Research

DIMENSION

Prone Position in Acute

Respiratory Distress
Syndrome Patients
A Retrospective Analysis of Complications
Alberto Lucchini, RN; Stefano Bambi, PhD, MSc, RN, CCN;
Elisa Mattiussi, MSc, RN, CCN; Stefano Elli, RN; Laura Villa, RN, CCN;
Herman Bondi, RN, CCN; Roberto Rona, MD; Roberto Fumagalli, MD;
Giuseppe Foti, MD

Background: Early application of prolonged prone positioning has been shown

to improve patient survival in moderate to severe adult respiratory distress
syndrome (ARDS) patients. Prone position is a key component of lung protective
mechanical ventilation in association with low tidal volume and neuromuscular
blocking agents in patients with severe ARDS. Pressure sores are the major prone
position complication. The rate of complication is lowering with the increase in
center expertise.
Aims: The aim of this study was to examine the onset of pressure sores and other
complications caused by the use of prone position in patients having ARDS.
Design: This is a single-center, retrospective, observational study.
Results: One hundred seventy patients were enrolled, with a median age of
49 years (interquartile range [IQR], 38-63). Of all participants, 58% (n = 98) survived
the intensive care unit recovery. The total prone position maneuvers were 526, with
a median of 2 prone position sessions for each patient (IQR, 1-3). The median
length of the prone position session was 9 hours (IQR, 7-12). Twenty-three patients
developed pressure sores after prone position (14%). The anatomical positions
of pressure sores were as follows: face/chin, 5% (n = 8); face/cheekbones, 6%
(n = 11); thorax, 2% (n = 3); trochanter, 1% (n = 1); and other sites, 5% (n = 8).
Complications were observed in 1% (n = 6) of all pronation maneuvers (vomit,
2%; respiratory device removal, 0.4%). No removal of intravascular catheter
was observed.
Conclusions: The onset rate of complications given by the use of prone position in
ARDS patients is similar to data reported by previous literature. The implementation
of a dedicated protocol in specialized centers and the involvement of 5 trained and

