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Prone Positioning in ARDS

Prone Positioning in ARDS: Adult moderate-severe ARDS on invasive ventilation → Prone early: after 12-24 h stabilisation → Unstable spinal fracture: do ...

Pathway Overview

18 steps

Algorithm Steps

18 total

  1. 01Start

    Adult moderate-severe ARDS on invasive ventilation

    P/F <150 mmHg (20 kPa) with PEEP ≥5 cmH2O, despite optimised lung-protective ventilation. Adults only.

  2. 02Action

    Prone early: after 12-24 h stabilisation

    Strong recommendation (ESICM 2023; ATS 2017, kept in ATS 2024). Start early after intubation if P/F stays <150 mmHg. ARDS that starts later still qualifies.

    • Stabilise first: VT 4-8 mL/kg PBW (PROSEVA used 6), plateau <30 cmH2O, set PEEP, optimise haemodynamics
    • Prone if P/F is still <150 mmHg after stabilisation
    • Do not wait for other rescue therapies to fail
    • PROSEVA: 28-day mortality 16% prone vs 33% supine
  3. 03Warning

    Unstable spinal fracture: do NOT prone

    This is the only absolute contraindication. Use other ARDS therapies (see "Do not prone" step).

    • Unstable spine or spinal cord injury: do NOT turn prone
    • Continue lung-protective ventilation and PEEP titration
    • Discuss VV-ECMO early with an ECMO centre if severe
  4. 04Warning

    Relative contraindications: senior ICU decision

    Prone only if benefit outweighs risk, with specialist agreement. Includes surgery or trauma to sternum, chest, trachea or face in the last 15 days.

    • Raised ICP or low CPP: neurosurgical agreement first; prone can raise ICP (PROSEVA excluded ICP >30 or CPP <60 mmHg)
    • Shock not controlled with vasopressors: stabilise before the turn
    • Pregnancy: obstetric input; pad to limit abdominal compression; continuous fetal heart monitoring
  5. 05Action

    Other relative contraindications

    Weigh each one against the benefit of proning. Get the relevant specialist view.

    • Sternotomy, thoracic or tracheal surgery in the last 15 days: surgical agreement
    • Facial trauma or facial surgery in the last 15 days
    • Unstable pelvic, femur or rib cage fractures
    • Open abdomen
    • Massive haemoptysis needing urgent surgery or embolisation
    • Single anterior chest drain with air leak (drain can kink)
    • DVT or PE treatment started, or pacemaker inserted, in the last 2 days
    • Burns ≥20% BSA
  6. 06Decision

    Safe to prone?

    Senior ICU doctor decides. No if unstable spinal fracture, or if the relative risks outweigh the benefit.

  7. If Yes
    1. Safe to prone
    2. 07Action

      Safe to prone: prepare the turn

      Team of 4-5 trained staff. One person controls the head and endotracheal tube (ETT).

      • Stop enteral feed and aspirate the gastric tube
      • Secure the ETT and record its depth; have suction and airway equipment ready
      • Rheumatoid arthritis of the atlanto-occipital joint: place a neck collar before the turn
      • Pre-oxygenate with FiO2 1.0; deepen sedation
      • Secure all lines, drains and catheters
      • Eye care; protective dressings on face, chest, pelvis and knees
      • Agree the plan for cardiac arrest while prone before the turn
    3. 08Action

      Perform the prone turn

      Coordinated turn led by the person at the head.

      • Turn through the lateral position to prone
      • Arms in swimmer's position; head turned to the side
      • Reverse Trendelenburg tilt to limit facial oedema
      • After the turn: check ETT depth, chest movement, SpO2, BP, tidal volume and pressures
      • Change head and arm position regularly (for example every 2-4 h)
    4. 09Warning

      Emergency while prone: act at once

      Stop the session and turn supine for a life-threatening problem, unless the turn would delay resuscitation.

      • Unplanned extubation or ETT obstruction
      • Severe desaturation or haemodynamic collapse despite treatment
      • Cardiac arrest: start CPR prone if the turn would delay it (hands on the spine between the scapulae, T7-T10); turn supine when safe
    5. 10Action

      Keep prone for ≥16 h per session

      ESICM 2023: sessions of 16 consecutive hours or more. ATS: more than 12 h per day.

