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Prone positioning in Acute Respiratory Distress Syndrome (ARDS)

Background, Rationale and Benefits

The increased utilisation – over the past few decades – of various imaging modalities in the investigation of respiratory disease has provided clinicians with a more robust understanding of the physiology of acute respiratory failure. This laid the foundation for the introduction of prone positioning in the management of ARDS (Acute Respiratory Distress Syndrome), a strategy which has been effectively translated to manage patients with COVID-19.

The effectiveness of prone positioning – highlighted in several peer-reviewed studies – results from it shifting intra-abdominal and mediastinal organs anteriorly which reduces alveolar compression, thereby increasing oxygenation and perfusion in the in dorsal lung. This has translated clinically into increases in serum oxygenation (during proning and maintained afterwards) and reduced mortality.

There are however contraindications to the utilisation of prone position, which are discussed in more detail below.

Proning Inclusion and Exclusion Criteria

It is important to note that there are risks associated


  • Spinal instability
  • Open chest post cardiac surgery/trauma
  • < 24hrs post cardiac surgery
  • Central cannulation for VA ECMO or BiVAD support


  • Multiple Trauma e.g. Pelvic or Chest fractures, Pelvic fixation device
  • Severe facial fractures
  • Head injury/Raised intracranial pressure
  • Frequent seizures
  • Raised intraocular pressure
  • Recent tracheostomy <24hrs
  • CVS instability despite resuscitation with fluids and inotropes
  • Previously poor tolerance of prone position
  • Morbid obesity
  • Pregnancy 2nd/3rd trimester

Application in COVID-19: A Step-by-Step Guide


Is There A Place for Lateral Positioning?

Peer-reviewed data on the effectiveness peer-reviewed on the use of lateral position in patients with acute respiratory disease is limited. However, there have been anecdotal reports of it contributing to reduced mortality when used in the context of COVID-19, making it available as a strategy to consider in time pressured and resource-limited settings.

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