Pa Patient Saf Advis 2015 Dec;12(4):158.
Prolonged Prone Positioning for Patients with Acute Respiratory Distress Syndrome
Critical Care; Internal Medicine and Subspecialties; Pulmonary Medicine
Expand All Collapse All

The Pennsylvania Patient Safety Authority received a request for guidelines and adverse event information about prolonged prone positioning (i.e., 16 or more consecutive hours) for patients with acute respiratory distress syndrome (ARDS). While early application of prolonged prone positioning for patients with severe ARDS has shown a reduction in patient mortality,1,2 no formal evidence-based guidelines were found in the literature; however, there are contraindications associated with this intervention.

Before prone positioning is implemented, contraindications to consider include increased intracranial pressure, spinal instability, severe hemodynamic instability, recent abdominal surgery or open abdominal wounds, unstable fractures, pregnancy, eye trauma or injury, recent pacemaker insertion, maxillofacial injuries, tracheostomy or tracheal surgery, and extracorporeal membrane oxygenation.3-5

Authority analysts queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) database for event narratives from the most recent 10 calendar years, 2005 through 2014, associated with prone positioning (i.e., keywords “prone” or “proning”) used as an intervention for patients with ARDS, respiratory failure, or pneumonia. The search returned 167 event reports. Pressure ulcers accounted for the majority (82.6%, n = 138) of events reported, which is consistent with the literature.1,2,6

Other events related to prone positioning identified in PA-PSRS reports or in the literature include unintended extubations; broken or displaced teeth; skin tears, lacerations, or abrasions; edema of the face, eyes, or tongue; disconnected tubes or intravenous lines; ventilator-associated pneumonia; cardiac events; pneumothorax; and ischemic optic neuropathy.1,2,6,7 Authority analysts were unable to determine the relative risks for these events because PA-PSRS does not collect data on the total incidence and duration of prone positioning.


  1. Guerin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome [online]. N Engl J Med 2013 Jun 6 [cited 2015 Sep 3].
  2. Park SY, Kim HJ, Yoo KH, et al. The efficacy and safety of prone positioning in adults patients with acute respiratory distress syndrome: a meta-analysis of randomized controlled trials. J Thorac Dis 2015 Mar;7(3):356-67.
  3. Chiumello DA, Algieri I, Brioni M, et al. The prone position in the treatment of patients with ARDS: problems and real utility. Chapter 1. In: Chiumello D, ed. Practical issues updates in anesthesia and intensive care. New York: Springer International Publishing; 2015:1-13.
  4. Guerin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome [supplementary appendix [online].N Engl J Med 2013 Jun 6 [cited 2015 Sep 3].
  5. London Health Sciences Centre. Critical care trauma centre: procedure for turning a ventilated patient prone in CCTC [online]. [cited 2015 Sep 3].
  6. Powers J. Use of prone positioning in ARDS [online]. Crit Connect 2011 Apr 2 [cited 2015 Sep 3].
  7. Ayoubieh H, Alkhalili E, El Kassis Y, et al. Ischemic optic neuropathy after prone ventilation for ARDS. Crit Care Med 2014 Dec;42(12 Suppl);A1641-2.

The Pennsylvania Patient Safety Advisory may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration, provided the source is clearly attributed.

Current and previous issues are available online at

©2019 Pennsylvania Patient Safety Authority