tension. Anesth Analg. 1995; 80(5):955-60. DOI: 10.1097/00000539-199505000-00017. View

15.

Petersson J, Rohdin M, Sanchez-Crespo A, Nyren S, Jacobsson H, Larsson S . Posture primarily affects lung tissue distribution with minor effect on blood flow and ventilation. Respir Physiol Neurobiol. 2006; 156(3):293-303. DOI: 10.1016/j.resp.2006.11.001. View

16.

Rimeika D, Nyren S, Wiklund N, Renstrom Koskela L, Torring A, Gustafsson L . Regulation of regional lung perfusion by nitric oxide. Am J Respir Crit Care Med. 2004; 170(4):450-5. DOI: 10.1164/rccm.200312-1663OC. View

17.

Hlastala M, Bernard S, Erickson H, Fedde M, Gaughan E, McMurphy R . Pulmonary blood flow distribution in standing horses is not dominated by gravity. J Appl Physiol (1985). 1996; 81(3):1051-61. DOI: 10.1152/jappl.1996.81.3.1051. View

18.

Lindahl S . Using the prone position could help to combat the development of fast hypoxia in some patients with COVID-19. Acta Paediatr. 2020; 109(8):1539-1544. PMC: 7301016. DOI: 10.1111/apa.15382. View

19.

Mure M, Domino K, Lindahl S, Hlastala M, Altemeier W, Glenny R . Regional ventilation-perfusion distribution is more uniform in the prone position. J Appl Physiol (1985). 2000; 88(3):1076-83. DOI: 10.1152/jappl.2000.88.3.1076. View

20.

Pelosi P, Croci M, Calappi E, Mulazzi D, Cerisara M, Vercesi P . Prone positioning improves pulmonary function in obese patients during general anesthesia. Anesth Analg. 1996; 83(3):578-83. DOI: 10.1097/00000539-199609000-00025. View