Patient Treatment Guidelines

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Prone Ventilation Guideline

Last update: March 17, 2020


Inclusion criteria

COVID-related ARDS, following a 12-24h stabilization period, with all of the following:

  • P:F ratio <150
  • TV <=6cc/kg PBW
  • FiO2 >60%
  • PEEP >10%
  • Total duration of ARDS <36h

Exclusion criteria (absolute)

  • Tracheal surgery or sternotomy in previous 15 days
  • Unstable spine, pelvic, or femur fractures
  • Massive hemoptysis

Exclusion criteria (relative)

  • Facial trauma or surgery in previous 15 days
  • Intracranial hypertension
  • Intraabdominal hypertension or open abdomen
  • Pregnancy >24wks


  • Specific risks discussed including: ETT and line dislodgement, facial and ocular pressure ulcers
  • Attending approval and presence of supervising provider for all repositionings
  • Prone positioning per prone positioning algorithm (see attached)
  • Prone position maintained for 16h/day
  • Head and arm repositioning every 2h
  • Supine position for 8h/day:
    • Ideal timing 8am-4pm
    • Patient assessment, CXR (not routine, only if needed), sedation/paralytic reevaluation done during this time

Minimum monitoring requirements during therapy

  • Secure central venous and arterial access
  • Feeding tube and Foley catheter

Discontinuation criteria

  • P:F ratio >150 with FiO2<=60% & PEEP <=10 maintained after 4h in supine position
  • Acute complication during prone positioning:
    • Cardiac arrest
    • Endotracheal tube dislodgement or malposition
    • Refractory hypoxia (sat <85% or PaO2 <55mmHg on FiO2 100% for >5min)
    • Bradycardia (<30bpm for >1min)
    • Hypotension (SBP <60 for >5min)
    • ICP elevation (>25mmHg for >5min)


Prone positioning has been used safely for many years in patients with ARDS. Physiologically, prone positioning increases blood flow to better-aerated lung (improved V/Q matching), increases functional residual capacity (FRC), reduces atelectasis, distributes plateau pressure more homogenously across the lung, and facilitates secretion drainage. It is, however, associated with the potential complications of endotracheal tube (and other line and tube) dislodgement, pressure ulcers, and increased intraabdominal and intracranial pressure, and the logistics of the position complicate many routine patient care activities.

A recent randomized controlled trial of prone ventilation at experienced centers in patients with severe ARDS (P:F <150) after 12-24h of initial stabilization demonstrated a >50% reduction in 28-day mortality (33% supine vs. 16% prone), with a number needed to treat of 6 (1). Subsequent meta-analysis confirmed this mortality benefit, also noting increased risk of pressure ulcers (OR 1.49) and airway complications (OR 1.55); however, no difference in other line/tube dislodgement or in cardiac events was seen, and none of the airway complications was fatal (2).  Prone ventilation has been systematically studied in trauma and surgical ICU patients specifically in two studies, although both broadly included patients with P:F ratio <300: a 40-patient prospective randomized trial showed improved P:F ratio in the prone group, but no difference in ventilator days or mortality (3); and a 61-patient retrospective study showed improved P:F ratio, fewer ventilator days, and lower overall mortality in the prone group (4). Although an early case series raised concern about surgical complications of prone positioning in the trauma population (5), this has not been systematically seen in a small retrospective study of postoperative patients, where no increase in abdominal surgical complications was seen (6).

While there is no specific high-quality evidence for prone ventilation in COVID-related ARDS, several groups’ early experience has suggested that early proning is clinically effective.

  • Guerin C et al. New Engl J Med 2013;368(23):2159-68.
  • Lee JM et al. Crit Care Med 2014;42(5):1252-62.
  • Voggenreiter G et al. J Trauma 2005;59(2):333-43.
  • Davis JW et al. J Trauma 2007;62(5):1201-6.
  • Offner PJ et al. J Trauam 2000;48(2):224-8.
  • Gaudry S et al. Ann Intens Care 2017;7(21):1-8.


These documents and content on this website are guidelines during the COVID-19 pandemic. Because new information is released rapidly, these documents can be updated or changed at any time. These documents are in no way to be considered as a standard of care and the content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. The information in these documents is provided with no guarantees, accuracy, or timeliness. All content in these documents and website are for informational purposes only and do not constitute the providing of medical advice.