DOI: 10.1097/DCC.0000000000000393 January/February 2020 39

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

 Prone Position and Complications
skilled professionals while moving the patient in the prone position are
recommended to prevent the occurrence of similar adverse events.
Keywords: ARDS, Complications, Mechanical ventilation, Pressure sores, Prone position
[DIMENS CRIT CARE NURS. 2020;39(1):39-46]
Prone position (PP) is a postural therapy capable of influenc-
ing patient oxygenation. This goal is obtained by improving
the balance between lung ventilation and perfusion, recruiting
dependent lung tissue, and promoting drainage of pulmo-
nary secretions.1-3 Using lung protective strategies in adult
respiratory distress syndrome (ARDS) patients, with low
tidal volumes and plateau pressures (<6 mL/kg of ideal
body weight and plateau pressure < 28 cm H2O), can lead
to poorly ventilated areas in dependent lung regions and
result in alterations of ventilation/perfusion ratio.4,5 Ac-
cording to Guérin and colleagues,3 prone positioning, when
compared with supine positioning, markedly reduces the
overinflated lung areas while promoting alveolar recruit-
ment. Several multicenter studies and meta-analysis have
shown that the application of long sessions of PP, together
with a namely lower tidal volume targeting 6 mL/kg of ideal
body weight, and a continuous intravenous infusion of
cisatracurium for 48 hours are the most important strate-
gies that lead to an overall mortality reduction in patients
having ARDS.4-6 The PROSEVA study indicated that PP
therapy in addition to standard care reduced mortality by
26%.3 The benefit was seen in severe hypoxemic patients
(PO2/FiO2 < 100 mm Hg) who were left prone for at least
16 hours, and early initiation of prone therapy seems to
be an important factor for success.
An international prospective epidemiological study
conducted in 459 intensive care units (ICUs) across the
world in 2014 that analyzed the treatment of 2377 ARDS
patients7 has shown that the PP was adopted only for 16%
of patients with severe ARDS.8 Recently, the APRONET
study (6723 patients) demonstrates that PP was used on
32.9% of patients with severe ARDS.9 This study has
shown that a reduction in complication rate is achieved
when the procedure is performed in experienced and spe-
cialized centers. The authors reported the onset of complica-
tions in 12 patients (11.9%) for whom prone positioning was
used (pressure sores in 5 patients, hypoxemia in 2 patients,
unplanned extubation in 2 patients, ocular injuries in
2 patients, and a transient increase in intracranial pressure
in 1 patient). Similar rates of complications are reported by
other authors. Sud and colleagues2 report these complications
related to PP: unplanned removal of central or arterial lines
40 Dimensions of Critical Care Nursing Vol. 39 / No. 1
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
(6.6%), pneumothorax (5.7%), cardiac arrest (13.8%), dis-
lodgement of thoracostomy tube (1.9%), and pressure sores
(46.4%). Furthermore, the incidence of pressure sores in a
study by Girard and colleagues10 was 56.9%. Moreover,
PP was related to the development of edema and pressure
sores of the anterior body regions, including the face.11
Aims of the Study
The primary aim of this study is to observe the incidence of pres-
sure sores and other complications caused by prone positioning
in a population of patients having ARDS and treated with PP in
a general ICU. The secondary aim was to investigate the modi-
fications of the PaO2/FiO2 mm Hg ratio induced by PP.
METHODS
Study Design and Observed Variables
An observational retrospective study was performed. The
study was developed between January 2008 and December
2018 in a general ICU of a university hospital in the north
of Italy, being part of the National ECMO (extracorporeal
membrane oxygenation) Network. In the study period, we
enrolled all patients with ARDS undergoing invasive me-
chanical ventilation (both with endotracheal tube or trache-
ostomy) who were treated with PP, even with veno-venous
ECMO support.12 Patients in PP but treated with noninvasive
ventilation were excluded.13 During the study, criteria for PP
were as follows: fulfilled the diagnostic criteria of ARDS8
and PaO2/FiO2 ratio equal to or lower than 200 mm Hg.
The observed variables, described by previous literature as
complications of PP, were as follows: pressure sores (face,
thorax, trochanters, knees, other sites), vomiting, unplanned
extubations, airway obstruction, unplanned removal of vas-
cular catheters, and thoracic drainages. An antidecubitus
mattress with alternate pressure was routinely applied to all
patients (Proficare, ArjoHuntleigh, United Kingdom).
Instruments and Data Collection
Our current in-hospital protocol for PP is the following:
mandatory filling of a dedicated electronic chart where
the typologies of potential complications related to PP have

