When is proning (prone positioning) recommended for patients in the Intensive Care Unit (ICU)?

From the Guidelines

Proning is recommended for invasively ventilated patients with ARDS and impaired arterial oxygenation (PaO2/FiO2 < 150 mmHg) in the ICU, and should be implemented early and maintained for at least 12, preferably 16 hours. This recommendation is based on the most recent and highest quality study available, which suggests that prone positioning can improve oxygenation and reduce mortality in patients with ARDS 1. The benefits of proning include improved ventilation-perfusion matching, redistribution of lung water, and reduced compression of lung tissue by the heart.

Key Considerations for Proning

• Proning should be considered in patients with moderate to severe ARDS, defined as a PaO2/FiO2 ratio less than 150 mmHg despite optimal ventilator settings
• The procedure should be implemented early in the course of ARDS, ideally within 36 hours of diagnosis
• Patients should be adequately sedated and possibly paralyzed with neuromuscular blocking agents to prevent self-extubation and ensure patient-ventilator synchrony
• A coordinated team of 4-5 healthcare providers is required to safely turn the patient while maintaining all lines, tubes, and monitoring equipment

Contraindications and Complications

• Contraindications to proning include unstable spine injuries, open abdominal wounds, hemodynamic instability, increased intracranial pressure, and recent sternotomy
• Complications that providers should monitor for include pressure injuries, facial edema, endotracheal tube displacement, and hemodynamic changes during the turning procedure
• The use of catecholamines is not a contraindication for prone positioning, but patients should be stabilized haemodynamically and have their volume status optimized prior to proning 1

Special Considerations

• Awake proning may be considered in non-invasively ventilated patients with COVID-19 and acute hypoxic respiratory failure 1
• Proning may be beneficial in patients with unilateral lung damage, with the healthy side down (good lung down) to improve gas exchange 1
• The decision to prone a patient should be made on an individual basis, taking into account the potential benefits and risks, and should be guided by the most recent and highest quality evidence available 1

From the Research

Recommendations for Prone Positioning in ICU

Prone positioning is recommended for patients in the Intensive Care Unit (ICU) with specific conditions, including:

• Acute Respiratory Distress Syndrome (ARDS) 2, 3, 4, 5, 6
• Moderate to severe ARDS due to COVID-19 3, 6
• Severe refractory ARDS in burn patients 4

Benefits of Prone Positioning

The benefits of prone positioning include:

• Improved oxygenation 2, 3, 4, 5, 6
• Increased PaO2/FiO2 ratio 3, 4, 5, 6
• Reduced need for mechanical ventilation 3
• Reduced length of stay in the ICU 3

Implementation of Prone Positioning

Prone positioning can be implemented in various ways, including:

• Prolonged prone positioning (> or = 12 hours) 5
• Long PP sessions (up to 10 hours) 3
• Use of dexmedetomidine for light sedation 3
• Careful consideration of potential risks, such as facial pressure ulcers 4

Patient Selection and Monitoring

Patient selection and monitoring are crucial for effective prone positioning, including:

• Identification of patients with moderate to severe ARDS 3, 6
• Monitoring of oxygenation and PaO2/FiO2 ratio 3, 4, 5, 6
• Assessment of patient tolerance and potential complications 4