Prone Positioning Nursing — ARDS & Critical Care

<150

P/F Ratio Threshold (mmHg) to indicate proning

16h

Minimum daily prone duration (PROSEVA protocol)

16%

28-day mortality — prone group (vs 32.8% supine)

NNT 6

Number Needed to Treat to prevent 1 death

50%

Relative mortality reduction (PROSEVA 2013)

📊PROSEVA Trial (2013) — Landmark Evidence

Guerin C et al. NEJM 2013 — The Definitive Trial 466 patients with severe ARDS (P/F <150 on PEEP ≥5, FiO2 ≥0.6). Randomised to proning ≥16h/day vs supine. 28-day mortality: 16% (prone) vs 32.8% (supine) — p<0.001. This is now the standard of care for moderate-severe ARDS.

Trial Design

Population: Severe ARDS within 36h of diagnosis
Criteria: P/F <150, PEEP ≥5 cmH2O, FiO2 ≥0.6
Intervention: Proning ≥16h/day until improvement
Control: Semirecumbent supine position
Primary outcome: 28-day all-cause mortality
Setting: 26 ICUs in France and Spain

Key Results

28-day mortality: 16% vs 32.8% (p<0.001)
90-day mortality: 23.6% vs 41% (p<0.001)
NNT: 6 patients to prevent 1 death
P/F improvement: Significant within 4h
No increase in adverse events
Ventilator-free days: Improved in prone group

✓Indications for Proning

All 3 criteria must be met

P/F ratio <150 mmHg on current ventilator settings
PEEP ≥5 cmH2O and FiO2 ≥0.6
Criteria present for >12 hours despite optimised conventional ventilation
No absolute contraindications present
Lung-protective ventilation already in place (TV 6 mL/kg IBW, Pplat <30)

ARDS Severity Classification (Berlin) Mild: P/F 200–300 | Moderate: P/F 100–200 | Severe: P/F <100. Proning indicated for moderate-severe (P/F <150).

!Contraindications

Contraindication	Type
Spinal instability / unstabilised fractures	Absolute
Open chest / sternotomy	Absolute
Severe facial / cranial fractures	Absolute
Recent tracheal surgery (<2 weeks)	Absolute
Raised intracranial pressure (>30 mmHg)	Absolute
Haemodynamic instability on high vasopressors	Relative
Morbid obesity (BMI >35)	Relative
Pregnancy (>20 weeks)	Relative
Massive anterior burns	Relative
Recent anterior abdominal surgery	Relative

⚙Mechanisms of Benefit

Ventilation Homogeneity

In supine ARDS, posterior (dependent) lung is collapsed/flooded
Prone redistributes ventilation more evenly
Reduces dorsal-to-ventral transpulmonary pressure gradient
Recruits previously dependent collapsed alveoli

Reduced VILI

Decreases cyclic atelectasis in dependent zones
Reduces stress concentration at aerated-consolidated boundaries
More homogeneous tidal volume distribution
Lowers driving pressure requirements

Other Benefits

Improved secretion clearance (gravitational drainage)
Cardiac output may improve (reduced lung compression of heart)
Reduced V/Q mismatch
Improved FRC (functional residual capacity)

Safety First: Never rush a prone turn. Preparation is the most critical phase. A poorly prepared prone turn risks ETT dislodgement, line disconnection, haemodynamic collapse, and severe pressure injuries. Allow 20–30 minutes for complete preparation.

👥Team Assembly — Minimum 5 Personnel

Each team member must know their role BEFORE the turn begins. Verbal briefing is mandatory.