to be recorded (eg, vascular catheter's dislodgement, develop-
ment of skin ulcers). In addition, monitoring of a patient's skin
status has to be recorded before and after every cycle of PP ma-
neuver, focusing on the detection of early-stage edema or pres-
sure sores. Pronation of patients involves a complex and
coordinated effort, involving physicians and nurses. Every
prone positioning maneuver was performed according to our
ICU protocol and policy10,13,14:
- A total of 5 health care professionals must be involved: 4
operators performing the positioning of the patient and 1
responsible for the overall coordination and protection of
the endotracheal tube. While 2 operators are ensuring the
stability and patency of the endotracheal tube, a nurse
looks after the intravenous lines and at least 2 members
of staff roll the patient. It is advisable for a senior physi-
cian to be always available at the bedside in case of emer-
gency reintubation need.
- Application of thin hydrocolloid dressing for pressure ul-
cer prevention on the risk areas: face, thorax, iliac crests,
and tibial plateau.11,15,16
- Application of a double sutureless device to preserve cen-
tral venous lines and prevent their displacement.
- Use of double sheets for turning. Using the bottom sheet,
2 nurses pull the patient toward them on the edge of the
bed. If rolling is performed on the right side, the right
arm of the patient should be placed under his right side,
whereas the opposite is true for left-sided rolls. Only when
the endotracheal tube and vascular lines are secured, the
team can gently roll the patient into PP.
- The standard monitoring during the entire procedure is
as follows: pulse oximetry, continuous mixed venous ox-
ygen saturation, end-tidal carbon dioxide, and invasive
arterial blood pressure.
- Placing the head of the patient on a C-letter–shaped pad
to prevent facial pressure ulcers. Face rotation at a regu-
lar interval is not scheduled. Face rotation on the left side
and, afterward, on the right side every pronation session
or every time redness on the skin is observed.
- Placement of the head over the upper edge of the patient's
bed, using customized facial padding if the patient had a
tracheostomy.
- Limbs are positioned so as to prevent abnormal extension
or flexion against the shoulders and elbows. Pillows can
be added to provide additional support to the hips, shoul-
ders, and face (Figure).
- Positioning of transversal rolls placed under the pelvis
and the chest in patients with poor neck flexibility (in
those patients, rolls improve a better facial repositioning)
and/or with tracheostomy.11,17
Occurrence of known complications related to PP ap-
plications (ie, displacement of indwelling catheters, facial
edema, second-degree pressure sores or higher, pressure
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Prone Position and Complications
Figure. Patient in prone position with transversal rolls.
neuropathies, compression of nerves and retinal vessels,
vomiting, and intolerance to the maneuver) was reported as
recorded in the medical and nursing charts. The European
Pressure Ulcer Advisory Panel (EPUAP) score was used to
classify the pressure sores.18 The Braden score was used
for predicting pressure ulcer risk (range, 9-23).19 The nurs-
ing workload was measured using the Nursing Activities
Score (range, 0%-177%).20,21
To calculate the PO2/FiO2 ratio for each patient, PaO2
and ventilator FiO2 values were collected during 4 different
time steps: before pronation (PRE-supine step), 1 hour after
pronation (1 h-PP step), at the end of pronation (END-PP
step), and 1 hour after supination (POST-supine step).
Research Ethics
The study protocol was evaluated by the local ethics com-
mittee that waived written informed consent because of
the following reasons: the retrospective study design and
the fact that prone positioning represents an integral part
of care provided routinely to patients with ARDS. The lo-
cal ethics committee approved the study in 2018 (decreto
numero: 874-15/05/2018).
Statistical Analysis
Statistical analysis was performed using SPSS version 22.0
(SPSS Inc, Chicago, Illinois). Continuous variables were
expressed as mean (SD) or median and interquartile range
(IQR). Nonparametric test was performed for the differ-
ence between groups (Mann-Whitney U test for 2 samples
or Kruskal-Wallis test for k sample). Unpaired Student t
test and 1-way repeated-measures analysis of variance
were used to evaluate the differences at the different time
points of the PO2/FiO2 ratio values. A P value less than
.05 was considered statistically significant.
RESULTS
A total of 170 patients were included in the study. The me-
dian age was 55 years (IQR, 41-66; range, 2-87). The
January/February 2020 41
 Prone Position and Complications
median ICU length of stay was 20 days (IQR, 12-40; range,
2-158). Fifty-eight percent (n = 98) of patients survived
and were discharged from ICU. At ICU admission, patients
presented a median Braden score of 11 (IQR, 10-14) and,
during their ICU stay, a median Nursing Activities Score of
80 (IQR, 73-89).
All the patients were mechanically ventilated with a tidal
volume less than 6 mL/kg of ideal body weight. During the first
session of PP, the median positive end-expiratory pressure
(PEEP) observed was 15 (IQR, 12-16) cm H2O. In 57 patient
cases (34%), PP was adopted while the patient was connected
