In severe COVID-19 pneumonia with refractory hypoxemia, patients are often proned (put on their abdomen), deeply sedated, and paralyzed to improve synchrony with the ventilator. The goal with proning is to create a more homogenous alveolar recruitment thereby decreasing shunting (parts of the lung where there is pulmonary blood flow but no ventilation leading to V/Q mismatch). Typically, our patients are kept prone for 18 hours and then placed supine for 6 hours.
Since so much time is spent in the prone position, we have to become comfortable with prone x-rays. This means that all we’re doing is mirroring structures in the horizontal axis (ie, left on the x-ray is the patient’s left). We can also have our radiology colleagues “flip” the image so it looks more like a traditional x-ray.
Here’s a chest x-ray showing severe COVID-19 pneumonia with an endotracheal tube (ETT), right internal jugular (IJ) central venous catheter (CVC), and lung fields chock-full of air bronchograms.