ARDS, COVID-19 and Pronation Therapy

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The first time a pulmonary physician asked me to prone his patient my reaction was, “You want me to do what?” Research has provided the evidence to support use of the procedure

The first time a pulmonary physician asked me to prone his patient my reaction was, “You want me to do what?” Research has provided the evidence to support use of the procedure. It has become almost commonplace in the ICU as a therapy for the subset of patients with acute respiratory distress syndrome (ARDS). I recently spoke with a hospital-based educator colleague who told me there were seven patients with ARDS due to COVID-19 receiving pronation therapy on her unit.

ARDS Categories

There are three categories of ARDS: mild, moderate or severe. Severe ARDS is acute hypoxemia with a P/F ratio (PaO2 from blood gas/FiO2 as a decimal) of ≤100 mmHg with PEEP ≥ 5cmH20. These patients are most likely to benefit from turning to a prone position. The goal is to match ventilation and perfusion by decreasing the pressure on the lungs from the abdominal contents, the heart and supporting structures, and the added weight of the edematous lungs. The ideal length of pronation is between 12–20 hours if the patient is showing improvement in the P/F ratio and is hemodynamically stable.

Safety First

Pronation therapy requires teamwork to achieve success safely and without complications. There have been different types of beds and equipment available to assist with pronation therapy. However, this can also be quite successful using some padding and an extra sheet. Ventilated patients may require neuromuscular blocking agents to maintain the position. Anecdotal information has suggested that non-ventilated patients on nasal cannula or high-flow oxygen may self-prone as tolerated for periods of time to prevent worsening of their condition, and they may show significant improvement even when lying prone for shorter periods of time.

Following are resources to help you understand the benefits of the procedure and see how pronation therapy can be done safely.

Resources to Support Your Practice

The following resources offer a variety of topics focused on safety and improved outcomes for your patients.

Featured in the book,”AACN Procedure Manual for High Acuity, Progressive, and Critical Care. 7th ed. Elsevier; 2011”, procedure 19 offers knowledge on pronation therapy.
This NTI session provides information on the latest evidence-based practice on ARDS and introduces a practical how-to guide for manual proning.
Through this NTI session, learn how to interpret new evidence and apply it to your practice to ensure these patients not only survive their ICU stay, but also return to their homes and communities.
Protocols and procedures discussed in this article in AACN Advanced Critical Care ensure successful prone repositioning and prevention of complications related to the procedure itself.

We hope the content provided in these resources helps you continue to deliver the best possible care during this time of crisis. Please share them with your colleagues and peers. As always, our AACN community is proud to serve you - our colleagues and co-workers - wherever you may be.

Do you have additional tips to share on how pronation therapy can be done safely? Tell us in the following comments section.

Linda Bell, MSN, RN

Clinical Practice Specialist, American Association of Critical-Care Nurses

Linda has a background in medical ICUs, unit-based education, advanced practice nursing with a liver transplant team and as a nurse manager. She has been with AACN in her current role for 20 years.

33 Comments

Are we recommending encouraging patients not vented to self-prone? What are other hospitals doing?

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Jean Little

07:25 AM · April 12, 2020 edited

We have started encouraging nonvented patients to self prone. We've definitely avoided some intubations by doing so. Even patients on as much as 60L h ... eated high flow we've been able to prone Read More

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Wendy Elliott

06:05 PM · April 12, 2020 edited

Good morning Wendy, Approximately, how long is a good amount of time for non-vented patients to be proned?

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Alma Huerta

08:30 AM · April 16, 2020 edited

We are proning ventilated patients and encouraging non ventilated patients to self prone. Proning patients without proning beds is labor intensive, an ... d takes 4 people. So usually it is done twice a shift without a proning bed, due to the labor requirements. I think Covid 19 is changing the way doctors consider intubating patients, because intubation does not always mean a life is saved, but it can mean high costs and the promise of false hope for families. If the prognosis and outcome is clinically poor in the ED should patients be intubated with Covid? Read More

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Jacquie Fischer

05:03 PM · April 16, 2020 edited

With a few hours of scanning through my resources affiliated with my institution sadly as I sense urgency with many of these requests about prone posi ... tioning, I want to answer your question quickly. I scanned about 50 abstracts and read a few articles. There isn't much research out there that fits your patient population and I'll echo the above "anecdotal" phrase (search phrases include: "prone"/"proning" as well as "non-intubated"/"non intubated"). A couple small studies report yes, prone position therapy looks to have positive results in non-intubated patients in studies, n=15 ("Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: A retrospective study", Scaravilli, V, et. al., doi: 10.1016/j.jcrc.2015.07.008), n=7 ("Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study", Ding, L, et. al., doi: 10.1186/s13054-020-2738-5). Read More

