Prone Breathing: It’s not just for COVID!

You may have heard about how hospital are experimenting with putting critically ill COVID-19 patients on their stomach, in some cases even while intubated. This is quite a novel idea for most medical practitioners in the West. As a rule, patients are generally on their backs (supine) or side (lateral). But our physicians have been getting real-time advice from their counterparts in China on what has helped treat this terrible disease and it turns out, “proning,” or placing patients on their stomachs, can really help improve their breathing.

Why is this? Let’s look first at the new science, and then see what ancient wisdom has to say about this. I attended a lecture by our of our physicians at work, Dr. James Malatack called “Bad to the Prone,” (the title was intended as a joke but it stuck). There was previously a smattering of literature suggesting that prone positioning can help patients with ARDS (acute respiratory distress syndrome). It has been found to improve oxygenation and reduce mortality. But what is the physiology behind this? In simple terms, when patients are kept on their back continually, their dorsal lung ( the back half) can accumulate water and/or partially collapse.

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Lung CT scan shows an increase in lung density (the darker areas) when the patient is prone. This is because the heart (the large white orb), the ventral (front) lung, and the abdomen can all put pressure on the dorsal (back) lung. When the patient is prone, there is more surface area ventilated. There’s also less fluid (the accumulation of white near the spine).

When a patient is flipped onto their stomach, it relieves pressure on that back lung and helps improve oxygenation (I’ll spare you the physiology, but for those pulmonary nerds reading, it reduces V/Q mismatch). It’s not a perfect therapy, and it can have some side effects, but it’s certainly worth a shot in select populations. Below is a nice graph showing a higher overall survival rate for those who were placed prone versus on their back. The difference become evident especially for patients kept on ventilators for over 20 days.

Survival is improved in ARDS (acute respiratory distress syndrome) patients who were placed prone occasionally.
Both pictures courtesy of Dr. James Malatack

Around the same week as the proning lecture, I attended an integrative medicine class on building immunity during the coronavirus crisis. I was surprised when our physician professor suggested that even when we are healthy, we can benefit from prone breathing to improve our oxygenation and lung health. In yoga, the crocodile pose (makarasana),can help one get into a diaphragmatic breathing rhythm, and release tension. This can be great for people (like me) who struggle with trying to breathe with the diaphragm. No matter how many times I’ve been told by my qi gong teacher, it doesn’t always feel natural to expand the belly on the inhalation breath, but when you lay down on your stomach, it does seem to coax the body along.

Laying on your stomach may seem a little awkward in general. But remember, we probably all got tummy time when we were babies. This activity plays an important role in muscle development, including respiratory muscles, which builds breathing endurance. Most adults have forgotten or dismissed the need for this position, which I’ll admit includes me. Some people still sleep on their stomachs. I’ve never liked that position – it seems weird to have to turn your head sideways just to breathe. But maybe a pillow like this would help. My physician also recommended belly breathing on a stability ball, which can help you expand through your lateral chest as well.

It’s great to see real-time studies coming out on a simple and innovative way to improve breathing for COVID patients who are struggling in the ICUs. But it’s even better if we can help strengthen our lungs pro-actively before we get sick by practicing prone breathing as part of our fitness or meditation routines!

Related Topics:

Integrative Medicine and the Coronavirus

Maintaining your Immune System

Bodies in Space: Normally and in a Pandemic

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