CPR in the Prone Position

A prone position, which is when the patient is lying on their front, is generally used in the operating room to facilitate surgical access or to optimize oxygenation in patients suffering from severe hypoxic respiratory failure. If patients under mechanical ventilation in the prone position suffer cardiac arrest however, considerable effort may be required to return the patient to the supine position (lying on their back) and initiate cardiopulmonary resuscitation (CPR) maneuvers. It can take as many as 5–6 people and up to 3 minutes to reposition a patient into the supine position [1]. In patients with severe cardiorespiratory instability, such as some COVID-19 patients, a rapid change in position may exacerbate their hemodynamic instability and worsen their hypoxemia. CPR in some contexts may thus be better managed in the prone position. 

The American Heart Association (AHA) 2010 guidelines prioritized placing the patient in the supine position to perform optimal CPR, since performing CPR in the prone position is only recommended when it is not possible to turn the patient supine. However, the recommended technique to carry out prone CPR remains unspecified, and prone CPR is mentioned neither in the 2015 nor the 2019 updated guidelines [2]. A 2020 update of basic and advanced CPR recommendations for the COVID-19 pandemic, however, explicitly recommends either returning a patient to a supine position or initiating CPR in a prone position; how CPR should be performed, again, remains unspecified [3]. 

A systematic review on the efficacy and feasibility of basic or advanced CPR maneuvers in a prone position in the operating room or in the intensive care unit was recently carried out in an attempt to describe the gold standard recommendations. Current data suggest that the cadence of the compressions needs to be adequate to allow backward movement of the chest (i.e. at about 100–120 compressions/min), like CPR in the supine position [4]. In addition, a 2017 imaging study identified that hand placement between T7 and T9 is best, locating the compressions over the largest transverse section of the left ventricle of the heart [5]. Furthermore, the patient needs to be on a hard surface, while the use of sandbags, serum bags, or even the clenched fist of a rescuer placed under the sternum may be helpful. Adhesive defibrillator pads can also be placed as needed in both armpits or one on the left axillary midline and the other above the right scapula [6].  

Several theories exist regarding the mechanism by which CPR sustains circulation in a prone position. According to the heart pump theory, compressions squeeze the heart between the anterior wall of the spine and the sternum, thereby creating a flow in both pulmonary and systemic circulations. In contrast, the chest pump theory posits that compressions produced in the thorax decrease intrathoracic volume, thereby increasing intrathoracic pressure, as a result generating a gradient that encourages blood flow to the aorta and pulmonary arteries [7]. Both theories are plausible, and both suggest that the rhythm and the depth of compressions are critical aspects of a successful CPR procedure.  

Observational studies and case reports have shown that both basic CPR and advanced CPR in the prone position provide hemodynamic and ventilatory support comparable to CPR in a supine position. In addition, prone CPR is the only option for patients who cannot be repositioned into a supine position 8. This said however, further work is required to determine whether the administration of prone CPR is effective in a range of real-world conditions and across a wide variety of patient populations [9]. 

References 

1. Mullen L, Byrd D. Using simulation training to improve perioperative patient safety. AORN J. 2013 Apr;97(4):419–27. DOI: 10.1016/j.aorn.2013.02.001
2. Soar J, Maconochie I, Wyckoff MH, Olasveengen TM, Singletary EM, Greif R, et al. 2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2019 Dec 1;145:95–150. doi: 10.1161/CIR.0000000000000734.
3. Edelson DP, Sasson C, Chan PS, Atkins DL, Aziz K, Becker LB, et al. Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association. Circulation. 2020;141(25):E933–43. doi: 10.1161/CIRCULATIONAHA.120.047463.
4. Travers AH, Rea TD, Bobrow BJ, Edelson DP, Berg RA, Sayre MR, et al. Part 4: CPR overview: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2;122(18 Suppl 3). doi: 10.1161/CIRCULATIONAHA.110.970913.
5. Kwon MJ, Kim EH, Song IK, Lee JH, Kim HS, Kim JT. Optimizing Prone Cardiopulmonary Resuscitation: Identifying the Vertebral Level Correlating With the Largest Left Ventricle Cross-Sectional Area via Computed Tomography Scan. Anesth Analg. 2017 Feb 1;124(2):520–3. DOI: 10.1213/ANE.0000000000001369
6. Anez C, Becerra-Bolaños Á, Vives-Lopez A, Rodríguez-Pérez A. Cardiopulmonary Resuscitation in the Prone Position in the Operating Room or in the Intensive Care Unit: A Systematic Review. Anesth Analg. 2021;285–92. DOI: 10.1213/ANE.0000000000005289
7. Mazer SP, Weisfeldt M, Bai D, Cardinale C, Arora R, Ma C, et al. Reverse CPR: A pilot study of CPR in the prone position. Resuscitation. 2003 Jun 1;57(3):279–85. doi: 10.1016/s0300-9572(03)00037-6.
8. Moscarelli A, Iozzo P, Ippolito M, Catalisano G, Gregoretti C, Giarratano A, et al. Cardiopulmonary resuscitation in prone position: A scoping review. Am J Emerg Med. 2020 Nov 1;38(11):2416–24. doi: 10.1016/j.ajem.2020.08.097
9. Olanipekun T, Bhardwaj A. Prone Cardiopulmonary Resuscitation. StatPearls. 2022 Oct 16;