JAMA® Search All ▾ Enter Search Term  


 Trending
 Thoracic Society 2022 Conference High- Effect of Prone Positioning on Endotracheal Intu-
American
lights bation in Patients With COVID-19 and Acute Res-


piratory Failure
News | June 28, 2022
Research | June 7, 2022

This Issue Views 206,975 | Citations 0 | Altmetric 366 | Comments 2

PDF  Cite  Permissions  Comment

JAMA Patient Page 

August 21, 2020

Prone Positioning for Acute Respiratory

Distress Syndrome (ARDS)
Joseph Hadaya, MD1; Peyman Benharash, MD1

 Author Affiliations | Article Information

JAMA. 2020;324(13):1361. doi:10.1001/jama.2020.14901

 Español
 COVID-19 Resource Center

Editorial Related
 Comment  Articles

Pronepositioningisthetechniqueofplacingpatientswithbreathing
difficultiesontheirstomachtohelpthembreathebetter.Pronepositioning
isgenerallyreservedforsedatedpatientswhorequireabreathingmachine,
knownasaventilator,butitmaybebeneficialforawakepatientswithCOVID-19.

Possiblebenefitsofpronepositioninginclude
•Reducedriskofventilator-inducedlunginjury
•Lesslungcompressionandmoreefficient
gasexchangeinthelungs
•Improvedheartfunctionandoxygendeliverytothebody
•Betterdrainageofsecretionsproducedindiseasedlungs

Allpatientsplacedinprone
positionshouldbemonitored
carefullyforworsening
respiratorystatusandsymptoms.
KAREN

P rone positioning is a technique used to help patients with acute respiratory distress syn-
drome breathe better.

Widespread inflammation in the lungs may result in a life-threatening condition called acute
respiratory distress syndrome (ARDS). Severe infections such as coronavirus disease 2019
(COVID-19) and influenza can cause ARDS. Breathing can be difficult for patients with ARDS.

Hospitalized patients typically lie on their backs, a position known as supine. In prone posi-
tioning, patients lie on their abdomen in a monitored setting. Prone positioning is generally
used for patients who require a ventilator (breathing machine).

Prone positioning may be beneficial for several reasons: (1) In the supine position, the lungs are
compressed by the heart and abdominal organs. Gas exchange, the process of trading carbon
dioxide for oxygen, is reduced in areas of collapsed lung, resulting in low oxygen levels. In the
prone position, lung compression is less, improving lung function. (2) The body has mecha-
nisms to adjust blood flow to different portions of the lung. In ARDS, an imbalance between
blood and air flow develops, leading to poor gas exchange. Prone positioning redistributes
blood and air flow more evenly, reducing this imbalance and improving gas exchange. (3) With
improved lung function in the prone position, less support from the ventilator is needed to
achieve adequate oxygen levels. This may reduce risk of ventilator-induced lung injury, which
occurs from overinflation and excess stretching of certain portions of the lung. (4) Prone posi-
tioning may improve heart function in some patients. In the prone position, blood return to the
chambers on the right side of the heart increases and constriction of the blood vessels of the
lung decreases. This may help the heart pump better, resulting in improved oxygen delivery to
the body. (5) Because the mouth and nose are facing down in the prone position, secretions
produced by the disease process in the lung may drain better.

Advertisement

Placement of Patients in the Prone Position

Movement of patients to a prone position involves risk of serious complications such as a dis-
lodged breathing tube or very low blood pressure. A team of trained clinicians, including respi-
ratory therapists, nurses, and a physician, are necessary to safely reposition a patient. Most
hospitals maintain patients in a prone position for at least 12 hours per day, though practices
vary. Proning sessions continue until there is a sustained improvement in oxygen levels, or if
proning does not improve oxygen levels.

While prone positioning is generally limited to patients on a ventilator, voluntary, awake pron-
ing is being studied in patients with COVID-19. These patients require monitoring for worsen-
ing respiratory status.