to veno-venous ECMO.
The median of the pronation cycles per patient was 2
(IQR, 1-3; range, 1-56); the median time spent in PP for
each cycle was 9 hours (IQR, 7-12; range, 1-22), whereas
the median total time in PP per patient was equal to 18 hours
(IQR, 9-39; range, 1-429). The total pronation maneuvers in-
vestigated were 526. The total number of patients who devel-
oped a pressure sore was 23 (14%). The anatomical positions
were as follows: face/chin, 5% (n = 8); face/cheekbones, 6%
(n = 11); thorax, 2% (n = 3); trochanter, 1% (n = 1); and other
sites, 5% (n = 8). In total, we identified 31 pressure sores re-
lated to PP on 23 patients. According to the EPUAP pressure
sores classification, 14 pressure sores (44%) were at stage I,
15 (48%) were at stage II, and the remaining 2 pressure sores
(6%) were at stage IV. No stage III pressure sores were recorded.
To identify the major risk factors for pressure sore de-
velopment, patients were divided into 2 groups: those with
and those without pressure sores developed from prone
positioning. The risk factors investigated were reported
in Table 1. In the comparison of the 2 groups, there was
a statistically significant difference for the following risk
factors: length of the PP session, total number of PP ses-
sions, and, consequently, the total time spent in PP.
Complications due to the maneuver of prone position-
ing occurred in 1% of cases, with the following incidence:
episodes of vomit in 1% (n = 5) and displacement of the re-
spiratory device in 0.2% (n = 1). No displacement of central
venous, arterial or, Swan Ganz catheters was observed, nor
of thoracic drainages. One hundred sixty-four patients (96%)
underwent PP with an endotracheal tube, whereas the
remaining 6 patients (4%) had a tracheostomy. The total
number of pronation maneuvers performed on patients with
tracheostomy was 17 (3%).
Collected data were classified by year, as reported in
Table 2. There was a progressive increasing of median
prone positioning time per cycle, without any significant
changes in pressure sore incidence.
The median value of PO2/FiO2 mm Hg ratio in all the
526 cycles before PP (PRE-supine step) was 109 (IQR,
80-148), then reached 144 (IQR, 96-200) after 1 hour
from the beginning of the session (1 h-PP step), then 158
(IQR, 110-213) before the patient was placed supine again
42 Dimensions of Critical Care Nursing Vol. 39 / No. 1
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
(END-PP step), and, finally, achieved 131 (IQR, 95-175)
when the patient was in the supine position for 1 hour
(POST-supine step). There was a statistically significant
difference in the PaO2/FiO2 ratios observed in the 4 time
frames (P < .0001). Data related to ventilator setup and
oxygenation are reported in Table 3.
DISCUSSION
The rate of overall complications attributed to PP in this
study was very low (1%), and the rate of pressure sores
was similar to the results from other studies previously
published.2,9,10 The physiological response to PP confirms
the finding of significant improvement in oxygenation.
Median time spent in PP had a progressive increase to
reach the time recommended by literature.3,9 Time spent
in a PP was, on average, around 9 hours from 2008 to
2013. This pronation time was linked to study protocols used
in previous studies that involved our ICU.14,22 After the study
by Guérin and colleagues, in 2013, we tried to implement the
pronation time to reach at least 12 hours. Only in the last year,
this time reached an average of 17 hours, as summarized in
our introduction, by PROSEVA trial.
The overall complications associated with PP in the
observed sample are lower in comparison with other previ-
ous literature reports. In a meta-analysis summarizing 11
Randomized controlled trials, the total percentage of airway-
related complications described for PP was 20%: a 9.1%
occurrence of unplanned extubation and/or selective intuba-
tion (211 events in 2309 patients) and a 10.8% occurrence of
endotracheal tube obstruction (200 events in 1847 patients).2
In our sample, only 1 unplanned extubation was recorded
(0.4% of overall PP maneuvers). In all the included pa-
tients, the artificial airway was secured with a 5-cm canvas
tape placed upon a thin hydrocolloid.23 Conventionally,
the tape is changed every 8 hours giving the opportunity
to relocate the tube from one side to the other side of the
mouth. Before every procedure of pronation, the tape was
replaced to guarantee better stability. Moreover, before pro-
nation, the tube was displaced on the side of the mouth not
leaning on the pillow (eg, when the head was rotated on the
right side, the tube was fixed on the left one, and vice versa).
For the 6 patients carrying a tracheostomy, an ulcer preven-
tion facial mask was used. This position prevented a higher
pressure to be applied on the cannula and provided nurses
with a good access for endotracheal suctioning.
The review conducted by Sud and colleagues2 reports
other kinds of complications related to PP: unplanned re-
moval of central or arterial lines (6.6%), pneumothorax
(5.7%), and cardiac arrest (13.8%). There was no occurrence
of these complications in our study. When looking at the un-
planned removal of central and arterial lines, we hypothesize
that the local procedure of placing 2 sutureless devices for
 Prone Position and Complications