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John Powell

06:59 PM · April 16, 2020 edited

This is such a great detailed video on pronation

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Jennifer Jackson

01:58 AM · April 17, 2020 edited

Hello Wendy, We are implementing the prone therapy in my unit and it works fantastic in most of the patients. We prone the patients for a minimum of ... 14 hours. Read More

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Malby Davila Rojas

06:43 PM · April 17, 2020 edited

I am looking for specific guidance on posterior CPR for proned COVID 19 ventilated patients. Has anyone found a good video for critical care staff to ... watch that demonstrates proper hand positioning to begin posterior CPR until additional members of the team arrive in PPE? Read More

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Robin McNabb

10:36 AM · April 18, 2020 edited

Hi Robin - American Heart has published interim guidelance for basic and advanced life support for adults, pediatrics and neonates with suspected or c ... onfirmed COVID-19 that can be found here: https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.120.047463. They address doing CPR with patient in prone position on page 7. This is their statement: While the effectiveness of CPR in the prone position is not completely known, for those patients who are in the prone position with an advanced airway, avoid turning the patient to the supine position unless able to do so without risk of equipment disconnections and aerosolization. Instead, consider placing defibrillator pads in the anterior-posterior position and provide CPR with the patient remaining prone with hands in the standard position over the T7/10 vertebral bodies. Read More

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Linda Bell

01:15 PM · April 20, 2020 edited

Is proning for awake, alert non vented patient, a nurse driven protocol which requires physician order? Can anyone share their order set to us?

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Alma Agulto

11:06 PM · April 20, 2020 edited

We prone our covid pts who present to ER/ICU c/o SOB and requiring oxygen from nasal prong to highflow. We ask them to stay prone as long as they can ... over night then alternate supine/prone as tolerated during day time. I don’t have exact statistics but i have seen drastic improvement from O2sat 85% on 100% highflow oxygen to less then 50% O2 requirements and o2 sat above 94% within 30min to 2 hours. We often see O2 requirements increasing again when supine and pts requesting to be proned again. We have been able to avoid intubation in a lot of cases. Since we have been doing this we have less intubated covid pts in our icu. Read More

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Lyne St-Louis

04:15 PM · April 23, 2020 edited

Good morning, Patients that are prone, should feeding be stopped?

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Althea Ellis-Jones

07:07 AM · May 06, 2020 edited

Thank you Linda, this is very helpful. Do you have any information or found any research on proning NON intubated patients? Lyne, your post is very ... interesting! What challenges have you seen in proning your patients who are non vented? Thank you for sharing! Read More

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Marfil Caguin

07:37 AM · May 09, 2020 edited

To John Powell, thank you for the articles you have posted. The research included parameters and steps to help reduce the RATE of intubating patients ... and therefore prevent negative outcomes (focus on progressive mobility goals). The patient population were of pneumonia and flu. Parameters used were PF ratio and oxygen requirement in the decision tree. If we are able to sift through these research, it can help with nursing load and ratio. I am definitely looking at these articles to meet patients goals, promote good outcomes, and get them back to their families! We have success stories in our facility. Anything helps! Read More

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Marfil Caguin

08:18 AM · May 09, 2020 edited

Althea: The AACN Procedure Manual suggests you stop feedings one hour prior to pronation and then restart once the patient is proned. This response is ... from Sharon Dickinson: Critically ill patients with severe hypoxemia receiving mechanical ventilation can be safely feed in the prone position. Enteral nutrition is feasible and is generally well tolerated when delivered via a continuous nasogastric/orogastric feeding. Nutritional delivery in prone position is comparable with that of supine position. Sources: Savio, RD, Parasuraman, R., Lovesly, D, et al., Feasibility, tolerance and effectiveness of enteral feeding in critically ill patients in prone position, Journal of Intensive Care Society, January 14, 2020. https://doi.org/10.1177/1751143719900100 Saez de la Fuente I, Saez de la Fuente J, Estelles MDQ et al. Enteral nutrition in patients receiving mechanical ventilation in a prone position. JPEN J Parenter Enteral Nutr.2016;40(2):250-255. Read More

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Linda Bell

12:05 PM · May 12, 2020 edited

Marfil: As John noted, the research on proning non-ventilated patients is scarce and the 2 studies he cited are very small and the same ones I would ... give you. At this time there is not enough evidence to either endorse or refute the procedure, however, we know that it is being done as part of efforts to not intubate COVID-19 patients. It would make a good study . . . Read More

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Linda Bell

12:11 PM · May 12, 2020 edited

Hi Linda, Thank you very much for the information. Very helpful. I was skeptic that stomach upset & vomiting would more likely happen when pt's are p ... rone. Read More

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Althea Ellis-Jones

03:45 AM · May 20, 2020 edited

Do we restart trickle tube feeds?

