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

In pandemic times, medical staff is becoming a key resource in fighting the infection. To achieve the best medical care, relevant techniques and procedures have to be taught to medical staff while reducing the risk of infection. COVID-19 patients often develop an acute respiratory distress syndrome with respiratory failure. Prone positioning is established as a core component of management in COVID-19 patients, to enable ventilation of a greater lung area and thereby improve gas exchange. This video shows the prone positioning of a COVID-19 patient while taking personal infection protection into account.

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.