Role	Position	Responsibilities
Airway Nurse (Team Leader)	Head of bed	Controls ETT throughout turn, leads the count, calls halt if problem, does not let go of airway
Lateral Nurse 1	Right side of patient	Controls right shoulder and hip, manages right-side lines
Lateral Nurse 2	Left side of patient	Controls left shoulder and hip, manages left-side lines
Foot Nurse	End of bed	Controls legs and feet, manages urinary catheter and lower extremity lines
Coordinator / Runner	Free movement	Manages ventilator, monitors, calls out vitals, fetches equipment, documents time

🛏Equipment Preparation

Positioning Pads (Anatomical Landmarks)

Forehead pad: Silicone foam — above eyes, allows face to hang free
Chest pad: Bilateral — clavicles to ASIS, allows abdomen to hang freely
Pelvic pad: Bilateral — anterior superior iliac spine (ASIS) to upper thigh
Knee pads: Bilateral — foam beneath patella
Foot/toe pad: Beneath dorsum of feet to prevent foot drop

Abdomen MUST hang freely — this is essential for diaphragm excursion and cardiac output benefit. Chest and pelvic pads must not meet in the middle.

Pressure Injury Prevention

Silicone foam dressings: forehead, chin, nose, cheeks
Additional foam: chest bony prominences, patellae
Hydrocolloid on ears if prolonged proning planned
Male patients: protect genitalia with soft padding

🔗Lines, Tubes & Airway Security

ETT Security

Re-tape/re-secure ETT with additional adhesive tape
Confirm and document ETT cm marking at lips/teeth
Confirm ETT position by auscultation before turn
Suction ETT before turn to clear secretions
Note ETCO2 waveform baseline

All Lines & Drains

Label all IV lines and invasive monitoring lines clearly
Ensure sufficient line length for 180° turn
Clamp chest drains temporarily during turn (re-open immediately after)
Clamp NG/gastric tube temporarily; drain/aspirate gastric contents before turn
Secure urinary catheter to avoid traction
Identify route for each line — plan which side it will exit
Remove unnecessary attachments before turn

Eye Care

Instil lubricating eye drops bilaterally
Apply eye gel (Lacrilube or equivalent)
Tape eyelids closed with micropore/paper tape
Corneal abrasion risk is high in prone — eyes must be protected every cycle

Gastric Preparation

Aspirate gastric tube and document volume
Hold enteral feeds 30 min before turn
Consider metoclopramide prophylactically

📋Pre-Prone Briefing Checklist

The team leader (airway nurse) should verbally run through this briefing with all team members. Each person confirms their role before the turn begins. Use the interactive checklist in the tool tab.

All 5 team members present and role-assigned
ETT secured with extra tape, cm mark confirmed
All pads prepared and at bedside
Silicone foam dressings on face
Eyes lubricated and taped
Gastric aspirated, feeds held

All IV lines labelled and length confirmed
Drainage bags clamped (ready to release)
Contraindications excluded and documented
Consent (if awake) or next-of-kin informed
Ventilator FiO2 temporarily increased to 1.0
Time and date documented — prone start time

Airway nurse LEADS and CONTROLS the count. No one moves until the count of 3. The airway nurse is the only person who can call "STOP" during the turn if there is a problem with the ETT or patient haemodynamics.

▶Prone Turn — Step-by-Step Procedure (180° Rotation)

