Prone Positioning and Organ Procurement

By Allison Varnum

Prone positioning is a hot topic around Turn Medical for obvious reasons. We are advocates for pronation because the research proves that the prone position is beneficial for patients with respiratory complications¹. There are many conditions or factors that lead to respiratory complications, and we’ve covered a lot of them in our blog and social media posts. However, there is one that we have not yet addressed – lung transplantation.

There is a shortage of lung donors worldwide and approximately 20% of patients waiting die annually². In the United States, as of September 2024, there are 898 patients waiting on a lung transplant³. One of the criteria for a donor’s lungs to be procured is that the PaO₂/FiO₂ (P/F) ratio is adequate. Patients with brain death often have atelectasis because of the absence of cough and respiratory drive. This results in ventilation-perfusion (V/Q) mismatch and hypoxemia. This risk for atelectasis can also be attributed to individual characteristics such as obesity, mechanical ventilation, and supine positioning. There are conventional methods to resolve atelectasis, but some cases have no response to those maneuvers².

In 2021, a case report was published in General Thoracic and Cardiovascular Surgery regarding a brain-dead patient with a P/F ratio of 49 and a chest x-ray showing progressive right lower lobe infiltrates and making the lung unviable for donation. She was a healthy 37-year-old non-smoker with an unremarkable medical history. Aggressive lung management was initiated to improve oxygenation and ventilation, but to no avail. Following failed recruitment maneuvers, the donor was placed in the prone position for 19 hours. The atelectasis improved and the P/F ratio increased significantly without hemodynamic instability or adverse events. Her lungs were then able to be transplanted. Immediately following transplantation, the P/F ratio increased to 637 and the patient was able to be successfully discharged 4 weeks post-transplant².

Prone positioning improves V/Q mismatch, allows for secretion drainage, and sustains improvement in atelectasis and shunting. While most used for acute respiratory distress syndrome (ARDS), studies have found pronation beneficial for brain-dead organ donors. The article mentions pressure on other organs such as the abdomen, heart, and liver from prone positioning may be of concern. However, in their evaluation there were no complications with the heart, liver, or abdomen and other studies have proven there has been no adverse complications in heart, liver, and kidney transplantation with the donor in the prone position².

Because of the shortage of viable organs available for donation, it is exciting to read about another method to improve availability for procurement. We are talking about automation in healthcare this month on our social media and how it can improve pronation for patients and providers. The Pronova-O₂^TM Automated Prone Therapy System provides support for critical care nursing staff during prone positioning by taking out the manual burden of the task. Contact us at turnmedical.com or 855-ASK-TURN to request a demo for your facility.