Proning' Is a Promising Treatment for Coronavirus—Here's How It Works

Some doctors on the frontlines of the coronavirus pandemic are having success treating COVID-19 patients with a simple technique called 'proning.' The term basically means putting a patient in the prone position, or "flat on their belly with their chest and face down, rather than on their back,” Jack Stewart, MD, a pulmonologist with St. Joseph Hospital in Orange County, California, tells Health.

Proning requires little or no equipment, and the technique may prove to help patients who are critically ill avoid being put on ventilators for breathing assistance.

Why does proning work? Flipping a patient on their stomach helps respiration because “oxygenation (getting more oxygen into the blood) is easier in the prone position," says Dr. Stewart. It's a function of anatomy, as the human body has more lung tissue in the back of the body than in the front. The coronavirus causes abnormal fluids and secretions to pool toward the back, where there's more lung tissue, and leads to greater interference with lung function.

“When a patient is in the prone position, gravity helps the secretions move downward, so more of the ‘good’ lung is on top and therefore less affected,” Harry Peled, MD, a medical director in critical care at St. Jude Medical Center in Fullerton, California, tells Health. 

Proning is also an effective treatment for a condition called acute respiratory distress syndrome (ARDS), a life-threatening complication of coronavirus infection that manifests as shortness of breath and quickly progresses. A study published last month in JAMA Internal Medicine suggests that more than 40% of individuals in the study hospitalized for severe and critical COVID-19 developed ARDS—and over 50% of those diagnosed died from the disease.

ARDS poses a risk to patients who have influenza, pneumonia, and pulmonary edema (fluid in the lungs from heart disease) as well. “Proning has been used to treat ARDS for a number of years,” says Dr. Stewart. A 2013 study by French doctors published in the New England Journal of Medicine found that patients suffering from ARDS had a lower risk of death if prone positioning was used in the hospital early on. 

Further research on how proning affects coronavirus patients is needed, but anecdotal evidence shows the effectiveness of the treatment since the global pandemic began.

In the US, a coronavirus patient at Long Island Jewish Hospital managed to avoid needing life support after being put in the prone position, CNN reported. In the UK, a 50-year-old woman with COVID-19 pneumonia who doctors were convinced only had a “couple of hours” to live made a remarkable recovery after medics turned her onto her belly, according to an article written by the patient’s husband for The Times. 

Proning isn’t just being used for patients in critical condition. In fact, new guidance from the UK’s Intensive Care Society, written by doctors and nurses who specialize in intensive care and respiratory medicine, says the technique can reduce the need for invasive ventilation and the chance of death for conscious COVID-19 patients before they reach intensive care.

“Prone positioning is a simple intervention that can be done in most circumstances, is compatible with all forms of basic respiratory support, and requires little or no equipment in the conscious patient,” states the new guidance. However, the technique is not suitable for all patients, such as morbidly obese people, pregnant women or those with facial injuries.

A team at Rush University Medical Center in Chicago is currently conducting a clinical trial to establish whether the prone position is helpful for COVID-19 patients who are not so sick that they need a ventilator to breathe for them, but sick enough to require supplemental oxygen delivered through a tube in their nose.

Proning does come with some risks, such as pressure sores and dislodging of an endotracheal tube (a flexible plastic tube placed through the mouth and inserted into the windpipe to help a patient breathe), says Dr. Peled. The greatest risk is difficulty performing CPR if a patient goes into cardiac arrest. “It’s crucial to have a highly trained team and organized approach to ensure the procedure is performed safely and efficiently,” he adds.

The information in this story is accurate as of press time. However, as the situation surrounding COVID-19 continues to evolve, it's possible that some data have changed since publication. While Health is trying to keep our stories as up-to-date as possible, we also encourage readers to stay informed on news and recommendations for their own communities by using the CDC, WHO, and their local public health department as resources.

 

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Mount Sinai to Begin the Transfer of COVID-19 Antibodies into Critically Ill Patients

The Mount Sinai Health System this week plans to initiate a procedure known as plasmapheresis, where the antibodies from patients who have recovered from COVID-19 will be transferred into critically ill patients with the disease, with the expectation that the antibodies will neutralize it.

The process of using antibody-rich plasma from COVID-19 patients to help others was used successfully in China, according to a state-owned organization, which reported that some patients improved within 24 hours, with reduced inflammation and viral loads, and better oxygen levels in the blood.