Increase FiO2 to 1.0 — pre-oxygenate for 3–5 minutes before initiating the turn. Confirm SpO2 stable.
Slide patient to the turning side rail — move patient laterally towards the direction of the first turn (typically right side). Ensures space to complete the 180° rotation without falling off the bed.
Cross the far arm — the arm on the side being turned toward goes across the body (under the patient's torso) to assist the rotation. The near arm stays alongside or is placed up by the head (swimmer position).
All team members take positions — airway nurse at head (hands on ETT and head), lateral nurses on sides, foot nurse at feet. Coordinator stands back to manage ventilator and monitor.
Final check and verbal confirmation — airway nurse asks: "Is everyone ready?" Each person verbally confirms. Lines checked clear. Airway nurse confirms ETT position at lips.
Turn onto side (90°) on count of 3 — "1, 2, 3, TURN" — smooth coordinated lateral rotation. Patient is now in lateral decubitus. PAUSE and reassess: SpO2, ETT, BP.
Complete rotation to prone (180°) — on second count from airway nurse: roll patient fully prone in one smooth, coordinated motion. Airway nurse rotates head simultaneously — head turns last to complete the rotation.
Position head in anatomical neutral — forehead on pad, slight lateral rotation (to one side), ensure face not flattened. Neck in neutral — not hyperextended or laterally rotated beyond comfort.
Arms — swimmer position or alongside body — Swimmer: one arm up (elbow flexed, hand near head), one arm down alongside body. Alternate arm position every 2 hours. Ensure no brachial plexus stretch.
Place chest and pelvic pads — bilateral chest pads from clavicles to ASIS. Bilateral pelvic pads from ASIS to upper thigh. Confirm abdomen hangs freely between pads — this is essential.
Knee and toe pads positioned — foam beneath patellae bilaterally. Dorsal foot pads to maintain ankle in neutral (prevent foot drop). Toes must not bear weight.
Reconnect all monitoring — SpO2 probe to finger/ear, ECG leads repositioned on back, arterial line transducer zeroed, central line infusions confirmed running.
Confirm ETT position — bilateral auscultation of chest, confirm ETCO2 waveform, note cm mark at lips unchanged. If any doubt — CXR.
Reduce FiO2 back to previous setting — after confirming SpO2 stable. Adjust ventilator as needed (PEEP may need fine-tuning).
Document prone start time — exact time, team members present, any events during turn, ETT cm mark, initial post-prone SpO2 and BP.

⚠If Desaturation During Turn

Call STOP — airway nurse calls halt immediately
Return to supine if SpO2 <85% and not recovering
Check ETT — listen bilaterally, confirm ETCO2
Increase FiO2 to 1.0
Manual ventilation if needed
If SpO2 recovers with position — can attempt turn again after stabilisation
Document the event in safety log

!If ETT Dislodgement Suspected

STOP the turn immediately. Do not complete the rotation.

Airway nurse holds ETT — do not release
Return patient to supine immediately
Confirm ETT position by auscultation and ETCO2
If confirmed displaced — follow emergency reintubation protocol
Notify medical team immediately
Complete incident report
Proning can be reattempted once ETT confirmed and patient stabilised

First 2 hours after proning require intensified monitoring. Physiological response (P/F improvement) is expected within 1–4 hours. If no improvement by 4 hours, escalate to medical team and reassess.

♥Vital Signs

Frequency

First 1–2 hours: HR and BP every 15 min
After 2 hours: Hourly if stable
Continuous: SpO2 and ECG monitoring

Expected Changes

SpO2 may transiently drop during turn — should recover within 30 min
BP may fluctuate with position — if MAP drops >20% escalate
HR often decreases as oxygenation improves

🫁Ventilator Parameters

Check P/F ratio at 1, 2, and 4 hours post-turn
Expect PaO2/FiO2 improvement within 1–4h in responders
Peak and plateau pressure — compliance may improve
PEEP — may need minor adjustments
Tidal volume — maintain 6 mL/kg IBW (lung-protective)
ETCO2 waveform — confirm continuous and normal morphology

Non-responders (no P/F improvement at 4h): Notify medical team. Consider: ETT malposition, secretion plugging, pneumothorax, positioning issue.

🫀Arrhythmia Monitoring

ECG electrodes repositioned on posterior chest after proning
Continuous cardiac monitoring mandatory
Position-related bradycardia — usually transient
Ventricular ectopy may occur with myocardial stretch
AF can be triggered or worsened
Notify medical team for any sustained arrhythmia
Defibrillation possible in prone — use anterior/posterior pads

🩹Pressure Injury Surveillance (2-Hourly)

Face and body must be checked every 2 hours during proning. Pad repositioning at every check.

