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Prone Positioning in the Intubated Adult ICU
Patient
By Dr Lee CK, Dr. Cheah KS, Dr. Chiang CF
Dept of Anaesthesia and Intensive Care, Sg Buloh Hospital
Introduction
Ventilation in the prone position has become an important treatment modality for patients with
Acute Respiratory Distress Syndrome (ARDS). A meta‐analysis in 2014 has concluded that mechanical
ventilation in the prone position significantly reduces mortality in patients with moderate to severe
ARDS when used early and for greater than 16 hours per day in patients receiving lung protective
ventilation². The following year, a Cochrane systematic review recommends that prone ventilation
for 16 or more hours per day should be actively considered in patients with severe hypoxaemia
within 48 hours of mechanical ventilation³.
Although turning patients prone is not an invasive procedure, it is complex and has many potential
complications. It is therefore important to ensure a good standard of care. Many complications are
preventable or at least minimised with proper preparation, training and education of health care
workers.
We adapted an existing guideline1
and included various other sources to better suit our usual
practices. It is our hope that this clinical guideline will help improve patient outcome, elevate the
standards of care and reduce complications associated with this important and potentially life‐saving
procedure.

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HOW TO DO IT
Before Starting
Personnel
1. At least 5 are required.
2. Team leader should be the anaesthetist or a senior anaesthetic medical officer experienced
in positioning and airway management.
3. If the patient is greater than 90kg, 6 or more personnel are required.
ROLE DESCRIPTION PERSON
Team Leader
and Airway
Stands at the patient’s head end.
Coordinates the entire event.
Airway management and neck support.
Re‐checks pressure points at the end.
Anaesthetist / Senior medical
officer
Padding Places the padding at the appropriate locations.
Persons on the same side to
which the patient will be
rotated to.
IV Lines and
arterial lines
Ensure the lines do not get caught, dislodged or
kinked during the movement.
Persons covering the upper
limbs/lower limbs to check
corresponding lines.
CBD Ensure the CBD tubing is secured to the patient’s
thigh, and that it does not get caught, dislodged
or kinked during the positioning.
Person on the same side to
which the patient will be
rotated to.
Drains Ensure the drain(s) tubing are secured to the
patient and that it does not get caught, dislodged
or kinked during the positioning.
Person on the same side to
which the patient will be
rotated to.

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Equipment
Large pillows x2 (for the shoulders and pelvis)
Small pillows x2 (for the ankles)
Water‐filled nitrile gloves, tied‐off, x4 (knees and elbows)
Gel/foam head positioner or similar device may be used if available
Difficult Airway trolley and Medications
Difficult Airway Trolley
1. Laryngoscope with Macintosh blades 3,4
2. Long and short handles, batteries checked
3. Video laryngoscope
4. ETT, with one size larger and smaller than the one currently in the patient
5. OPA – various appropriate sizes
6. Suction – Yankauer and catheter
7. BVM with appropriate face mask, oxygen tubing.
Medications
1. IV Adrenaline 1mg/mL ampoule
2. IV Phenylephrine 0.1mg/mL
3. IV Ephedrine 6mg/mL
4. IV Rocuronium 50mg vial x1
5. Sedation – IV propofol/fentanyl/midazolam – as ordered
6. IV Infusion pumps are sufficient and functioning

