- Open Access
Prone ventilation of critically ill adults with COVID-19: how to perform CPR in cardiac arrest?
Critical Care volume 24, Article number: 258 (2020)
We read with great interest an editorial by Siow et al. on managing COVID-19 in resource-limited critical care settings . As critically ill COVID-19 patients seem to benefit from prone position ventilation, we think it would be worth mentioning another clinical intervention that—performed in this position—would limit workload and reduce exposure risks of the staff, i.e., CPR. The idea of “prone-CPR” is not novel. It was first introduced by McNeil in 1989 and followed by some other authors publishing research papers and case reports [2, 3], but it did not gain significant traction among medical professionals. There are some instances though when there may be little alternative to CPR in the prone position, e.g., cardiac arrest in neurosurgical patients, when the brain or spinal cord are exposed during surgery and turning to the conventional supine position would cause neural damage [3, 4]. We believe that cardiac arrest in a prone-ventilated patient with COVID-19 may be another indication for commencing CPR without de-proning. There seem to be some undisputable advantages of performing prone cardiopulmonary resuscitation in this particular group of patients. Firstly, it would limit the amount of people being exposed to environment with highly contagious material. Some guidelines suggest that optimal staffing involved in turning a critically ill prone patient should count minimum of five people and may take up to 5 min to be completed, and time during cardiac arrest is of the essence. Secondly, there is a risk of displacement of the endotracheal tube or even inadvertent extubation of the trachea which might have disastrous consequences for the patient and the staff (aerosol-generating incident). Disconnection of vascular lines as well as injury to the patient and staff might occur.
During prone-CPR, chest compressions may be performed placing hands over each scapula or over the thoracic spine with or without counter-pressure on the sternum. Successful defibrillation has also been described with several pad positions ..
In the current epidemiological situation, understaffed ICU teams should be prepared for the situations which are far from the daily routine. While the effectiveness of CPR in the prone position is not completely known, we think that the prone-CPR should be given a consideration during a sudden cardiac arrest in COVID-19 victims being prone-ventilated. This idea was also reflected in the recently published online interim guidance for BLS and ALS in patients with suspected or confirmed COVID-19 .
Availability of data and materials
Siow WT, Liew MF, Shrestha BR, et al. Managing COVID-19 in resource-limited settings: critical care considerations. Crit Care. 2020;24:167. https://doi.org/10.1186/s13054-020-02890-x.
McNeil E. Re-evaluation of cardiopulmonary resuscitation. Resuscitation. 1989;18:1–5.
Atkinson MC. The efficacy of cardiopulmonary resuscitation in the prone position. Crit Care Resusc. 2000;2:188–90.
Feix B, Sturgess J. Anaesthesia in the prone position. Contin Educ Anaesth Crit Care Pain. 2014;14(6):291–7. https://doi.org/10.1093/bjaceaccp/mku001.
Edelson et al.: Interim Guidance for Life Support for COVID-19 . https://doi.org/10.1161/CIRCULATIONAHA.120.047463.
Ethics approval and consent to participate
Consent for publication
The authors declared no conflict of interest.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
About this article
Cite this article
Mędrzycka-Dąbrowska, W., Lewandowska, K., Ślęzak, D. et al. Prone ventilation of critically ill adults with COVID-19: how to perform CPR in cardiac arrest?. Crit Care 24, 258 (2020). https://doi.org/10.1186/s13054-020-02970-y