Face — 2-Hourly Check

Forehead — foam pad pressure, blanching?
Nose — tip and bridge (high risk)
Chin — contact with pad or bed?
Cheeks — bilateral assessment
Ears — especially the dependent ear
Alternate head position (left/right lateral) every 2 hours

Body — 2-Hourly Check

Chest — clavicles and anterior ribs
Knees — bilateral, reposition knee pads
Toes and dorsum of feet
Male genitalia — ensure no pressure
Grade any lesion using EPUAP/NPUAP scale and document

👁Eye Protection & ETT Care

Eye Monitoring

Check eye closure hourly — tape must remain intact
Re-apply eye gel if tape loosens
Confirm no direct pressure on eyeballs from pad
Check for chemosis (conjunctival oedema) — document
Ophthalmology review if any concern on return to supine

ETT Monitoring

Check ETT cm mark at lips/teeth every 2 hours
Listen for bilateral air entry at each check
Suction as needed — prone improves secretion mobilisation
Expect increased secretion volume (gravitational drainage benefit)
Note secretion character: colour, consistency, volume

Enteral Nutrition During Proning

Continue EN at reduced rate 20–40 mL/hr
Check GRV (gastric residual volume) every 4 hours
Hold if GRV >200 mL — recheck in 2h
Elevated head of bed not possible in prone — aspiration risk managed by rate reduction
Ensure NGT patent; flush every 4h

↩Supination Criteria — When to Return to Supine

Standard Supination (Planned)

Minimum 16 hours of prone positioning completed
SpO2 stable on current ventilator settings
5-person team available and prepared
Scheduled as part of daily weaning assessment
Medical team aware and agreed

Emergency Supination (Unplanned)

Cardiac arrest — return to supine immediately
ETT dislodgement requiring reintubation
SpO2 <85% unresponsive to FiO2 increase
Haemodynamic collapse (MAP <50 unresponsive)
Life-threatening arrhythmia
Document reason and prone duration achieved

▶Supination Procedure

Same 5-person team, same roles, reverse procedure. Airway nurse leads the count and controls the head. FiO2 increased to 1.0 before turning.

Pre-supination preparation: Increase FiO2 to 1.0. Team in position. Verbal briefing. Confirm ETT cm mark. Remove face and body pressure dressings for inspection.
Reposition cross-arm: Place the arm for rotation across body as per proning preparation.
Slide to side rail: Move patient to side of bed in direction of rotation.
Coordinated 180° turn on count of 3: Airway nurse leads — same smooth rotation. Lateral and foot nurses coordinate.
Return to semi-recumbent supine: Aim 30–45° head-of-bed elevation to reduce VAP risk once stable.
Confirm ETT position: Bilateral auscultation + ETCO2 waveform. If cm mark changed — reassess and CXR if concern.
Reconnect all monitoring: ECG leads to anterior chest, SpO2, arterial transducer zeroed, infusions confirmed.
Document supination time and actual prone duration.

🔍Post-Supination Assessment

Haemodynamic Response (First 30–60 min)

BP and HR every 15 min for first hour
May transiently desaturate — usually self-resolves
May transiently drop BP — if persistent, notify medical team
P/F ratio benefit can persist 4–12h post-supination in responders
If P/F deteriorates significantly — consider re-proning

Pressure Injury Inspection

Full face assessment — forehead, nose, chin, cheeks, ears
Grade all lesions using EPUAP/NPUAP scale
Photograph and document all findings
Chest wall, knees, dorsal feet
Wound management team referral if grade 2+

🔄Repeat Proning & Ventilator Management

Repeat Proning Criteria

Can repeat daily 16h cycles if P/F still <150 on return
Typically 1–4 cycles in first week of ARDS
Same indications and contraindications apply
Stop cycling when P/F >150 on PEEP ≤10 and FiO2 ≤0.6 (improved)

Ventilator Adjustments Post-Supination

PEEP may need to be increased if oxygenation deteriorates
Recruitment manoeuvre may help post-supination atelectasis
Continue lung-protective ventilation (TV 6 mL/kg IBW)
Consider spontaneous breathing trials when P/F improves and PEEP ≤8
FiO2 should be reduced as oxygenation improves — titrate to SpO2 92–95%

Eye Assessment on Return to Supine Remove eye tape carefully. Assess for corneal abrasion (pain, photophobia, fluorescein staining). Ophthalmology referral if suspected. Continue lubricating drops and taping if proning will be repeated.

