Overview of Prone Cardiopulmonary Resuscitation
Using a mechanical ventilator to help patients breathe while laying on their stomachs, or in the prone position, in intensive care units (ICUs) has shown to improve oxygen levels in patients with a severe lung condition known as Acute Respiratory Distress Syndrome (ARDS). Prone positioning can also help more air sacs in the lungs open (alveoli recruitment) and improve the distribution of air and blood in the lungs. This helps to improve breathing by reducing lung compression and increasing lung blood flow.
Sometimes, patients may need to be placed in a prone position outside of the ICU, especially during surgical procedures. This positioning helps doctors to better access parts of the body located on the back side. However, patients in a prone position due to respiratory failure or surgery might experience a sudden stopping or irregular heartbeat, otherwise known as cardiac arrest. Since the aim of cardiopulmonary resuscitation (CPR) is to minimize the time the brain goes without healthy blood flow, moving patients from prone to supine (laying on their back) position can cause a harmful delay in starting CPR. This delay in starting CPR can result in worse health outcomes.
The American Heart Association (AHA) guidelines state that it is advisable to start CPR while a patient is in the prone position if it’s not possible or safe to move them to a supine position. This article offers a better understanding of when and how CPR should be performed in the prone position and emphasizes the critical role of healthcare teams in emergency situations to efficiently perform CPR in the prone position, ensuring the best patient care.
Anatomy and Physiology of Prone Cardiopulmonary Resuscitation
Different parts of your body can be impacted when your heart suddenly stops, a condition known as cardiac arrest. These parts include the circulatory system, which is your heart and blood vessels, the respiratory system, which includes your lungs and breathing, and the cerebrovascular system, which involves the brain and its various functions. During cardiac arrest, doctors try to restore these systems as soon as they can by performing CPR.
Your circulatory system involves your heart and blood vessels. The heart works by receiving blood that lacks oxygen from your body and sending it to the lungs. The lungs then supply the blood with oxygen. After that, this oxygen-rich blood is taken back to the heart and sent to the rest of your body. Sometimes, however, cardiovascular diseases or conditions that affect the normal functioning of the heart can lead to cardiac arrest. Irregular heartbeats, which are also called arrhythmias, can also lead to the heart suddenly stopping. One such type of irregular heartbeat is ventricular tachycardia and ventricular fibrillation (VT/VF), that significantly reduces the amount of blood pumped out of heart and resulting in cardiac arrest.
When heart stops, doctors perform CPR which involves chest compressions and using a defibrillator to restore normal heart beats in cases of arrhythmias. Although the patient is usually laid on their backs (or supine) during CPR, they needn’t be moved to that position if they are on their stomachs (or prone) when cardiac arrest occurred. In fact, some studies show CPR performed when the patient is prone could be much more effective.
Your respiratory system, which includes your airways, lungs, and the muscles you use to breathe, serve vital roles in carrying oxygen to different parts of your body and removing carbon dioxide from your body. When this system isn’t working as it should be, it can lead to cardiac arrest. When performing CPR, doctors ensure the patient gets enough oxygen to prevent a state of excessive acidity in the body. In fact, CPR done when the patient is prone is found to give better results. It can lead to better oxygen supply and ventilation and lower the risk of complications like stomach contents being aspirated (or inhaled).
The cerebrovascular system involves your brain and spinal cord. It’s in this system that the medulla, a part of your brain, regulates essential life-sustaining functions like breathing and regulating blood pressure. When things go wrong and cause the failure of these functions, it can lead to cardiac arrest. As quick initiation of CPR does when the patient is prone, this helps deliver oxygen to the brain and prevent damage to it, if the patient survives the cardiac arrest. Hence, it’s crucial to start CPR promptly, even if the patient is in a prone position, to improve their chances of survival and reduce possible long-term damage.
Why do People Need Prone Cardiopulmonary Resuscitation
Prone CPR refers to resuscitation efforts performed while a person is lying on their stomach, and it is usually used in situations when a person experiences a sudden heart attack while already lying in this position for medical reasons, like oxygen delivery, improved breathing, or during a surgery.
