Version 2.

0 04/08/2020
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 Massachusetts General Hospital
Prone Positioning Guideline
Designated Clinical Areas:
All areas caring for critically ill ARDS patients

Introduction/Purpose:
Many ICU patients have acute respiratory distress syndrome (ARDS) requiring advanced
therapies to improve oxygenation. Most interventions and therapies do not improve mortality or
better long-term patient outcomes. Prone positioning of ARDS patients leads to improved
oxygenation and has recently been found to decrease mortality.1,2 This document serves to inform
our ICU clinicians about prone positioning of critically ill ARDS patients.
Contraindications:
• Spinal instability
• Facial or pelvic fractures
• Open chest or unstable chest wall
• Uncontrolled intracranial pressure
• Relative contraindications: Severe hemodynamic instability

Equipment:
• Minimal of 5 staff members to safely position the patient
• At least 5-10 foam dressings for padding
• 3 Waffle cushions: 2 for upper extremities and 1 for head
• 2 flat sheets
• EKG stickers
• Ambu with mask
• Nova Plus Jellies pillow (blue gel pad) for side of face/nose
• Additional off-loading may be needed around nose to protect from ETT/NGT,
use: (1) Allevyn foam strip to cover nares/tip of nose, and (1) Allevyn foam strip
to cover bridge of nose
Link to Video:

 https://www.youtube.com/watch ?v=E_6jT9R7WJs or search “Prone Positioning in Severe

Acute Respiratory Distress Syndrome” NEJM

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Nursing Actions/Special Considerations
Nursing Action Special Considerations
Assessment

1. Assess hemodynamic status The healthcare team should effectively manage

2. Assess mental status. agitation to provide a safe proning environment.
3. Assess size and weight to determine Ensure whether a 180-degree turn may be safely
the ability to turn within the bed accomplished within the confines of the
frame. bedframe.
4. Evaluate for absolute/relative
contraindications (noted above).

Preparation

1. Ensure order for prone positioning.

2. Discuss with team use of bolus dose

of a paralytic to ensure safety of staff
and patient during the procedure

3. There is no requirement for ongoing

paralytic once patient is in prone
position.

4. If possible, turn off enteral feeding 1 Reduces the risk of aspiration during turn.
hour prior to proning.

5. Disconnect enteral feeding

6. Keep 5 leads on anterior chest wall

Limb leads may be placed lateral on all limbs so
and remove remaining V2-V6 leads.
as not to require removal with each turn

7. Perform eye care (lubrication and

taping of the eyelids horizontally
closed).

8. Protect and secure the airway. Note

Frequently assess commercial endotracheal
the position of the tube.
securement device during prone positioning
because of the possibility of skin breakdown and
9. Empty ileostomy/colostomy bags. potential of adhesive breakdown due to salivary
drainage.
10. Secure tubes and catheters.
Disconnect nonessential tubing.

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11. Apply 3M Cavilon moisture barrier Will protect from drainage of oral secretions.
to patient’s face.

12. Place foam dressing to upper The foam dressing will reduce the risk of
chest/clavicles, shoulders, pelvis, friction, shear, and pressure
elbows, knees, forehead, and tops of (Refer to appendix A).
feet. Place Novaplus Jellies gel pad
under side of face/nose.

13. Disconnect arterial line from the

pressure bag. Cap the arterial line at
the t-piece.

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Method for turning the patient in the
prone position (five-step method)
1. Start with ensuring there is flat sheet At least 5 staff members may be required to turn
under the patient. the patient.

2. Position the staff at the sides of the The person on the side of the bed closest to the
bed and the respiratory therapist at patient maintains body contact with the bed at
the head of the bed. all times to serve as a side rail. The RT at the
head of the bed is responsible for securing the
3. Maximally inflate the bed. ETT, ventilator tubing.

4. Pull patient using the underlying flat

sheet while in the supine position to
the side of the bed away from the
ventilator.

In order to turn the patient in the direction of the

ventilator.

5. Cross the patient’s outer leg over the Chest and/or pelvic support can be done by
inner leg at the ankle placing a pillow at the abdomen before
completing the turn.
6. Keep both patients arms straight
against the body

7. Tuck a new flat sheet, and the arm

closest to the ventilator with palm
facing up, underneath the patient to
the side you are turning. The new flat
sheet will pull through as you are
turning the patient.

New flat sheet being tucked

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 Patient should be laying directly on the arm that
is going to be pulled through. EKG voltage may
be altered as the heart shifts within the thorax. If
a 12 lead EKG is needed, place precordial leads
on the posterior thorax.

Begin by turning patient towards the

ventilator and onto their side THEN
stop. With the patient in the lateral
position, reposition the patient’s
ECG leads on the patient’s posterior
thorax, placing the limb leads
laterally to prevent any pressure on
the anterior portion of the body.
Evaluate the quality of waveform
and assess for arrhythmias. May
consider delaying the reposition of
the patient’s 5 lead ECG until the
patient is in the prone position based
on clinical stability and ease of turn.

The staff member at the head of the bed

supports the head during the turn and ensures all
tubes and lines are intact.
8. Under the direction of the person at
the head of the bed, at the count of
3, the patient is carefully turned
over by pulling the tucked arm and
new flat sheet through.

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 9. The patient is now prone. Pull and
center the patient. Straighten and
reconnect lines. Position the head to
prevent pressure areas. Position arms
in a modified swimmers position or
aligned with the body. Utilize foam
dressings to support the shoulders,
abdomen, penile tip and pelvis where
necessary.