Challenges of Prone Positioning for ARDS

Prone positioning is considered on an individual basis. Although it is beneficial in some set-
tings, not all patients improve and some may worsen. With changes in position, medical de-
vices, breathing tubes, and drains may dislodge (unintentionally fall out). If a breathing tube
becomes dislodged, replacement in the prone position is difficult. Performing procedures or
cardiopulmonary resuscitation (CPR) is also challenging in the prone position and may require
immediate repositioning. Also, with prone positioning, pressure is placed on the shoulders,
chest, knee, and face, predisposing these areas to pressure ulcers. This may also result in nerve
injury.

For More Information

A JAMA Patient Page on acute respiratory distress syndrome was published in the February
20, 2018, issue of JAMA.

The JAMA Patient Page is a public service of JAMA. The information and recommendations ap-
pearing on this page are appropriate in most instances, but they are not a substitute for med-
ical diagnosis. For specific information concerning your personal medical condition, JAMA sug-
gests that you consult your physician. This page may be photocopied noncommercially by
physicians and other health care professionals to share with patients. To purchase bulk re-
prints, email reprints@jamanetwork.com.

Article Information Back to top

Published Online: August 21, 2020. doi:10.1001/jama.2020.14901

Conflict of Interest Disclosures: None reported.

Sources: Aoyama H, Uchida K, Aoyama K et al. Assessment of therapeutic interventions and

lung protective ventilation in patients with moderate to severe acute respiratory distress syn-
drome. JAMA Netw Open. 2019;2(7):e198116. doi:10.1001/jamanetworkopen.2019.8116

Marini JJ, Gattinoni L. Management of COVID-19 respiratory distress. JAMA.

2020;323(22):2329-2330. doi:10.1001/jama.2020.6825

Comment

2 Comments for this article

August 29, 2020

Proning

John R. Dykers, Jr., MD | Chatham Hospital, Siler City, NC (now UNC West) Chair Emeritus
Thursday Morning Intellectual Society, CME for 35 years

Why not provide face rests for proning patients? They are on every massage table. Any begin-
ning carpenter or metalworker or plumber can make one out of copper tubing, or a baby potty
seat from Peds; just add a bit of foam rubber or padding from a shipment of chocolate from
Harry and David! or anywhere. Or Bubble wrap. The patient would be so much more comfort-
able that the one pictured above. Plenty of room for access for intubation or O2.

CONFLICT OF INTEREST: None Reported

August 29, 2020

Conscious Proning

Paul Elgert, BA | NYU Grossman School of Medicine/Bellevue Hospital

A face pillow is necessary. And some patients may develop anxiety if not used to prone posi-
tioning, especially when sick. I suggest sedation when this occurs, if not contraindicated by
other factors.

CONFLICT OF INTEREST: None Reported

See More About

Critical Care Medicine JAMA Patient Information Patient Information

Respiratory Failure and Ventilation Pulmonary Medicine Coronavirus (COVID-19)

 Monkeypox Resource Center

Trending
News 
American Thoracic Society 2022 Conference Highlights
June 28, 2022

Research 
Effect of Prone Positioning on Endotracheal Intubation in Patients With COVID-19 and Acute Respiratory
Failure
June 7, 2022

Opinion 
Is the Prone Position Helpful During Spontaneous Breathing?
June 9, 2020

Select Your Interests

Advertisement

JOB LISTINGS ON JAMA CAREER CENTER®

Breast Surgeon
Bridgeport, Connecticut

Hematologist/Oncologist Opportunities
Fresno, California

Director of Breast Medical Oncology

Springfield, Massachusetts

Hematology-Oncologist Opportunity in Minnesota With

$100K Starting Bonus
Brainerd, Minnesota

See more at JAMA Career Center

Others Also Liked

Management of respiratory failure due to covid-19
Susan R Wilcox et al., The BMJ, 2020

Extracorporeal membrane oxygenation support in 2019 novel coronavirus disease: indications, timing, and
implementation
Min Li et al., Chinese Medical Journal, 2020