The current guidelines from the American Heart Association (or AHA) say that for patients in a hospital setting who might have tubes in their throat for breathing, it is acceptable to perform CPR in this prone position if it’s not possible to flip them over onto their back. However, these guidelines were not included in the more recent updates in 2015 and 2020.
Randefinedom recommendations from medical authorities in the UK suggest that when a patient during a neurosurgery experiences a cardiac arrest, chest compressions should be started right away, without needing to move them from their prone position. However, if these compressions don’t appear to be working, based on particular medical readings like ETCO2 and capnography waveforms, then the patient should be turned over onto their back.
With the recent COVID-19 pandemic, prone CPR has become more important because many patients with severe COVID-19 infection require to be ventilated in this prone position and are at higher risk of experiencing a heart attack.
In response to the pandemic, multiple scientific communities, including AHA, have suggested that for COVID-19 patients who are awake but ventilated in the prone position, CPR should be ideally performed after moving them onto their back, unless doing so would risk spreading the virus through the air or interfere with their ventilator or other equipment.
The European Resuscitation Council (ERC) also say that patients should be flipped over if chest compressions are difficult to perform, they have trouble breathing, or there are delays in achieving a stable heartbeat.
Similarly, a joint statement from Brazilian medical societies recommend flipping patients over as soon as it’s safe to do so, due to the lack of available studies supporting the effectiveness of prone CPR. They also recommend monitoring the status of CPR using particular measurements of diastolic pressure and ETCO2 pressure.
When a Person Should Avoid Prone Cardiopulmonary Resuscitation
There aren’t any reasons why CPR (an emergency procedure used when someone’s heart stops) can’t be done while the person is lying on their stomach. However, not everyone in the healthcare field might be comfortable doing CPR in this position. Usually, people are taught to do CPR with the person lying on their back, and it can feel unusual and unfamiliar to do it while the person is laying face down.
Equipment used for Prone Cardiopulmonary Resuscitation
The tools needed for a specific type of CPR, known as prone CPR, are as follows:
1. Oxygen masks and bag valve devices: these are used for the patient to breathe.
2. Defibrillators with electrodes and pads: these are special machines that use electricity to jumpstart the heart if it’s not beating correctly.
3. A crash cart: this is a movable set of drawers filled with emergency equipment and drugs that may be needed during the CPR process. This includes medications like epinephrine/adrenaline (to boost heart rate), atropine (to treat heart-related issues), amiodarone (to control heart rhythm), naloxone (to reverse effects of opioids), and other life-saving drugs. The cart also holds items like tapes, gloves, scissors, an IV cannula (a small tube placed into a vein to provide medication or fluids), syringes and needles, saline flush (used to clean out the IV line), and IV fluids (which are given through the vein to provide hydration and medication).
4. Suction system: this helps remove fluids or other substances that may block the airways.
5. Endotracheal tubes: these are inserted into the patient’s windpipe to maintain an open airway or deliver drugs.
6. Mechanical ventilators: these machines assist or replace the function of lungs, helping patients breathe.
Who is needed to perform Prone Cardiopulmonary Resuscitation?
In the hospital, a kind of life-saving procedure called Prone CPR is done by a team of different health professionals. This team usually includes doctors, nurses, pharmacists, lab workers, and respiratory therapists (experts who help with breathing issues). It’s important to know that if something happens during a surgery that requires Prone CPR, the surgery team will not wait for the hospital’s special emergency response team to arrive.
Instead, because time is critical, the surgery team itself will start the Prone CPR. This team usually involves the surgeon (the doctor who is leading the operation), the anesthesiologist (the doctor who makes sure you stay asleep during surgery), nurses, and surgery assistants. They have all been trained to handle such situations and will work together quickly to provide the needed care.
Preparing for Prone Cardiopulmonary Resuscitation
If you’re a patient lying on your stomach (prone position), there’s a risk that your heart could suddenly stop working (cardiac arrest). Because of this, the healthcare team, including the nurses, your primary care doctor, and the heart emergency team, must be ready to take immediate action. Crucial emergency equipment, like the tools needed for chest compressions (CPR), should be readily available either inside or near your room.
