Prone Position Puts Severe COVID-19 Patients on Ventilation at Risk of Permanent Nerve Damage

PRONING patients on ventilation is common practice to help breathing and reduce mortality and has been utilised for those with acute respiratory distress syndrome as a result of coronavirus disease (COVID-19). But according to a new study, patients seriously ill with COVID-19 could be at risk of developing permanent nerve damage from being placed in the prone position while on ventilation.

Nerve damage rarely occurs when non-COVID-19 patients on ventilators are placed in the prone position; however, generalised weakness is a common occurrence due to being bedridden for long periods of time. This is a reason why the researchers believe the nerve injuries to be initially missed, as they were masquerading as common effects of being bedridden. However, during the rehabilitation process, the researchers identified a pattern of weakness in patients who had been severely ill with COVID-19 that was concerning, which often included severe weakness or even one-sided paralysis of important joints such as the wrist, ankle, or shoulder.

The authors published their findings from 11 patients who presented with these patterns of weakness. Injuries were most common in larger joints, and consisted of wrist drops; foot drops, which would sometimes require wheelchair, brace, or cane assistance for patients to walk; loss of hand function; and frozen shoulder. Furthermore, some patients had as many as four distinct nerve injury sites.

Permanent nerve damage is suspected to occur in 12–15% of the most severely ill patients with COVID-19, according to data from this present study and another recent study. Lead investigator Dr Colin Franz, Shirley Ryan AbilityLab and Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA, commented: “This is a much higher percentage of patients with nerve damage than we’ve ever seen in any other critically ill population. Ordinarily, very sick people can tolerate the position that helps their breathing. But COVID-19 patients’ nerves can’t tolerate the forces other people can generally bear.”

As a result of this study, physicians at Northwestern Memorial Hospital are changing their prone position protocol for COVID-19 patients to help prevent nerve damage, which includes adjusting the way joints are positioned and placing extra padding under the elbow and knee joints to relieve those areas that are especially under pressure while in the prone position.