ARDS and refractory hypoxaemia

Prone positioning

Reviewed Nov 2026·3 references
New· views rounded down, updated weekly

Prone early (within 36 h) when P/F < 150 mmHg on FiO2 ≥ 0.6 and PEEP ≥ 5 despite optimisation, for at least 16 h per session, using a trained team and a checklist. Repeat daily until P/F ≥ 150 is sustained supine.

At the bedside

Timed steps
  1. 1

    P/F < 150

    Indication

    On FiO2 ≥ 0.6, PEEP ≥ 5, Vt ~6 mL/kg after 12-24 h stabilisation.

  2. 2

    Check

    Contraindications

    Unstable spine, open abdomen, raised ICP, massive haemoptysis, recent sternotomy, unstable fractures, pregnancy (relative), haemodynamic instability (relative).

  3. 3

    Team of 5

    Prepare

    Team leader at head (airway); pre-oxygenate FiO2 1.0; secure tube and lines; empty stomach; protect eyes; ECG leads to the back; pads for face, chest, pelvis, knees.

  4. 4

    Sheet technique

    Turn

    Envelope with sheets, lateral, then prone; arms in swimmer's position (alternate every 2-4 h); head turned and repositioned every 2-4 h.

  5. 5

    ≥ 16 h

    Duration

    Sessions ≥ 16 h (PROSEVA mean ~17 h).

  6. 6

    Criteria

    Stop

    P/F ≥ 150 with PEEP ≤ 10 and FiO2 ≤ 0.6 at least 4 h after turning supine; or complications.

Red flag · call your senior now
Accidental extubation or line loss during turn: airway team at head, plan in advance.
Red flag
Facial pressure sores and ocular injury: check every 2 h.
Pitfall
Proning late (after days) or for short sessions (< 12 h).
Pitfall
Stopping proning because oxygenation did not improve immediately (benefit is not only through oxygenation).
Pearl
Enteral feeding can continue in prone position (reverse Trendelenburg 10-25°).
Pearl
CPR in prone position is possible (compress between scapulae) while preparing to turn.

References

  1. 1

    Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome (PROSEVA). N Engl J Med. 2013;368(23):2159-2168

  2. 2

    Qadir N, Sahetya S, Munshi L, et al. An update on management of adult patients with acute respiratory distress syndrome: an official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2024;209(1):24-36

  3. 3

    Grasselli G, Calfee CS, Camporota L, et al. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med. 2023;49(7):727-759

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