No minimum or maximum time in

prone position. In most cases,
improvement in oxygenation, Every attempt is made to prevent pressure
defined as PaO2/FiO2 ratio > 150 injuries. Alternate arms and head every 2 hours.
mmHg with an FiO2 <60% with
≤10cm of PEEP *Additional off-loading may be needed around
nose to protect from ETT/NGT, use: (1) Allevyn
10. Reapply Prevalon boots inside out foam strip to cover nares/tip of nose, and (1)
Allevyn foam strip to cover bridge of nose

Interruption of therapy

1. Unintended extubation
2. Unintended right mainstem intubation
3. ETT obstruction
4. Hemoptysis
5. Cardiac arrest

Nursing Considerations

1. Collaborate with the team to assess Recommended duration for proning is 16 hours,
the patient’s response to the prone but note that longer periods have been used with
position: no adverse events.
 Pulse Oximetry
 Mixed venous oxygenation or The team will determine the frequency of blood
central venous mixed gases and enter the order as indicated.
oxygenation saturation (Scvo2)
and hemodynamics
 Arterial blood gases
 PaO2/FiO2 ratio (P/F ratio)

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2. Provide frequent oral care and
suctioning of the airway as needed.

3. Maintain eye care to prevent corneal The prone position promotes postural drainage.
abrasion.

4. Maintain tube feedings. It is important to maintain lubrication to prevent

dryness and corneal abrasions.
5. Assess skin frequently for areas of
nonblanchable redness or
breakdown.
 Microshift sheets q 2 hours when
turning head and repositioning
arms.

6. Alternate side to side head position

every two hours.

7. Alternate “swimmers arm” position One arm raised and head rotated toward the
every two hours. raised arm; the other arm is positioned alongside
the body
8. Document the patient’s response to
the prone positioning, ability to
tolerate the turning procedure, length
of time in the prone position,
complications noted during or after
the procedure, and patient and
family education.

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Preparation for Returning to Supine Note:
Position Plan to supine patients qAM (can be >24hrs
prone with no adverse events)
1. PEEP on the ventilator is often
decreased during periods of prone Assess for any hypotension associated with the
ventilation. This lower PEEP can be PEEP increase and consider returning to
associated with de-recruitment and baseline PEEP should it be thought that the
hypoxemia on return to supine hypotension is directly related to the PEEP
position. Discuss with team increase
increase.
of PEEP to at least half of pre-prone
level PRIOR to supine.

2. Position the staff at the sides of the The person on the side of the bed closest to the
bed and the respiratory therapist at patient maintains body contact with the bed at
the head of the bed. all times to serve as a side rail and prevent a fall.
The RT at the head of the bed is responsible for
3. Maximally inflate the bed securing the ETT, ventilator tubing.

Disconnect arterial line from the

pressure bag. Cap the arterial line at
the t-piece

4. Pull patient using the underlying flat

sheet while in the prone position to
the side of the bed towards the
ventilator

5. Cross the leg next to the edge of the

bed over the opposite ankle.

6. Keep both patients arms straight

against the body

In order to turn the patient away from the

ventilator.

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7. Tuck a new flat sheet, and the arm
away from the ventilator with palm
facing up, underneath the patient to
the side you are turning. The new
flat sheet will pull through as you
are turning the patient

8. Begin by turning patient away from

the ventilator and onto their side
THEN stop. With the patient in the
lateral position, reposition the
patient’s ECG leads on the patient’s
anterior thorax. Evaluate the quality
of waveform and assess for
arrhythmias. May consider delaying
the reposition of the patient’s 5 lead
ECG until the patient is in the
supine position based on clinical
stability and ease of turn.

9. Under the direction of the person at

the head of the bed, at the count of 3,
the patient is carefully turned over
by pulling the tucked arm and new
flat sheet through towards the
ventilator.

10. The patient is now supine. Pull and

center the patient. Straighten and
connect lines and tubes.

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 11. Collaborate with the team to assess Special Considerations
the patient’s response to the supine If patient is not tolerating being placed supine
position: from prone, discuss increasing proning length of
 Pulse Oximetry time with the team.
 Mixed venous oxygenation or
central venous mixed
oxygenation saturation (Scvo2)
and hemodynamics
 Arterial blood gases
 PaO2/FiO2 ratio (P/F ratio)
If P:F > 150 mmHg and Driving
Pressure (Pplat – PEEP) < 15 cm
H2O after two hours in supine
position, consider not returning to
prone position, in collaboration with
team.

References:
Drahnak, D., & Custer, N. (2015). Prone Positioning of Patients with Acute Respiratory Distress
Syndrome. Critical Care Nurse, 32(6): 29-37.
Guerin C, Reignier J, Richard J et al. Prone positioning in severe acute respiratory distress
syndrome. NEJM (2013); 368(23): 2159-2168.
Guerin C, Constatin P, Bellani G et al. A prospective international observational prevalence study
on prone positioning of ARDS patients: the APRONET (ARDS prone position network) study.
Intensive Care Med (2018); 44:22-37.

Vollman, K, Dickinson, S, & Powers, J. (2017). Pronation Therapy. AACN Procedure Manual
for Critical Care 7th ed. Elsevier Sanders, St Louis, Missouri pp. 142-163.
Revision Detail:
APPROVED: Critical Care Operations Committee (April 8, 2020)

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Figure 1. – Areas at risk for pressure injury

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