What is the procedure for safely placing an intubated patient in a prone position?

Procedure for Placing an Intubated Patient in Prone Position

For intubated patients requiring prone positioning, use a minimum of 5 personnel (4 to turn the patient plus 1 dedicated to controlling the head, neck, and airway), ensure complete 180° prone positioning rather than partial positioning, and follow a systematic protocol that prioritizes airway security and pressure point protection. 1, 2

Pre-Positioning Assessment and Preparation

Hemodynamic Stabilization

• Optimize volume status before initiating prone positioning 1, 2
• Do not delay prone positioning for ongoing vasopressor therapy—this is not a contraindication as the intervention is generally well-tolerated hemodynamically 1, 2
• Patients may experience improved right ventricular loading in prone position 1, 2

Screen for Absolute Contraindications

Perform interdisciplinary risk-benefit assessment if any of the following exist: 1

• Open abdomen
• Spinal instability
• Increased intracranial pressure (ICP)
• Cardiac arrhythmias with hemodynamic consequences
• Shock

Special Population Considerations

• For patients with abdominal surgery, abdominal pathologies, or abdominal obesity, perform individual risk-benefit assessment 1
• For patients at risk of increased ICP, ensure continuous monitoring capability and plan to maintain head in central position without lateral rotation 1, 2

Equipment and Airway Security Preparation

Secure All Tubes and Lines

• Verify and document tracheal tube depth before positioning 3
• Ensure tracheal tube cuff pressure is 20-30 cm H₂O; if using high airway pressures, maintain cuff pressure at least 5 cm H₂O above peak inspiratory pressure 3
• Secure all intravenous lines, arterial lines, chest tubes, and monitoring equipment 1
• Apply prophylactic foam dressings to vulnerable pressure areas (face, forehead, chest, knees, anterior iliac crests) before positioning 1

Ventilator Management

• Before any disconnection: ensure adequate sedation, consider neuromuscular blockade, pause the ventilator to stop all gas flows, clamp the tracheal tube, then separate the circuit with HME filter still attached to patient 3
• Use closed tracheal suction systems 3
• Maintain HME filter close to the patient rather than heated humidified circuit 3

Positioning Technique

Personnel Requirements

• Minimum of 5 personnel: 1 dedicated to controlling head/neck/airway, 4 to facilitate safe transfer 2
• The anesthesiologist or most experienced airway provider must control the head, neck, and airway throughout the maneuver 2

Execution of Complete (180°) Prone Positioning

• Use complete 180° prone positioning rather than incomplete prone positioning, as complete positioning has stronger effects on oxygenation and improved clinical outcomes 1
• Position patient with head turned to one side or face-down with appropriate support devices 1, 2
• Ensure head is positioned centrally without lateral rotation, especially in patients at risk for increased ICP 1, 2

Immediate Post-Positioning Checks

• Immediately verify tracheal tube depth and cuff pressure after positioning 3
• Confirm bilateral breath sounds and adequate chest rise 3
• Verify waveform capnography—this is mandatory for all intubated patients and is the single change with greatest potential to prevent airway-related deaths 3
• Check all pressure points and padding 1, 2

Monitoring During Prone Position

Continuous Monitoring Requirements

• Maintain continuous waveform capnography throughout prone positioning 3
• Perform continuous hemodynamic monitoring during and after positioning 1, 2
• For patients with ICP risk, maintain continuous or close ICP monitoring 1, 2
• Monitor and document tracheal tube depth at every shift change 3

Regular Assessments

• Regularly inspect pressure points throughout the procedure to detect early signs of pressure injury 1, 2
• Check cuff pressure and tracheal tube depth before and after any patient repositioning, nasogastric tube manipulation, tracheal suction, or oral care 3

Ventilator Settings in Prone Position

• Use protective ventilation with tidal volume 6-8 mL/kg predicted body weight 2
• Set initial PEEP at 5 cm H₂O and individualize to avoid increases in driving pressure while maintaining low tidal volume 2
• Prone positioning and PEEP have additive effects on improving oxygenation 1, 2

High-Risk Interventions While Prone

Procedures Requiring Extra Precautions

Interventions such as turning, physiotherapy, transfers, nasogastric tube insertion, and tracheal suction increase risk of airway displacement: 3

• Nominate an experienced team member solely to safeguard the airway during these procedures 3
• Verify cuff pressure and tube depth both before and after these procedures 3

Managing Tracheal Tube Cuff Leak

• If cuff leak develops, pack the pharynx while administering 100% oxygen and prepare for re-intubation 3
• Immediately before re-intubation, pause the ventilator 3

Common Pitfalls to Avoid

• Never proceed with prone positioning without first securing all tubes and lines—dislodgement during turning is a preventable catastrophe 1
• Do not assume vasopressor use is a contraindication—optimization of volume status is necessary but proceeding with positioning is appropriate 1
• Do not use incomplete prone positioning—there is no evidence for clinical benefit and complete positioning has superior oxygenation effects 1
• Never neglect pressure point protection—prone positioning significantly increases pressure ulcer risk and prophylactic measures must be taken before positioning 1
• Do not rely on chest X-ray alone to confirm tracheal placement—it can confirm depth but not tracheal vs. esophageal placement; waveform capnography is mandatory 3
• Apparent cuff leak should be assumed to be partial extubation until proven otherwise 3