Mount Sinai is collaborating with the New York Blood Center and the New York State Department of Health’s Wadsworth Center laboratory in Albany, with guidance from the U.S. Food and Drug Administration, and expects to begin implementing the treatment later this week.

“We are hoping to identify patients who can provide the antibodies,” says Dennis S. Charney, MD, Anne and Joel Ehrenkranz Dean of the Icahn School of Medicine at Mount Sinai, and President for Academic Affairs, Mount Sinai Health System. “We are at the front lines in fighting this pandemic and making discoveries that will help our patients.”

Late last week, researchers at the Icahn School of Medicine, in collaboration with scientists in Australia and Finland, were among the first to create an antibody test that detects the disease’s antibodies in a person’s blood. Development of the enzyme-linked immunosorbent assay (ELISA) was led by Florian Krammer, PhD, Professor of Microbiology, in collaboration with Viviana A. Simon, MD, PhD, Professor of Microbiology and Medicine (Infectious Diseases). Dr. Krammer, a renowned influenza researcher, recently made this so-called recipe available to other laboratories around the world so they can replicate it during the pandemic. In January, his lab was quickly retooled to begin studying COVID-19.

In addition to its widespread use in plasmapheresis, the antibody test will provide experts with an accurate infection rate so they can track the trajectory of the disease. The test will help identify health care workers who are already immune to the disease, who can work directly with infectious patients, and it can also help scientists understand how the human immune system reacts to the virus.

The new assay uses recombinant or manufactured antigens from the spike protein on the surface of the SARS-CoV-2 virus. That protein helps the virus enter cells, and it is a key target in the immune reaction against the virus, as the body creates antibodies that recognize the protein and seek to destroy the virus. The researchers also isolated the short piece of the spike protein called the receptor-binding domain (RBD), which the virus uses to attach to cells it tries to invade. The scientists then used cell lines to produce large quantities of the altered spike proteins and RBDs.

According to Dr. Krammer and his co-authors, the assay is “sensitive and specific,” and allows for the screening and identification of COVID-19 in human plasma/serum as soon as three days after the onset of symptoms. The antibodies were derived from three patients who had the disease. The study’s control participants—who did not have COVID-19 but had other viruses, including the common cold—ranged in age from 20 to 70.

Dr. Krammer says his preliminary findings also show that humans have no natural immunity to the SARS-CoV-2 virus, which would help explain why it spreads so quickly. But once the antibody sets in humans do become protected. He also says that at this early stage in the research, there is no evidence that people can lose their immunity and become re-infected.

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Many factors influence decisions to withdraw life-support brain injury patients

There are several factors that determine the decisions to withdraw life support treatments in critically ill patients with severe brain injury, says a recent study.

The study provides a new understanding of the decision-making processes for this patient population, which accounts for most hospital deaths from trauma.

One of the researchers said, many clinicians struggle to make recommendations to withdraw life-sustaining treatments because decision-making is often complicated by uncertainty from trying to match family or caregiver opinions about  what they think the patient would have wanted in terms of quality of life and how well physicians can predict a prognosis.

The death rate in critically ill patients with severe traumatic brain injury is generally high as it occurs after a decision to withdraw life-sustaining treatments.

This patient population differs from the general intensive care unit (ICU) population as most patients were healthy before admission to the ICU, as compared with older patients who may already have a poorer quality of life due to pre-existing illness.

Therefore, decisions to withdraw life-sustaining treatments are made differently, mainly based on long-term prognosis and quality of life.

The researchers performed a descriptive qualitative study of interviews with critical care physicians from across Canada to understand the factors that determine a critical care physician's decision to discuss with families the withdrawal of life-sustaining treatments in patients with severe traumatic brain injury.

Results show that several factors are accountable including the patients' pre-expressed wishes and the family's wishes, severity, and location of the injury, along with evidence.

Past physician experience, legislation, opinions of colleagues and time are additional factors influencing decisions. The incidence of withdrawal of life-sustaining treatments and of death in critically ill patients with traumatic brain injury varies between hospitals.

Better evidence, tools to help predict patient outcomes, standardisation, better ways to integrate patient values and preferences into decision-making, improved training during critical care fellowships and more time to estimate prognosis are some things that could improve decision-making whether to withdraw life-sustaining treatments.

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