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Prone Positioning in ARDS

Prone Positioning in ARDS: Moderate-Severe ARDS → Early Initiation (<36h of Intubation) → Check Contraindications → ⚠️ Absolute Contraindications.

Pathway Overview

14 steps

Algorithm Steps

14 total

  1. 01Start

    Moderate-Severe ARDS

    P/F <150 on FiO2 ≥0.6 and PEEP ≥5

  2. 02Action

    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
  3. 03Decision

    Check Contraindications

    Assess safety for prone positioning

  4. 04Warning

    ⚠️ Absolute Contraindications

    Do NOT prone

    • Unstable spine/spinal cord injury
    • Unstable pelvic fractures
    • Open abdomen
    • Anterior burns >20% BSA
    • Pregnancy (relative - 2nd/3rd trimester)
  5. 05Action

    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)
  6. 06Action

    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
  7. 07Action

    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
  8. 08Action

    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
  9. 09Action

    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)
  10. 10Decision

    Assess Response After 4h Supine

    Check P/F ratio 4h after returning supine

  11. 11Action

    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
  12. Path rejoins step 08Shared downstream outcome
  13. 12Outcome

    Refractory Despite Proning

    Consider ECMO evaluation if appropriate candidate

  14. 13Action

    Discontinue Proning

    When criteria met

    • P/F >150 on FiO2 ≤0.6, PEEP ≤10
    • Sustained for 4h in supine position
    • Clinical improvement overall
  15. 14Outcome

    ARDS Improving

    Continue lung protective ventilation, wean as able

Guideline Source

An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: ATS Clinical Practice Guideline

DOI: 10.1164/rccm.202311-2011STView Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Requires trained team for safe turning
  • Contraindicated in spinal instability
  • May not be feasible with open abdomen
  • Facial/airway edema can develop
  • Pressure injury risk requires vigilance

Contraindicated Populations

pediatricspinal_injury

Applicable Regions

USEUGlobal

Global: ATS/ESICM/SCCM strong recommendation for severe ARDS

Version 1Next review: 2028-01-01

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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 An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: ATS Clinical Practice Guideline.

What guideline is the Prone Positioning in ARDS based on?

This algorithm is based on An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: ATS Clinical Practice Guideline (DOI: 10.1164/rccm.202311-2011ST).

What are the limitations of the Prone Positioning in ARDS?

Known limitations include: Requires trained team for safe turning; Contraindicated in spinal instability; May not be feasible with open abdomen; Facial/airway edema can develop; Pressure injury risk requires vigilance. Individual patient factors may require deviation from these recommendations.

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