Protective ventilation of patients with acute respiratory distress syndrome

E. D. Moloney et al., BJA: British Journal of Anaesthesia

Powered by

Trending

American Thoracic Society
2022 Conference Highlights
JAMA | News | June 28, 2022
Supine vs Prone Breast Radio- Effect of Prone Positioning on
therapy and Acute Toxic Ef- Endotracheal Intubation in
fects of the Skin Among Patients With COVID-19 and
Women With Large Breast Acute Respiratory Failure
Size JAMA | Research | June 7, 2022
JAMA Oncology | Research |

July 1, 2022

® ™
JAMA JAMA Network

CONTENT PUBLICATIONS INFORMATION

Home JAMA® For Authors
New Online JAMA Network Open For Institutions & Librarians
Current Issue JAMA Cardiology For Advertisers
JAMA Dermatology For Subscription Agents
JAMA Health Forum For Employers & Job Seek-
PODCASTS ers
JAMA Internal Medicine
Coronavirus (COVID-19) Q&A For the Media
JAMA Neurology
Clinical Reviews Online Commenting Policy
JAMA Oncology
Editors' Summary Statement on Potentially
JAMA Ophthalmology
Medical News Offensive Content
JAMA Otolaryngology–Head & Neck Surgery
Author Interviews
JAMA Pediatrics
JAMAevidence: Care at the JAMA NETWORK
Close of Life JAMA Psychiatry
PRODUCTS
JAMAevidence: JAMA Guide to JAMA Surgery
Statistics and Methods Archives of Neurology & Psychiatry (1919- AMA Manual of Style

JAMAevidence: The Rational 1959) JAMAevidence®

Clinical Examination Peer Review Congress
JAMAevidence: Users' Guides
SITES
to the Medical Literature
Art and Images in Psychiatry JN LEARNING
Best of the JAMA Network Home
JOURNAL INFORMA-
Clinical Crosswords from JAMA State CME
TION
Coronavirus Resource Center Clinical Challenge CME
For Authors
Evidence-Based Medicine: An Oral History Atrial Fibrillation Course
Editors & Publishers
Fishbein Fellowship CME / MOC Reporting Pref-
RSS erences
Genomics and Precision Health
Contact Us About CME & MOC
Hypertension
JAMA Forum Archive
 JN Learning / CME
JAMA Network Audio
 Store JAMA Network Video

 Apps JAMA Network Conferences

JAMA Surgery Guide to Statistics and Meth-
 Jobs
ods
Institutions Machine Learning

Reprints & Permissions Medical News

Monkeypox
Research Ethics
Subscribe Topics and Collections

Go Visual Abstracts
War and Health

FEATURED ARTICLES
CONSERVE 2021 Guidelines for Reporting
Trials Modified for the COVID-19 Pandemic
FDA Approval and Regulation of Pharmaceu-
ticals, 1983-2018
Global Burden of Cancer, 2010-2019
Global Burden of Long COVID
Global Burden of Skin Diseases, 1990-2017
Managing Asthma in Adolescents and Adults:
2020 NAEPP Asthma Guideline Update
Practices to Foster Physician Presence and
Connection With Patients in the Clinical En-
counter
Spirituality in Serious Illness and Health
The US Medicaid Program: Coverage, Financ-
ing, Reforms, and Implications for Health
Equity
US Burden of Neurological Disease, 1990-
2017
USPSTF Recommendation on Screening for
Colorectal Cancer
USPSTF Recommendation on Screening for
Hypertension
USPSTF Recommendation on Screening for
Lung Cancer
USPSTF Recommendation on Screening for
Prediabetes and Type 2 Diabetes

BLOGS
AMA Style Insider

 
Subscriptions & Renewals Get the latest from JAMA
Manage Emails
Update My Address
  Email address

Contact Us Sign Up
My Account Privacy Policy | Terms of Use

JAMA CAREER CENTER

Physician Job Listings

© 2022 American Medical Association. All Rights Reserved.

Terms of Use | Privacy Policy | Accessibility Statement

Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Contin-
ue," you are agreeing to our Cookie Policy | Continue