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Pre‐flight Checklist
1. Nurse in charge documents all pressure sores, ulcers and other injuries already present.
Cover them with DuoDERM® or similar dressings.
2. Withhold feeding and aspirate gastric contents.
3. Ensure sufficient personnel
4. Identify each person and assign roles (refer to the table of “Roles”)
5. Briefing
a. Step‐by‐step plan, including final position.
b. Decide on direction of rotation. For this guideline, it is depicted as right‐lateral, but
you may wish to adjust depending on special circumstances eg: presence of
drains/lines.
c. Consider also the location of any central lines. During turning, the lines and tubings
should be placed above the patient instead of underneath; to avoid any kinks or
obstructions.
d. Ask if any team member has any questions and address them.
e. Emphasise the avoidance of pressure sores, nerve and eye injuries.
6. Ensure difficult airway trolley and medications are prepared.
7. Ensure equipment is functioning, and necessary medications diluted.
8. Check mattress and padding.
9. Place the patient supine in a neutral position.
10. Eyes cleaned and taped.
11. Check intubation difficulty.
12. Check ETT depth and size, and ensure anchors are secure.
13. Check breathing circuit – adequate length.
14. Position breathing circuit and ventilator to the side where the patient is being turned
towards. (In this guideline, it is on the patient’s right).
a. This also aids during team communication, as it may be clearer to say “towards” or
“away from” the ventilator when specifying direction.
b. This also helps prevent the breathing circuit from getting trapped or dislodged.
15. Maintain the same FiO2 patient is on.
16. Flush IV access to check patency (maintain sterility). Make sure the lines are secure.
17. Aim for a RASS of ‐5 and give a bolus of muscle relaxant.
18. Disconnect all non‐essential IV infusions while maintaining sterility.
19. Place the IV infusion pumps at the corresponding sides of the patient.
20. IV infusions that are still ongoing – make sure the tubing is long enough for the positioning.
Bear in mind the final position of the syringes and pumps and reposition as needed.
21. Re‐position the ECG leads to the dorsum of the torso. Remove any of the adhesive pads
from the chest of the patient.
22. Are the vitals signs stable for the positioning?
23. Ensure the arterial line is securely taped to the patient. Maintain sterility when
disconnecting from the tubing.
24. Check for any drains especially chest drains, repositioning the underwater seal or bottle as
needed. Check that the tubing does not get obstructed or kinked.
25. Check for CBD tubing – place it in between the patient’s legs without crossing over or under
the patient. Secure the proximal end of the tubing.

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Step‐By‐Step Prone Positioning
1. Team Leader stands at the patient’s head end, to the left of the breathing circuit and
ventilator if the plan is to rotate the patient right‐lateral.
2. At least 2 staff on either side of the patient. Check that each person knows which line/drain
they are responsible for.
3. Tuck the arm closest to the ventilator underneath the buttock with the palm facing
anteriorly.
4. You may choose to place the pillows/padding over the patient at this point, thereby covering
and “wrapping” the patient with a clean bedsheet.
5. Alternatively, the padding can be placed on the bed after the patient has completed the
horizontal move.
6. The edges of the bedsheet are rolled tightly together
7. HORIZONTAL MOVE: Keeping the bedsheet pulled taught and the edges rolled tight, move
the patient horizontally away from the ventilator until the edge of the bed. Place the
paddings now if not already done.
8. 90° ROTATION UP: On the count of the team leader, the patient is rotated up, facing the
side of the ventilator.
9. HOLD in this position while the staff change their hand positions to prepare to receive the
patient and to check for any obstruction eg bedding, tubes.
10. READY: Receiving side signals they are ready to receive the patient.
11. 90° ROTATION DOWN: On the count of the team leader, the patient is rotated down onto
the receiving arms. The patient’s head may be placed facing either side in the prone
position.
12. Place the patient in the PRONE SUPERMAN position with both arms raised. Alternatively you
may place it in the SWIMMERS POSITION: Raise one arm on the same side to which the head
is facing, whilst placing the other arm by the patient’s side. Shoulder abduction to 80° with
elbow flexion of 90° on the raised arm.
13. Make any adjustments necessary to the pillows/padding, taking extra care around the
pressure areas and eyes. Avoid overstretching any joints that may lead to neural plexus
injuries.
a. As far as possible, the abdomen hangs free and moves with respiration.
b. Breasts and male genitalia should not be compressed.
c. Breasts are positioned medial to the gel bolsters.
d. Penis hanging between the legs with the catheter secured.
e. Ears not bent over.
f. ETT not pressed against the corner of the mouth/lips.
g. NG tube not pressed against the nostril.
h. Lines/tubing not pressed against the skin.
14. Place an absorbent pad under the patient’s head to catch secretions.
15. Reattach the patient monitors and IV infusions.
16. Team leader re‐checks all the pressure areas. No direct pressure on the eyes.
17. Alternate the head and arm positions every 2‐4 hours.
18. Nurse in the 30° reverse‐Trendelenburg position.

