Patients experiencing respiratory distress may be manoeuvered into the prone position for the delivery of ventilation if other methods have proven unsuccessful (Malhotra & Kacmarek 2022). The prone position may also be used for patients undergoing spinal surgery or neurosurgery (Kaur et al. 2016).

These patients may begin to deteriorate or experience cardiac arrest, requiring immediate cardiopulmonary resuscitation (CPR) (Nanjangud & Nileshwar 2017). In some circumstances, though it is not ideal, CPR may need to be performed while the patient is still in a prone position.

When is Prone CPR Performed?

Prone CPR is uncommon and unusual, as it is not a preferable position for resuscitation. A face-down patient impedes access to the airway and veins, posing a significant challenge to those performing the resuscitation (Bhatnagar et al. 2018; Nanjangud & Nileshwar 2017).

However, even though the supine position is considered optimal for CPR, and supine CPR is easier, it is not always feasible to manoeuvre a patient from prone to supine before commencing resuscitation (Kaur et al. 2016; Nanjangud & Nileshwar 2017). This is because:

• The process of turning a critically ill patient supine (which may take five to six minutes) delays the commencement of compressions and means losing precious time
• Recruiting the necessary number of staff needed to perform a safe manoeuver (approximately four to six) may also delay the commencement of compressions
• Attempting to turn a critically ill patient may result in loss of airway or disconnection of invasive lines
• The patient may have ongoing bleeding or an unstable spine (in the event of surgery)
• Maneuvering a patient during spinal surgery or neurosurgery may cause neural damage
• The manoeuvre may cause injury to the patient or staff.

(Nanjangud & Nileshwar 2017; ICS 2019; Saracoglu & Saracoglu 2018)

The American Heart Association (2020) states that:

‘The efficacy of CPR in the prone position is not established, but the very limited evidence suggests it may be better than providing no CPR, when a patient cannot be placed in supine position, or until this can be done safely.’

Furthermore, in the event of arrest during neurosurgery, the Resuscitation Council (2014) advises that chest compressions and/or defibrillation should be commenced immediately, without changing the patient’s position.

For these reasons, CPR may need to be performed on a patient in the prone position in some circumstances, or at least until they can be manoeuvered into the supine position (Nanjangud & Nileshwar 2017).

Is Prone CPR Successful?

Despite the infrequency of prone CPR, there have been a handful of successful resuscitations detailed in case reports (Bhatnagar et al. 2018).

In all of these cases, the patient was being mechanically ventilated and invasively monitored with an advanced airway already secured prior to deterioration. Successful cases demonstrated compressions being performed on the thoracic spine with the same rate and force as compressions that would be delivered in the supine position (Bhatnagar et al. 2018).

It has been concluded that if resuscitation is commenced immediately, and the cause of arrest is simultaneously addressed, CPR in the prone position can generate a sufficient cardiac output (Kaur et al. 2016).

How to Perform Prone CPR

In order to perform any CPR, you must have basic or advanced life support training and knowledge on how to manage a deteriorating patient.

1. Ensure the patient is safely positioned on the bed and all therapies are optimised as per the medical team.
2. Ensure the endotracheal tube is secure.
3. Compressions should be delivered on the thoracic spine at the same rate and force as in the supine position.
   • Both hands should be interlocked and placed on the patient’s back on the midthoracic spine T7-T9/10.
   • Provide sternal counter pressure such as sandbags or 1-litre fluid bags under the patient’s chest.
   • Chest compressions should be carried out at a rate of 100-120 compressions per minute.
4. Refer to advanced and basic life support as per the hospital guidelines.
5. Ensure CPR mode on the bed is activated.
6. Ensure rotation amongst peers when performing CPR, as it is physically demanding.

(Al Harbi 2020; Intensive Care Society 2019; Saracoglu & Saracoglu 2018; Bhatnagar et al. 2018; Feix & Sturgess 2014)

Possible Complications

Complications from poor positioning may lead to an increase in mortality or morbidity rates. Other complications may include:

• Pressure injuries
• Injuries to the eye from direct pressure
• Accidental displacement of intubation. Air viva must be available to assist with this complication.

(Feix & Sturgess 2014)

Conclusion

Despite being a relatively uncommon procedure, prone CPR has been proven successful if the situation is attended to immediately.

If a patient goes into cardiac arrest while in a prone position, and a manoeuvre is not feasible, it is best to begin CPR immediately and reposition the patient later if required. Ensure you apply sternal counter pressure to the patient.

Note: This article is intended as supplementary learning and should not replace best-practice care. Always ensure your advanced and basic life support training is up to date and that you refer to your organisation’s policy on performing CPR.