Prone Ventilation

Patients With or Under Investigation for COVID-19



Prone ventilation (PV) is a life-saving strategy that improves oxygenation by recruiting the dorsal lung zones to promote ventilation-perfusion matching. Proning 6 patients with ARDS is expected to save 1 life (PROSEVA trial). COVID-19-related ARDS appears to respond favorably to PV. In the Chinese cohort, 15% of mechanically ventilated COVID-19 patients received PV.

My lecture, "Prone Ventilation: Physiology and Practice" can be found here.


  • P/F – ratio of paO2/FIO2

  • ETT – endotracheal tube

  • ACE – airborne plus contact plus eyewear

  • DICE – droplet plus contact plus eyewear

  • IAP – intra-abdominal pressure

  • ICP – intracranial pressure


  • P/F ≤ 150 on 60%/+10

  • Most beneficial: early ARDS (initiate within 12 hours of meeting criteria); stiff lung mechanics (plateau ≥ 40 cmH2O or driving pressure ≥ 18); basilar-predominant ARDS pattern; left lower lobe collapse

  • Less beneficial: late ARDS, homogeneous ARDS pattern



  • Absolute: imminent circulatory collapse or pericoding; spinal instability; unmonitored intracranial hypertension; open facial, chest, or abdominal wounds; massive hemoptysis; inexperienced care team

  • Relative: fresh tracheostomy; chest tubes; pregnancy; high vasopressor requirement


Team & Equipment

  • 4 persons (6 if large patient or excessive apparatus)

    • 1 person (RT) dedicated to airway at head of bed

    • 1 or 2 person dedicated to drains, lines, chest tube (if applicable)

    • 2 or 3 persons for rolling

  • Airway cart

  • Gel padding for pressure points

  • Pillows

  • 1 drawsheet



  • Proning is considered a potentially aerosol-generative procedure. ACE required for all HCW


Pre-Proning Checklist

  • Perform any required cleaning, wound care

  • Pre-oxygenate at 100%

  • Suction ETT, evacuate stomach, cap or streamline IV lines if possible

  • Decide on direction. Usually best if turned towards ventilator


Proning Checklist

  • Shift patient to side of bed opposite ventilator

  • Place pillows over chest and abdomen. Place flat sheet over pillows.

  • Rotate pillow-cushioned patient 90° towards ventilator

  • Pause to reattach EKG leads, oximeter

  • Complete proning, rotating final 90°, placing arms in “swimmers’ position” (see diagram)

  • Placing the bed in mild reverse Trendelenburg may reduce gastric residuals and facial edema

  • *Place gel padding over pressure points on face, arms, legs*

  • Re-check ETT position and cuff pressure

  • Reattach lines and resume drips






Post-Proning Checklist

  • Reposition q2 hours, checking for pressure injury

  • Keep prone for ≥ 16 hours/day (ideally 20 hours/day)

  • Duration of Protocol: discontinue protocol (do not re-prone) if (1) sustained improvement in oxygenation and lung mechanics lasting > 4 hours after supination, or (2) demonstrated clinical intolerance to proning


  • Migration, kinking, or dislodgement of ETT, catheters, drains

  • Pressure injury

  • Increased IAP may compromise visceral organ perfusion

  • Delayed gastric emptying, increased reflux

  • Brachial plexopathy

  • Increased ICP (impaired jugular vein drainage)

  • Increase in respiratory secretions (can be profuse, and is probably a good thing)

Swimmer's position rotation to prevent pressure injury

Information presented on this website does not reflect the views or positions of the US Veterans Health Administration, Emory Healthcare, or its affiliated institutions. This is a rapidly evolving field. As such. the content on this site is being updated daily and protocols will be updated in real time.  The purpose of this site is to provide a centralized resource for ICU topics and protocols to promote the well-being of hospitalized or critically ill patients suffering from COVID-19.  Defer to your institutional guidelines for all clinical practice decisions.


© 2020  Victor Tseng, MD