Prone positioning: the team, the turn, protecting tubes, eyes and pressure points

What it is

Prone position (lying face down) makes ventilation of the injured lung more even and, in moderate to severe ARDS, reduces mortality when sessions are long and started early. The turn is a team manoeuvre with a rehearsed protocol: four to five trained people, one of them at the head to make sure the tube and central lines are not pulled or kinked. Most of the risk is in the turn itself (tube or line displacement) and in the hours face down (pressure injuries, eye injury, nerve injury). The nursing care of ARDS in general is on the ARDS nursing page.

Indications

• Moderate to severe ARDS with PaO2/FiO2 below 150 mmHg despite optimised ventilation.
• Early after intubation, once low tidal volume and PEEP have been set and the patient is stabilised.
• Long sessions: WHO 12–16 h a day; ESICM 16 consecutive hours or more.
• Awake prone position in selected non-intubated hypoxaemic patients on oxygen, high flow or NIV (WHO, COVID-19).

Contraindications and precautions

• The only absolute contraindication is an unstable spinal fracture.
• WHO toolkit lists as contraindications: raised intracranial pressure, massive haemoptysis, recent tracheal surgery or sternotomy, serious facial trauma or surgery.
• Also: deep vein thrombosis treated for less than 2 days, a pacemaker placed in the last 2 days, unstable femur or pelvic fractures, MAP below 65 mmHg, pregnancy, a single anterior chest tube with an air leak.
• Haemodynamic instability is a relative contraindication; the decision belongs to the team.
• Each turn risks tube and line displacement: never turn without enough trained people.

Equipment

• A new draw sheet.
• Pillows, foam pads or other supports for the head, face, shoulders, chest, pelvis and knees.
• Preventive dressings for pressure points and device sites, as the protocol says.
• Suction ready and ECG electrodes for the back.
• Monitoring of SpO2 and invasive blood pressure throughout.

Step by step (and why)

1. Check contraindications and explain the manoeuvre to the patient or family — safety and information before the turn.
2. Confirm the tube position on a recent X-ray, note its depth and secure the tube and all lines — displacement is the main risk.
3. Stop tube feeding, aspirate and empty the stomach, and cap the tubes — it reduces vomiting and aspiration.
4. Prepare suction and supports, and move lines and drains toward the planned side with enough length — nothing must pull.
5. Place people on both sides and one at the head to guard the tube and lines — coordinated moves prevent extubation.
6. Raise FiO2 to 1.0 and note mode, tidal volume, minute ventilation and peak and plateau pressures — baseline for after the turn.
7. Turn in steps (side, then prone) using the new sheet, and move ECG leads to the back — a controlled turn protects lines.
8. Turn the face to one side, support face and shoulders without pressure on eyes or orbits, place the arms comfortably.
9. Listen to both lungs, recheck tube depth, volumes, pressures, SpO2 and blood pressure, and suction if needed.
10. Tilt into reverse Trendelenburg, change head and arm position every 2–4 h and inspect the ventral skin every shift.

Complications

• Displacement or obstruction of the endotracheal tube, and accidental extubation.
• Loss of venous access and displacement of other devices.
• Vomiting and haemodynamic instability during the turn.
• Pressure injuries of the face and chest; brachial plexus injury.
• Eye problems: raised intraocular pressure, conjunctivitis and corneal ulcers.

Next step: when to call for help

• Unplanned extubation, a tube in one bronchus or a blocked tube: call for help at once.
• SpO2 below 85%, or PaO2 below 55 mmHg for more than 5 minutes on FiO2 1.0: tell the doctor; the session may be stopped.
• Heart rate below 30/min for more than 1 minute, systolic pressure below 60 mmHg for more than 5 minutes or cardiac arrest: emergency call.
• PaO2/FiO2 falling by more than 20% compared with supine: report it to the team.

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Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Clinical care for severe acute respiratory infection: toolkit, update 2022 (COVID-19 adaptation), tool 9.16 (World Health Organization, 2022); Prone position in ARDS patients: why, when, how and for whom (Intensive Care Medicine (open access, PMC), 2020); Strategies to preventing pressure injuries among intensive care unit patients mechanically ventilated in prone position: a systematic review and a Delphi study (Frontiers in Medicine (open access, PMC), 2023); ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies (Intensive Care Medicine (open access, PMC), 2023).

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