1. Indication
Moderate to severe ARDS with PaO2:FiO 2 ratio < 150 mmHg and FiO 2 ≥ 0.6
2. Contraindications
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Absolute |
Relative* |
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● Spinal instability. ● Open chest post cardiac surgery/trauma. |
● Multiple Trauma e.g., Pelvic or Chest fractures, Pelvic fixation device. ● Severe facial fractures. ● Head injury/Raised intracranial pressure. ● Frequent seizures. ● Raised intraocular pressure. ● Recent tracheostomy < 24 hrs. ● CVS instability despite resuscitation with fluids and inotropes. ● Morbid obesity. ● Pregnancy 2nd/3rd trimester. |
*In these cases, the ICU team has to make decision for proning after risk-benefit analysis.
3. Duration
Typically, 16-18 hrs. but may consider up to 24 hrs if tolerated. Supination for 4 hrs before next session of proning.
4. Articles required
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Airway trolley. |
Closed circuit suctioning. |
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Endotracheal tube (ETT) tapes. |
Slide sheet and clean bed sheets. |
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3-5 pillows. |
ECG electrodes. |
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Gauze pad for padding pressure areas. |
Head ring. |
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Paper tape. |
Resuscitation drugs. |
5. Consideration prior to Proning
5.1. Airway/Breathing
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Difficult airway trolley should be checked and available at bedside. |
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Note the previous laryngoscopy grade and length of the endotracheal tube (ETT) at the incisor teeth. |
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Securely tape or tie the ETT. If tied then ensure padding in situ between tie and skin. |
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Suction oropharynx and airway prior to procedure. |
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Ensure closed circuit suctioning is available and working throughout procedure. |
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Patient should be pre-oxygenated with 100% O2 and ensure appropriate ventilator settings. |
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Note ventilator settings such as tidal volume, FiO2, respiratory rate, PEEP, and inspiratory pressure. |
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Perform pre-proning arterial blood gas and document results. |
5.2. Cardiovascular system
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Patient should be hemodynamically stable. |
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Prepare for post-proning instability with preparation of vasopressors/inotropes. |
5.3. Neurological system
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Patient should receive adequate sedation and analgesia. |
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Target RASS score -2 to -3. |
5.4. Skin
Nursing staff should document skin integrity.
5.5. Eyes
Eyes cleaned, lubricated and taped to prevent drying and ulceration. Ideally eyes should be protected with gel pad or similar.
5.6. Tubes and lines
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Ensure all the tubes and lines are secured. |
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Discontinue non-essential infusions. |
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Nasogastric feed should be hold for 1hr prior proning. |
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Document Nasogastric tube length. |
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Chest drains need to be well secured and placed below the patient. Tubing should run down the patient and be managed by a separate team member. Clamp only if safe to do so. |
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Adequate length on the remaining lines/cables running up the patient if above the waist, or down the patient if below. |
5.7. General
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Daily hygiene addressed, e.g., mouthcare, washing, dressing, changing of stoma bags. |
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Ventilator as close to the patient as possible on the appropriate side. The patient should be rolled towards the ventilator. |
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Assemble 3-6 persons depending upon patients’ size, lines and tubes present. An airway expert at the head end of the bed and primary nurse and additional 1-4 persons on either side of the patient to perform as “flippers and catchers”. |
6. Steps for proning
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Patient should be laid flat with the bed in a neutral position. |
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Airway expert remain at the head end of the bed and two persons remain on both side of the patient. |
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Perform the paddings in pressure areas. |
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Tape the eyelids. |
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Remove the ECG leads, unnecessary infusions, and lines. |
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Move the patient horizontally to lie on the edge of the bed away from the ventilator on the count of the person at the head end. |
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Tuck arm closest to the ventilator underneath the buttock with the palm facing anteriorly. |
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Spread the bedsheet, draw sheet, and under pads. |
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If pillow is required, place one pillow at chest, iliac crests and shins level. |
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Now on the count of the person at the head end roll the patient towards the ventilator carefully supporting the head and neck. |
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Pull and spread the bedsheet, draw sheet and under pads at opposite side from underneath the patient. |
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Ensure the ETT is not kinked and that a CO2 trace is still present on the capnograph. Note the length of the ETT at the incisor teeth and review ventilator settings. |
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Reattach the ECG electrodes and ensure all monitoring is re-established. Resume all the required infusions. |
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Keep the patient in reverse Trendelenburg position 30°. |
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Place the hand in swimmers’ position. |
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The head direction and hand position should be changed every 4hrs. |
Prone position is accomplished by first turning the patient toward the ventilator until the patient is positioned on the side. After a pause, continue to turn the patient over by pulling the tucked arm and a new flat sheet away from the ventilator until the patient is in the prone position. The position of the endotracheal tube should be monitored carefully during this procedure.
At least 5 care personnel, including a clinician trained in airway management, are needed to safely place an intubated patient in the prone position. The role of each personnel should be assigned in briefing that takes place before the procedure is performed.
After turning the patient over to the prone position, confirm that the patient remains ventilated by auscultating breath sounds in both lung fields. Also confirm that the tidal volume and ventilating pressures are being correctly delivered by the ventilator.
7. Prone to Supine
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Airway trained doctor and adequate staffs available. |
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Preparation as per proning; ● Pre-oxygenate with 100% oxygen. ● Endotracheal tube and venous lines secure. ● Discontinue non-essential infusions / monitoring. ● Adequate sedation. ● Nasogastric feed stopped and nasogastric tube aspirated. ● Chest drains if present, secure and below patient. |
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Horizontal move away from the ventilator if patient is facing away from the ventilator or vice versa. |
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Spread the bedsheet, draw sheet and under pads. |
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Turn the patient to supine position. |
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Pull the bedsheet, draw sheet and under pads and spread it. |
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Reattach the monitor and resume all the infusions. |
8. Special conditions
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If the situation arises to provide CPR, two handed techniques for chest compressions over the mid thoracic spine located between the two scapula is recommended and counter pressure may be applied using a second person. |
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Successful defibrillation can be achieved with the pads either applied posterolateral (one in the left mid-axillary line, the other over the right scapula) or in the bi-axillary positions. |
Further Readings:
1. Scholten, E. L., Beitler, J. R., Prisk, G. K., & Malhotra, A. (2017). Treatment of ARDS with prone positioning. Chest, 151(1), 215-224.
2. Roche-Campo, F., Aguirre-Bermeo, H., & Mancebo, J. (2011). Prone positioning in acute respiratory distress syndrome (ARDS): when and how? La Presse Médicale, 40(12), e585-e594.
3. Wiggermann, N., Zhou, J., & Kumpar, D. (2020). Proning patients with COVID-19: a review of equipment and methods. Human Factors, 62(7), 1069-1076.
4. Rampon, G. L., Simpson, S. Q., & Agrawal, R. (2023). Prone positioning for acute hypoxemic respiratory failure and ARDS: a review. Chest, 163(2), 332-340.
