Cardiopulmonary Resuscitation in the Prone Position: A Good Option for Patients With COVID-19 : Anesthesia & Analgesia

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Cardiopulmonary Resuscitation in the Prone Position: A Good Option for Patients With COVID-19

Ludwin, Kobi MSc, EMT-P; Szarpak, Lukasz PhD; Ruetzler, Kurt PhD, MD; Smereka, Jacek PhD, MD; Böttiger, Bernd W. PhD, MD; Jaguszewski, Milosz PhD, MD; Filipiak, Krzysztof Jerzy PhD, MD

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Anesthesia & Analgesia 131(3):p e172-e173, September 2020. | DOI: 10.1213/ANE.0000000000005049

To the Editor

Prone positioning of intubated patients suffering from pneumonia improves ventilation-perfusion matching, recruits collapsed alveoli, provides a more uniform distribution of tidal volume through improved chest wall mechanics, and may decrease mortality in more severely hypoxemic patients. Guérin et al1 enrolled 466 patients with moderate-to-severe ARDS (the arterial oxygen tension [PaO2]/fractional inspired oxygen [FiO2] ratio < 150 mm Hg) and reported a significant mortality benefit in the prone positioning group (hazard ratio [HR], 0.39; 95% confidence interval [CI], 0.25–0.63; P < .001).1 Patients infected with coronavirus disease 2019 (COVID-19) are at high risk for developing severe pneumonia and subsequent ARDS. Prone positioning is therefore a common strategy in their intensive care as well.

Recent reports indicate based on multiple pathologies COVID-19 patients are at higher risk for cardiac arrest.2 Immediate initiation of cardiopulmonary resuscitation (CPR), including chest compressions, are crucial but challenging when the patient is prone. Performance of CPR in the prone position is uncommon, but there are several reports of CPR in patients in the prone position having spine surgery (Supplemental Digital Content, Table 1,

A reasonable question is whether a prone patient with cardiac arrest be turned supine before initiating CPR or remain in the prone position. Turning a patient is time-consuming, requires multiple individuals and therefore multiple exposures, and increases the risk for adverse events like endotracheal tube displacement and disconnection of arterial and venous lines. In the prone position, the proper hand positioning is important. Kwon et al3 reported that the largest left ventricular cross-sectional area is 0–2 vertebral segments below the inferior angle of the scapula in at least 86% of patients in patients positioned prone.

Two separate studies investigated the efficacy of CPR in the patients positioned prone. Wei et al4 reported that CPR in prone position compared to the supine position was associated with higher mean systolic blood pressure (SBP; 79 ± 20 vs 55 ± 20 mm Hg) and higher diastolic blood pressure (DBP; 17 ± 10 and 13 ± 7 mm Hg, respectively). The analysis indicates that in the prone position, SBP was statistically significantly higher than in supine position (mean difference [MD] = 24.00; 95% CI, 5.79–42.21; P = .010), while in DBP, the difference was not statistically significant (MD = 4.00; 95% CI, −3.65 to 11.65; P = .31). Mazer et el5 reported the advantage of prone position over the supine position in the context of SBP (72 vs 48 mm Hg; P < .05; mean arterial pressure (46 vs 32 mm Hg; P < .05) and DBP (34 vs 24 mm Hg; P > .05).

During CPR in prone position, endotracheal/tracheostomy tube dislodgement can occur and the patient may then need to be turned for intubation. Injuries to ribs, spine, scapula, clavicles, or eyeballs and shoulder dislocation are possible. The effectiveness of CPR is affected by the depth of chest compressions and therefore it is still recommended to place the patient on a hard surface or to place a hard board under the patient. ARDS patients are placed in prone position for several hours, while COVID-19 ARDS patients for even 12–18 hours or more. The prone position is also used in patients undergoing noninvasive ventilation, in spontaneously breathing nonintubated patients, for example, due to refractory hypoxemia in acute respiratory failure including lung transplantation.6

In summary, CPR in the prone position seems to be a reliable method to provide CPR in patients positioned prone.

Kobi Ludwin, MSc, EMT-P
Outcomes Research
Polish Society of Disaster Medicine
Warsaw, Poland

Lukasz Szarpak, PhD
Comprehensive Cancer Center in Bialystok
Bialystok, Poland
Outcomes Research
Polish Society of Disaster Medicine
Warsaw, Poland
[email protected]

Kurt Ruetzler, PhD, MD
Departments of General Anesthesiology and Outcomes Research
Anesthesiology Institute
Cleveland Clinic
Cleveland, Ohio

Jacek Smereka, PhD, MD
Department of Emergency Medical Service
Wroclaw Medical University
Wroclaw, Poland
Outcomes Research
Polish Society of Disaster Medicine
Warsaw, Poland

Bernd W. Böttiger, PhD, MD
Department of Anaesthesiology and Intensive Care Medicine
University Hospital of Cologne
Cologne, Germany

Milosz Jaguszewski, PhD, MD
First Department of Cardiology
Medical University of Gdansk
Gdańsk, Poland

Krzysztof Jerzy Filipiak, PhD, MD
Department of Cardiology
Medical University of Warsaw
Warsaw, Poland


1. Guérin C, Reignier J, Richard JC, et alPROSEVA Study Group. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368:2159–2168.
2. Shao F, Xu S, Ma X, et al.In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China. Resuscitation. 2020;151:18–23.
3. Kwon MJ, Kim EH, Song IK, Lee JH, Kim HS, Kim JTOptimizing prone cardiopulmonary resuscitation: identifying the vertebral level correlating with the largest left ventricle cross-sectional area via computed tomography scan. Anesth Analg. 2017;124:520–523.
4. Wei J, Tung D, Sue SH, Wu SV, Chuang YC, Chang CYCardiopulmonary resuscitation in prone position: a simplified method for outpatients. J Chin Med Assoc. 2006;69:202–206.
5. Mazer SP, Weisfeldt M, Bai D, et al.Reverse CPR: a pilot study of CPR in the prone position. Resuscitation. 2003;57:279–285.
6. Scaravilli V, Grasselli G, Castagna L, et al.Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: a retrospective study. J Crit Care. 2015;30:1390–1394.

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