      • PROSEVA: at least 16 consecutive hours, then supine
      • Continue the session even if oxygenation does not improve at first
      • Continue lung-protective ventilation throughout
    6. 11Action

      Monitor while prone

      Watch for complications. Pressure sores and facial oedema are the most common.

      • SpO2, P/F ratio, plateau and driving pressure
      • P/F falls >20% below the supine value: senior review; proning may stop
      • Meets EOLIA criteria at any time: discuss VV-ECMO with an ECMO centre now; do not wait for the session to end
      • ETT position and patency; secretions
      • Pressure areas: face, eyes, chest, pelvis, knees
      • Lines, drains and catheters: displacement or kinking
      • Restart enteral feeding after the turn; watch for vomiting
    7. 12Decision

      Stop criteria met 4 h after return to supine?

      P/F ≥150 mmHg with PEEP ≤10 cmH2O and FiO2 ≤0.6, at least 4 h after the end of the prone session.

    8. If Yes
      1. Criteria met
      2. 13Action

        Stop criteria met: stop proning

        P/F ≥150 mmHg, PEEP ≤10 cmH2O, FiO2 ≤0.6, at least 4 h supine.

        • Continue lung-protective ventilation
        • Reassess daily; senior review if oxygenation worsens again
      3. 14Outcome

        ARDS improving

        Continue lung-protective ventilation. Wean as able.

      If No
      1. Criteria not met
      2. 15Decision

        Criteria not met: severe hypoxaemia despite proning?

        EOLIA ECMO criteria: P/F <50 mmHg for >3 h, P/F <80 mmHg for >6 h, or pH <7.25 with PaCO2 ≥60 mmHg for >6 h, despite optimised ventilation.

      3. If Yes
        1. Refractory
        2. 16Outcome

          Refractory: refer to an ECMO centre

          Meets EOLIA-type criteria despite proning. Discuss VV-ECMO with an ECMO centre now. Proning can continue on ECMO.

        If No
        1. Not refractory
        2. 17Action

          Not refractory: next prone session

          Return to prone for another session of ≥16 h. Repeat daily until stop criteria are met.

          • Several sessions are often needed
          • Keep proning even if oxygenation improves little
        3. Path rejoins step 10Shared downstream outcome
    If No
    1. Do not prone
    2. 18Outcome

      Do not prone: use other ARDS therapies

      Lung-protective ventilation and PEEP titration. Consider NMBA in early severe ARDS. Discuss VV-ECMO early with an ECMO centre.

Guideline Source

ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies (Grasselli et al., 2023)

DOI: 10.1007/s00134-023-07050-7View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Unstable spinal fracture is an absolute contraindication; raised ICP, shock, pregnancy and recent chest or facial surgery need a senior and specialist decision
  • Needs a trained team of 4-5 staff and a local proning protocol; not for awake (non-intubated) proning or children
  • Stop criteria and session length come from one trial (PROSEVA)
  • Pressure injury, facial oedema and tube displacement are common complications

Contraindicated Populations

pediatricspinal_injury

Applicable Regions

AUUSEUGlobal

AU: Blood gases are reported in mmHg, as used here. VV-ECMO is available only in designated ECMO centres; discuss referral early.

Global: ESICM 2023 (Rec 7.1, 7.2) and ATS 2017, kept in place by ATS 2024: prone for ≥12-16 h per day in moderate-severe ARDS (strong).

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Prone Positioning in ARDS?

The Prone Positioning in ARDS is a management clinical algorithm for Critical Care. It provides a structured decision tree to guide clinical decision-making, based on ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies (Grasselli et al., 2023).

What guideline is the Prone Positioning in ARDS based on?

This algorithm is based on ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies (Grasselli et al., 2023) (DOI: 10.1007/s00134-023-07050-7).

What are the limitations of the Prone Positioning in ARDS?

Known limitations include: Unstable spinal fracture is an absolute contraindication; raised ICP, shock, pregnancy and recent chest or facial surgery need a senior and specialist decision; Needs a trained team of 4-5 staff and a local proning protocol; not for awake (non-intubated) proning or children; Stop criteria and session length come from one trial (PROSEVA); Pressure injury, facial oedema and tube displacement are common complications. Individual patient factors may require deviation from these recommendations.

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