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STEPS 1‐2
STEP 3

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STEP 4
(With pillows placed on the patient prior to turning)
STEPS 5 ‐ 6

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STEP 7
STEPS 8‐11

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STEP 12
STEP 13

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When to Do It (And when not to do it!)
Indications 1
Severe ARDS; PF ratio <150mmHg with FiO2 ≥ 0.6, PEEP 5 cmH2O
Early course of disease (ideally 48 hours) following 12‐24 hours ventilation
Contraindications (Absolute)8
Spinal instability
Open chest post cardiac surgery/trauma
<24 hours post cardiac surgery
Central cannulation for VA ECMO or BiVAD
Contraindications (Relative)8
Polytrauma (Chest, Pelvic)
Severe facial fractures
Head injury, raised intra‐cranial pressure >30mmHg, or cerebral perfusion pressure <60mmHg
Morbid obesity
Pregnancy (2nd
, 3rd
trimester)
Raised intra‐ocular pressure
Frequent seizures
Recent tracheostomy <24hours
Haemodynamic instability
Previous history of poor tolerance to prone
Recent DVT treated < 2 days
Anterior chest tube with air leak
Recent pacemaker
Severe burns
Recent abdominal surgery

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Complications8
Nerve compression (brachial plexus)
Crush injury
Venous stasis (facial oedema)
Dislodging endotracheal tube
Diaphragm limitation
Pressure sores (facial)
Dislodging vascular catheters or drain tubes
Retinal damage
Transient reduction in oxygen saturation
Vomiting
Transient arrhythmias

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Special Circumstances
Cardiac arrest in the prone position
Resuscitation council (UK) guidelines published in 2014 recommend that chest compressions should
be started without change in position during cardiac arrest. Adequacy may be assessed using end
tidal CO2 and/or arterial pressure waveforms, with the patient turned supine if chest compressions
are ineffective.
Chest compressions
There are several published case reports on the success of CPR in the prone position using various
techniques described below:
Case Report Method
Two successful CPR in prone
neurosurgical patients. ⁴
Chest compression over mid thoracic spine using a hand
under the lower sternum as counter‐pressure.
Successful CPR in a prone patient
with severe pneumonia in the ICU. ⁵
Two handed chest compressions over the mid‐thoracic spine
with a second rescuer providing counter pressure
underneath the sternum.
Successful CPR in a prone
neurosurgical patient. ⁶
Chest compression at the mid thoracic level without sternal
counter pressure.
For the purposes of this guideline, we adapt the following⁷:
1. Chest compressions can be started by compressing the spine in between the scapulae
(shoulder blades). The same compression rate (100‐120/min) and depth of compression (5‐6
cm) as conventional chest compression should be used.
2. Aim for a diastolic pressure of 25 mmHg on the arterial line.
3. If the cardiac arrest rhythm is shockable, attempt defibrillation by placing the defibrillator
pads in a bi‐axillary (both armpits in the mid‐axillary line) or antero‐posterior (front and
back) position.
4. If there is a problem with the airway (e.g. displacement of tracheal tube), it will be necessary
to rapidly turn the patient supine – this requires practice and should be planned for in units
managing prone patients with COVID‐19.
5. If initial attempts at resuscitation are unsuccessful, or chest compressions are ineffective
turn the patient supine to facilitate resuscitation.
6. It may be possible to continue mechanical ventilation during continuous chest compressions
by making adjustments to the ventilator settings and not disconnect the ventilator. Set the
ventilator at 10 breaths per minute. If there is a need to break the circuit, follow guidance
for disconnection to minimize aerosol generation.

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Two handed CPR without sternum counter pressure (left), with sternum counter pressure (right)
Defibrillation
Successful defibrillation can be achieved with pads over either the posterolateral (left mid‐axillary
line, right scapula) or bi‐axillary positions. (NB: reversed in dextrocardia/situs inversus).
Placement of defibrillator pads in prone position

