Prone Positioning in ARDS

Algorithm Steps

1. ▶

   Start

   Moderate-Severe ARDS

   P/F <150 on FiO2 ≥0.6 and PEEP ≥5

   1. ●

      Action

      Early Initiation (<36h of Intubation)

      Strong recommendation for severe ARDS

      • PROSEVA trial: mortality benefit in severe ARDS
      • Start early - within 36 hours of meeting criteria
      • Do not delay waiting for other therapies to fail
      1. ◆

         Decision

         Check Contraindications

         Assess safety for prone positioning

         1. ⚠

            Warning

            ⚠️ Absolute Contraindications

            Do NOT prone

            • Unstable spine/spinal cord injury
            • Unstable pelvic fractures
            • Open abdomen
            • Anterior burns >20% BSA
            • Pregnancy (relative - 2nd/3rd trimester)
         2. ●

            Action

            Relative Contraindications - Assess Risk/Benefit

            May proceed with caution

            • Recent sternotomy (>24-48h usually OK)
            • Facial trauma (protect airway)
            • Recent tracheostomy (<24h)
            • Hemodynamic instability (optimize first)
            • High ICP (may help or worsen)
            1. ●

               Action

               Preparation for Proning

               Team approach - minimum 4-5 people

               • Secure ETT (tape, not ties)
               • Pre-oxygenate on 100% FiO2
               • Increase sedation temporarily
               • Verify all lines/tubes secured
               • Apply protective dressings (face, chest)
               • Ensure IV access visible after turn
               1. ●

                  Action

                  Perform Prone Turn

                  Coordinated team maneuver

                  • One person dedicated to airway/ETT
                  • Lateral turn then prone (swim position)
                  • Arms: swimmer's position, change q2h
                  • Head: turn q2h, HOB 15-30°
                  • Confirm ETT position post-turn
                  • Resume ventilation, verify TV and pressures
                  1. ●

                     Action

                     Maintain Prone Position ≥16h/day

                     Strong recommendation: >12h, typically 16h sessions

                     • Standard: 16h prone, 8h supine
                     • Minimum effective: 12h prone
                     • Longer sessions may be more beneficial
                     • Monitor pressure points q2h
                     1. ●

                        Action

                        Monitoring While Prone

                        Vigilance for complications

                        • P/F ratio (expect improvement)
                        • Driving pressure, plateau pressure
                        • Pressure injuries (face, chest, knees)
                        • ETT position (equal breath sounds)
                        • Facial/tongue edema
                        • Enteral feeding (can continue)
                        1. ◆

                           Decision

                           Assess Response After 4h Supine

                           Check P/F ratio 4h after returning supine

                           1. ●

                              Action

                              Continue Proning Cycles

                              If P/F <150 supine, continue proning

                              • Return to prone for another 16h
                              • Continue until sustained improvement
                              • Typically multiple days of proning needed
                              1. ✓

                                 Outcome

                                 Refractory Despite Proning

                                 Consider ECMO evaluation if appropriate candidate

                           2. ●

                              Action

                              Discontinue Proning

                              When criteria met

                              • P/F >150 on FiO2 ≤0.6, PEEP ≤10
                              • Sustained for 4h in supine position
                              • Clinical improvement overall
                              1. ✓

                                 Outcome

                                 ARDS Improving

                                 Continue lung protective ventilation, wean as able