🏥COVID-19 ARDS Proning in GCC (2020–2022)

Major proning volumes across GCC ICUs during COVID-19 pandemic
Saudi Arabia, UAE, Qatar, Kuwait, Bahrain, Oman — all developed institutional prone protocols 2020
Significant nursing expertise built during pandemic waves
Many centres ran prone teams 24/7 during peak ICU occupancy
Nurses trained in both intubated and awake prone positioning
Simulation-based proning training became standard in tertiary centres
Multi-language patient instructions developed including Arabic

Awake Proning (Non-Intubated) — Arabic Instructions

"تقدر تتقلّب على بطنك؟"
"نحتاج منك تنام على بطنك لتحسين تنفسك."
"هذا الوضع يساعد رئتيك."

"Can you roll onto your tummy?" | "We need you to lie on your stomach to improve your breathing." | "This position helps your lungs."

⚠High Obesity Prevalence in GCC — Technical Challenges

GCC has some of the world's highest obesity rates (BMI >30: 35–40% of adults in some GCC states)

BMI >35: Relative contraindication — requires senior decision and additional planning
Extra staff: Consider 6–7 personnel for obese patients
Bariatric beds: Wider turning space essential; standard beds may be inadequate
Additional foam pads: Larger body surface requires more padding at more points
Abdominal decompression: Critical — abdomen must hang freely; harder to achieve in morbid obesity
Tracheostomy consideration: For prolonged ARDS in obese patients — improves airway security during repeated turns
Increased pressure injury risk: More surface contact area — check every 1–2h
Line management: More difficult to access lines in deep tissue

🦠MERS-CoV ARDS in GCC

Middle East Respiratory Syndrome — endemic to Arabian Peninsula
MERS-CoV ARDS has high case fatality rate (35–40%)
GCC ICUs have most experience globally with MERS-CoV critical care
Proning protocols adapted for MERS — full PPE required during prone turns
Aerosol-generating procedure protocols for prone turns in MERS patients
Saudi Arabia developed MERS ICU protocols referenced internationally
Camels as zoonotic reservoir — episodic outbreaks continue in KSA

📚GCC Proning Programmes & Training

Simulation-based team training: Standard in tertiary GCC centres (King Faisal Specialist, Cleveland Clinic Abu Dhabi, Hamad Medical Corporation, etc.)
Prone teams: Designated trained prone teams in most GCC tertiary ICUs
Competency assessment: Annual prone positioning competency for ICU nurses
Multi-language protocols: Arabic, English, Tagalog, Hindi — reflecting GCC ICU nursing workforce diversity
Safety reporting: Proning incidents reported through institutional adverse event systems (e.g., CERNER, Epic safety reporting modules)
National guidelines: SCCC (Saudi Critical Care), ESICM guidelines used across GCC

📋Documentation & Safety Reporting for Prone Episodes in GCC

Mandatory Documentation

Prone start and end time (calculate duration)
Team members present (names and roles)
Pre-prone and post-prone P/F ratio
ETT cm mark before/after
Pressure injury findings — each body region
Any events during turn

Reportable Incidents

ETT dislodgement or change in position
Accidental extubation
Line disconnection / medication interruption
Cardiac arrest during turn
New pressure injury grade 2 or above
Corneal abrasion confirmed

Quality Metrics

Prone duration achieved vs target (≥16h)
% patients receiving proning who met criteria
Pressure injury incidence per prone episode
ETT dislodgement rate per 100 prone turns
P/F ratio response at 4h (responder rate)
28-day mortality in ARDS patients proned