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Bronchoscopy
Although bronchoscopy in patients with lung parenchymal disease may be beneficial in removing
secretions to overcome atelectasis, and for obtaining samples for culture & sensitivity, it is
recommended that mechanical ventilation in the prone position be delivered for at least 16 hours
per day in moderate/severe ARDS. Early termination of the prone position for bronchoscopy may
have a negative impact on the benefits derived from the prone position.
Performing flexible bronchoscopy in the prone position carries additional risks. Partial obstruction of
the endobronchial tree by a bronchoscope increases the airway resistance, airway pressure and
reduces tidal volume. Therefore, modification of ventilator settings is necessary to prevent severe
complications such as pneumothorax or worsening lung parenchymal injury.
In general, a careful risk‐benefit assessment should be undertaken prior to performing bronchoscopy
for a patient in the prone position.
ECMO
Indications to turn a patient prone while on ECMO include:
1. Refractory hypoxia on ECMO
2. To facililate pulmonary toilet and drainage
3. Failure to wean VV ECMO
In addition to the risks inherent in ECMO, prone positioning carries additional potential problems:
1. The possibility of dislodging the ECMO cannulae
2. Increased risk of air entrainment into the ECMO circuit
3. Reduction in ECMO blood flows through compression of ECMO cannulae and circuit tubing
or through abdominal pressure changes
4. Bleeding from cannulae sites that are no longer accessible
5. Difficulty managing an oxygenator thrombosis that requires immediate circuit change.
It is recommended that prone patients requiring ECMO to be done in specialist ECMO centre with
sufficient experience and established protocols in place.

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Local safety standards for invasive procedures (LocSSIP)
Please refer to the appendix for the LocSSIP checklist.
The checklist is designed to improve communication between team members carrying out the
procedure. Identifying roles and responsibilities and creating a culture where team members have
the autonomy to speak out if they identify any problems, should also help to reduce the frequency
of complications.
The core components of the checklist are as table below:
Pre‐procedure check Time out Sign out
All team members introduce
themselves and allocate role.
Essential pre procedure check.
Final check before begin the
procedure.
Ensure that handover is given
to the nursing staff to ensure
safe ongoing care of the
patient.
Complete a post‐proning check
of the patient to ensure all
aspects of the post‐proning
care bundle are address.

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Appendix : Equipment and Medications Checklist
Airway and oxygen √
Laryngoscope with Macintosh blades 3,4
Long and short handles, batteries checked
Video laryngoscope
ETT, with one size larger and smaller than the one currently in the
patient
OPA – various appropriate sizes
Suction – Yankauer and catheter
BVM with appropriate face mask, oxygen tubing.
Medications
IV Adrenaline 1mg/mL ampoule
IV Phenylephrine 0.1mg/mL
IV Ephedrine 6mg/mL
IV Rocuronium 50mg vial x1
Sedation – IV propofol/fentanyl/midazolam – as ordered
IV Infusion pumps are sufficient and functioning
Others
Large pillows x2 (for the shoulders and pelvis)
Small pillows x2 (for the ankles)
Water‐filled nitrile gloves, tied‐off, x4 (knees and elbows)
Gel/foam head positioner or similar device may be used if available

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Appendix : LocSSIP Checklist

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Appendix : Post Proning Nursing Checklist

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References
1. Intensive Care Society. Guidance for Prone Positioning in Adult Critical Care, Nov 2019
2. Sud, S., Friedrich, J., Adhikari, N. et al. Effect of prone positioning during mechanical
ventilation on mortality among patients with acute respiratory distress syndrome: a
systematic review and meta‐analysis. CMAJ (2014); 186 (10): 381‐390.
3. Bloomfield, R., Noble, D., Sudlow, A. (2015) Prone position for acute respiratory failure in
adults. Cochrane database of systematic reviews. CD008095.pub2.
4. Sun W, Huang F, Kung K, Fan S, Chen T. Successful Cardiopulmonary resuscitation of two
patients in the prone position using reversed precordial compression. Anesthesiology
1992;77(1):202–4.
5. Dequin P‐F, Hazouard E, Legras A, Lanotte R, Perrotin D. Cardiopulmonary resuscitation in
the prone position: kouwenhoven revisited. Intensive Care Med 1996;22:1272
6. Gomes D de S, Bersot CDA. Cardiopulmonary resuscitation in the prone position. Open
Journal of Anesthesiology 2012; 2: 199‐201
7. RCUK statement on COVID‐19, CPR and resuscitation. COVID 19: FAQ for health care
professionals
8. UpToDate.com; Prone ventilation for adult patients with acute respiratory distress syndrome