Prone ventilation as treatment of acute respiratory distress syndrome related to COVID-19

Prone ventilation refers to the delivery of mechanical ventilation with the patient lying in the prone position. The improvement of oxygenation during prone ventilation is multifactorial, but occurs mainly by reducing lung compression and improving lung perfusion. CT imaging modeling data demonstrated that the asymmetry of lung shape leads to a greater induced pleural pressure gravity gradient when supine as compared to prone positioning. Although proning is indicated in patients with severe ARDS who are not responding to other ventilator modalities, this technique has moved away from a salvage therapy for refractory hypoxemia to an upfront lung-protective strategy intended to improve survival in severe ARDS, especially due to the current COVID-19 pandemic. In view of different roles, we surgeons had to take during the COVID-19 pandemic, it is of importance to learn how to implement this therapeutic measure, especially in a surgical critical care unit setting. As such, this article aims to review the physiological principles and effects of the prone ventilation, positioning, as well as its contraindications and complications.