6: COVID-19 / Coronavirus Outbreak: How to perform complete prone positioning in COVID-Patients

1. Prepare the materials needed for prone positioning, including large and small foam pieces. Use four large foam squares to assemble two large foam rolls. One large foam roll is to be placed under the anterior chest wall, and the second is placed under the pelvis. Approximately seven smaller pieces are used to support the hands, knees, and head. Each piece is cut according to size. When assembling the rolls, it is important to fasten them as close to the edges as possible, without compromising the structure. Using a scalpel, you should also make additional cutouts for the breasts in female patients. Alternatively, pillows and blankets can be used.
2. Prone positioning should be carried out with full personal protection equipment including a FFP3 protective mask, as there is a high risk of disconnection of the breathing circuit. The personal protective equipment should be donned outside of the patient's room.
3. Assemble a team of four personnel:
   • One assistant at the head to secure the C-spine, endotracheal tube, and central catheters. 
   • A second assistant positioned by the ventilator. They are responsible for the foam rolls, and should also maintain an overview of the patient's vital parameters. 
   • A third assistant positioned by the torso and next to the intravenous perfusors. 
   • A fourth assistant positioned at the pelvis and legs, within reaching distance of injectable intravenous medications. 
   • A fifth assistant is optional. They are usually required in patients treated with ECMO or ECLS, or adipose patients.
   
   NOTE: For the purposes of clarity in this video, and despite its necessity in real life contexts, a closed suction system is not shown.
4. Next, prepare the patient. Fix the endotracheal tube in such a way as to avoid any decubitus ulcers from developing and accidental extubation from occuring. Secure the gastric tube and check it to avoid any dislocation. Apply eye protection, such as Dexpanthenol eye ointment. Suction any secretions in the oro- and naso-pharyngeal cavity.
5. Preoxygenate the patient with a FiO₂ of 1.0.
6. If required, deepen anaesthesia with usage of muscular relaxants.
7. Monitor the haemodynamic status of the patient, and optimize if necessary. 
8. Optimize the conditions by removing the patient's pillow and laying them flat.
9. When attempting any form of prone positioning, the patient is typically turned in the direction of the ventilator. In this case, in a leftwards direction.
10. Loosen the breathing circuit tubes and lay them on the arms of the first assistant. This assistant will also coordinate and communicate the manipulation of the patient to the whole team.
11. Move the patient to the edge of the bed opposite from the ventilator, in this case rightwards.
12. Disconnect and move away the monitoring cable and arterial line. If the telemetry unit is placed on the opposite side of the bed to the ventilator, the cables may be left attached. Do not forget to remove the ECG electrodes.
13. Straighten the patient's arm closest to the ventilator, and with the palms facing towards the body, place it in contact with the buttocks.
14. Roll the patient over this arm.
15. Have the assistant on the side of the ventilator make the two foam rolls available. Turn the patient away from the ventilator and place the foam rolls in line with the shoulders and pelvis. It is important that the patient is not laid on the bed frame in order to avoid pressure sores and injuries.
16. Roll the patient to a 90° side position facing towards the ventilator.
17. Once all tubes and cables are checked, the patient can be fully prone positioned. Check the position of the patient, and if necessary, have the assistants on both sides of the patient optimize the positioning. The first assistant should remain at the head of the patient at all times to protect the C-spine, endotracheal tube, and central catheters.
18. Stick the new ECG electrodes onto the patient and attach and connect all relevant monitoring devices.
19. Rotate the head slightly and position it, paying attention to ensure that the ears, nose and carotids are free and under no pressure. The smaller pieces of foam can be used and adjusted in order to assist with individual patient positioning.
20. Lay the arms next to the body and pad any venous cannulas.
21. Support the lower legs on a large pillow and place the knees on foam. Note that correct positioning of the breasts and genitals is particularly important.
22. Finally, review the endotracheal position through auscultation with the allocated stethoscope.
23. Depending upon clinical findings, the patient can remain in this position for up to 24 hours.