In anticipation of such an emergency, defibrillation pads, which are used to deliver an electric shock to restart your heart, can be placed on your back and connected to the heart monitor even before a cardiac arrest happens.
For ensuring a smooth emergency response, unneeded materials must be removed from your room so they don’t interfere with the CPR process. Also, all medical staff, especially those who look after patients in prone positions, should be professionally trained to perform CPR while you’re lying on your stomach.
How is Prone Cardiopulmonary Resuscitation performed
If a person is lying face-down (prone) or face-up (supine) and they need cardiopulmonary resuscitation (CPR), the techniques are largely the same, but the hand positions used to compress the chest and the placement of the defibrillation pads (used to deliver an electric shock to the heart) are different.
In the prone position, the person’s chest and front part of their belly would lay on a firm surface, and their arms would be tucked under their shoulders with elbows bent at right angles. The person giving chest compressions places the fleshy part of their hand (hypothenar region) over the person’s backbone between the shoulder blades and the other hand is locked over the first hand.
For compressions to be effective, there should be a counter-pressure applied to the chest. This can be done with the help of sandbags or fluid bags tucked under the person’s chest or another person applying a hand’s pressure on the person’s chest.
Chest compressions are a very important part of the CPR process. The compressions must be focused on a specific spot, roughly around the area of the eighth and ninth thoracic vertebrae, which is just below the bottom edge of the shoulder blade. Research has shown that this spot allows direct access to a large part of the left ventricle (one of the heart’s main pumping chambers) in more than 80% of people.
The CPR steps followed for a person in prone position should be the same as traditional CPR at a rate of 100 to 120 compressions per minute and a depth of at least 2 inches for adults and at least one-third of the chest depth in infants. An end-tidal CO2 (ETCO2) goal of at least 10 to 15 mmHg should be used to assess the effectiveness of compressions.
If the patient doesn’t have an advanced airway (a tube that helps them breathe), they should be given 2 breaths using face masks or bag valve devices after every cycle of 30 compressions (or 15 compressions if multiple people are doing CPR) to minimize interruptions in chest compressions. However, if the patient does have an advanced airway, between 8 and 10 breaths should be given every minute without stopping chest compressions.
If a patient’s heart rhythm requires a shock (like with pulseless ventricular tachycardia and ventricular fibrillation), the defibrillator pads can be placed in different positions to ensure that the heart receives enough energy. They can be placed on the front and back of the chest, on both underarms, or on the side and back of the chest, with one pad positioned in the mid-line of the left or right side and the second one over left or right shoulder blade.
Possible Complications of Prone Cardiopulmonary Resuscitation
During CPR, when a person is lying on their stomach (also known as prone CPR), there’s a chance they could get injuries to their ribs, shoulder bones, shoulder joints, spine, and even eyes. Sometimes, the tubes used to help the person breathe (called endotracheal or tracheostomy tubes) could accidentally get knocked out of place. If this happens, the person might need to be turned over so they can be put back, which could make the CPR less effective.
Performing CPR during surgical procedures can also be difficult. This is because the person’s chest needs to be pushed on, and if the chest is already open because of the surgery, it might be hard to do this correctly. Sometimes, pushing back on the breastbone (this is called a counterforce) may be needed to prevent damage.
What Else Should I Know About Prone Cardiopulmonary Resuscitation?
Cardiac arrest, which is when the heart suddenly stops beating, can sometimes occur when a patient is lying face-down (prone position). This situation can become more frequent as prone position treatment has been increasingly used during the COVID-19 pandemic. It is used for very sick patients who are asleep, under anesthesia and have breathing tubes inserted, as well as in patients who are awake receiving non-invasive ventilation – a treatment that pushes air into the lungs without the need for a major surgery or breathing tube.
If someone has a cardiac arrest while lying face-down, doctors can still start cardiopulmonary resuscitation (CPR). CPR is a life-saving procedure that involves chest compressions and rescue breaths to pump blood around the body when the heart cannot. Furthermore, starting CPR in the prone position might improve the patient’s chances of survival, especially if it’s not possible to quickly turn them over to lie flat on their back (supine position).