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Maria Withrow

03:35 PM · June 03, 2020 edited

Hi Maria. The recommendations say that you should stop feedings for 1 hour prior to proning if possible and then restart once the patient is proned. T ... he rate will be determined by patient tolerance and your nutritional plan determined by the team. Read More

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Linda Bell

10:16 AM · June 09, 2020 edited

Is it absolutely necessary to use paralytics on a roto-prone bed if the patient tolerates the procedure with sedation?

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Rita Green-Meadows

12:06 AM · June 13, 2020 edited

Hi Rita: The goal is always to only use medication that the patient needs. If they are tolerating the procedure with only sedation, it would be a disc ... ussion with the team about the value and/or utility of using NMBs if the patient's clinical condition does not warrant use. Read More

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Linda Bell

09:20 AM · June 17, 2020 edited

Hi, I see a lot of comments about TF, I am wondering about NG/OG vs NJ, can a pt be proned with a gastric tube? or is a post-pyloric tube required?

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Caitlin Magoffin

07:23 AM · July 11, 2020 edited

Hi Caitlin: This response is from Sharon Dickinson: Critically ill patients with severe hypoxemia receiving mechanical ventilation can be safely feed ... in the prone position. Enteral nutrition is feasible and is generally well tolerated when delivered via a continuous nasogastric/orogastric feeding. Nutritional delivery in prone position is comparable with that of supine position. Sources: Savio, RD, Parasuraman, R., Lovesly, D, et al., Feasibility, tolerance and effectiveness of enteral feeding in critically ill patients in prone position, Journal of Intensive Care Society, January 14, 2020. https://doi.org/10.1177/1751143719900100 Saez de la Fuente I, Saez de la Fuente J, Estelles MDQ et al. Enteral nutrition in patients receiving mechanical ventilation in a prone position. JPEN J Parenter Enteral Nutr.2016;40(2):250- Read More

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Linda Bell

11:54 AM · July 14, 2020 edited

Our Physicians are requesting patients to be proned as long as possible,supine for meals and hygiene otherwise prone for the day.

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Beullah Arends-Terrell

11:07 AM · August 03, 2020 edited

Are ICU's making ventilated patients who are proned 1:1 care

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Patricia McCracken

07:07 AM · September 02, 2020 edited

Our ratio remains the same: ( 2:1 ) 2 patients/RN; because we have on overhead lift, at times when everybody's busy we are able to prone the patient w ... / 2 RN's and an RT Read More

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M Sheila Gasacao

03:24 PM · September 07, 2020 edited

Hi Patricia - thanks for your question and thanks to Sheila for her response. We are seeing variability around the country depending on availability o ... f staff and what level of the emergency response they are working in. I'd love to be able to tell you that all patients are being managed in the same way, but that is not possible universally. Read More

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Linda Bell

01:29 PM · September 11, 2020 edited

Is it safe to feed a COVID-19 patient in a prone position and on paralytic?

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Catherine Smithson

07:35 PM · September 26, 2020 edited

Hi Catherine - The recommendations from ASPEN regarding enteral nutrition for patients proned and on mechanical ventilation suggest that there is no d ... ifference between feeding a proned vs. supine patient on mechanical ventilation. The concern is for patients who are hemodynamically unstable on multiple vasopressors as well as narcotics and/or paralytics. You would still include assessing for feeding tolerance, such as vomiting or gastric ileus especially while receiving narcotics and/or paralytics. Should this occur you may have to consider using trophic feeds or holding feedings. Here's a short video from ASPEN that may help: https://www.youtube.com/watch?v=rUUK3lSpkqw&feature=youtu.be Read More

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Linda Bell

12:50 PM · October 05, 2020 edited

What type of ETT device holder are you all using for proning patients?

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Shannon Cotton

07:00 PM · December 12, 2020 edited

Has anyone seen an increase in their Cauti rates specifically related to patients in the prone position?

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Amanda Schwenk

07:25 AM · February 18, 2021 edited

Hi Shannon - I would suggest you put this question to one of the AACN Practice discussion groups as anecdotally it seems that practice varies. This pa ... ge will give you the options: https://www.aacn.org/clinical-resources/online-nursing-community-forums Read More

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Linda Bell

07:19 AM · February 22, 2021 edited

Hi Amanda - We have been noting questions on the various listservs and discussion groups about the issue of increased CAUTI rates in COVID-19 patients ... , however, no one has specifically directed their questions r/t proned patients. I would suggest you put this question to one of the AACN Community discussion groups for their responses. You can access them through this page on the AACN website: https://www.aacn.org/clinical-resources/online-nursing-community-forums Read More

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Linda Bell

07:22 AM · February 22, 2021 edited