Dearest colleagues, prone positioning is a key part of ARDS therapy, enabling ventilation of a greater lung area and, hence, improving gas exchange. Prone positioning is established as a core component of management in COVID-19 patients. The following materials are required for prone positioning therapy.

Both large and small foam pieces are used when prone positioning a patient. Use four large foam squares to assemble two large foam rolls. One role is used to place under the anterior chest wall, and the second is placed under the pelvis.

Approximately seven smaller pieces are used to support the hands, knees, and head. And each are cut accordingly to size. When assembling the rolls, it is important to fasten them as close to the edges as possible without compromising the structure.

Using a scalpel, you should also make additional cutouts for the breasts in female patients. Pillows and blankets can be alternatively used. Prone positioning is to be carried out with full personal protection equipment, including an FFP3 protective mask, as there is a high risk of disconnection of the breathing circuit.

The personal protective equipment will be put on outside of the patient's room. The team consists of four personnel. One assistant at the head to secure the C-spine, endotracheal tube, and central catheters.

The second assistant is positioned by the ventilator. They are responsible for the foam rolls and should also maintain an overview of the patient's vital parameters. The third assistant is positioned by the torso and next to the intravenous perfusors.

The fourth assistant is positioned at the pelvis and legs and is within reaching distance of injectable intravenous medications. A fifth assistant is optional. They are usually required in patients treated with ECMO or ECLS or adipose patients.

For the purposes of clarity in this video and despite its necessity in real life contexts, a closed suction system is not shown. The patient will now be prepared. The endotracheal tube is fixed in such a way as to avoid any decubitus ulcers from developing, and also accidental extubation from occurring.

The gastric tube must be secured and checked to avoid any dislocation. Eye protection is to be applied. This may be in the form of Dexpanthenol eye ointment.

Any secretion in the oral or nasopharyngeal cavity will be suctioned. The patient will be pre-oxygenated with an FiO2 of 1.0. If required, the anesthesia will be deepened, including usage of muscular relaxants.

The hemodynamic status of the patient must be monitored and, if necessary, optimized. Conditions may be optimized by removal of the patient's pillow and laying them flat on the bed. When attempting any form of prone positioning, the patient is typically turned in the direction of the ventilator-in this case, in a leftwards direction.

The breathing circuit tubes are loosened and laid on the arms of the first assistant. This assistant also coordinates and communicates the manipulation of the patient to the whole team. The patient is moved to the edge of the bed opposite from the ventilator-in this case, rightwards.

Disconnect and move the monitoring cable and arterial line away. If the telemetry unit is placed on the opposite side of the bed to the ventilator, the cables may be left attached at your discretion. For the purpose of this film, the patient's gown will not be removed.

Do not forget to remove the ECG electrodes. Now the patient's arm closest to the ventilator is straightened. And with the palms facing towards the body, they are placed in contact with the buttocks.

The patient can, in turn, be rolled over this arm. The assistant on the side of the ventilator makes the two foam rolls available. Now the patient is turned away from the ventilator, and the foam rolls are placed in line with the shoulders and pelvis.

It is important that the patient is not laid on the bed frame, in order to avoid pressure sores and injuries. The patient is now rolled in a 90 degree side position facing towards the ventilator. Once all tubes and cables are checked, the patient can be fully prone positioned.

The position of the patient is checked and, if necessary, optimized by the assistants on both sides of the patient. The first assistant remains at the head of the patient at all times to protect the c-spine, endotracheal tube, and central catheters. Stick the new ECG electrodes onto the patient and attach and connect all relevant monitoring devices.

The head is slightly rotated and positioned. However, attention must be paid to ensure that the ears, nose, and carotids are free and under no pressure. The smaller pieces of foam can be used and adjusted in order to assist with individual patient positioning.

The arms are laid next to the body, and any venous cannulas are padded. The lower legs are supported on a large pillow, and the knees placed on foam. The correct positioning of the breasts and genitals is particularly important.

Finally, review the endotracheal tube position through oscillation with the allocated stethoscope. Depending upon clinical findings, the patient can remain in this position for up to 24 hours. Thank you very much.