TABLE 1 Differences in Variables Between Patients With and Without Development of

Pressure Sores
Patients With Pressure Sores Patients Without Pressure
Total Sample (N = 170), (n = 23 [14%]), Sores (n = 147 [86%]), Median
Median (IQR) or n (%) Median (IQR) or n (%) (IQR) or n (%) P

Prone position single cycle, 9 (7-12) 11 (8-15) 9 (7-12) .041a

median time, h
Median prone position cycles 2 (1-3) 3 (2-6) 2 (1-3) .030a
per patient, n
Prone position total time, h 19 (10-40) 35 (15-54) 16 (8-37) .015a
Alive at ICU discharge, n (%) 98 (58) 14 (61) 84 (57) .737b
Age, y 55 (41-66) 62 (50-76) 55 (41-66) .928a
Female, n (%) 47 (28) 4 (17) 43 (29) .238b
Length of ICU stay, d 20 (12-40) 21 (10-41) 20 (12-40) .930a
Veno-venous ECMO, n (%) 57 (34) 8 (35) 49 (33) .891b
Braden (ICU admission) 11 (10-14) 10 (9-14) 11 (10-14) .171a
Nursing Activities Score, % 80 (73-89) 77 (69-90) 80 (74-89) .398a
Pressure sore site
Face: cheekbones 11 (6%) 159 (94%)
Grade I 7
Grade II 2
Grade IV 2
Face: chin 8 (5%) 162 (95%)
Grade I 4
Grade II 4
Thorax 3 (2%) 167 (98%)
Grade I 1
Grade II 2
Trochanter 1 (1%) 169 (99%)
Grade I 1
Other sites 8 (5%) 162 (98%)
Grade I 2
Grade II 6

Abbreviations: ECMO, extracorporeal membrane oxygenation; ICU, intensive care unit; IQR, interquartile range.
a
Mann-Whitney U test.
χ Test.
b 2

each catheter used on the patient could have been protective.
The first sutureless device is applied to ensure the correct
device's placement (Grip-Lock, Vygon, Italy). The second
one is applied to prevent any unplanned traction that can
occur while nursing interventions are performed to the pa-
tients (ie, bathing the patient, sheet changing, mobilization).
The most frequent complication reported in the litera-
ture was the onset of pressure sores (43.4% in a review con-
ducted by Sud and colleagues,2 56.9% in a study by Girard
and colleagues,10 and 36% by Gattinoni and colleagues14).
In our population, the development of 14% of pressure
sores (23 patients) is given using the PP. These pressure sores
mainly occurred on the face of the patient and, in a lesser ex-
tent, on the trochanters and thorax. These data are similar
to the ones reported by Girard and colleagues.10 The study
is the only one exploring in detail the incidence of pressure
sores given by the PP alone. The pressure sores were ob-
served as follows: 29% on the face, 18% on the anterior
part of the thorax, 20% on the sacrum, 12% on the heels,
and 25% in other anatomical regions. In our study popula-
tion, the results in terms of pressure sores are very encourag-
ing, especially when considering the occurrence of sores on
the face and chin (6% and 5%, respectively) and on the an-
terior part of the thorax (2%).10 In our study, as a first

January/February 2020 43

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

 Prone Position and Complications

choice for prone positioning, there was no application of cy-

17 (16-18) <.001b

38 (23-51) <.001b
.009b
.015a
P
lindrical cushions under the thorax and trochanters.
(n = 22)
Chiumello and colleagues17 demonstrated that the patient
2018

can be placed prone directly on the antidecubitus surface

3 (2-3)
4 (18) usually applied, without any impact on gas exchange. Our
first choice, combined with an extensive use of hydrocolloids

40 (15-52)
to protect the skin surface, could have led to a reduction of
(n = 15)

9 (7-13)
2017

4 (2-5)
3 (20)

the occurrence of pressure sores. Moreover, the rotation of the

head of the patient at every single PP session could have had
an additional benefit in decreasing the pressure sore onset. The
Patients With Pressure Sores and Time Spent in Prone Position During the Investigated Years

(n = 32)

22 (8-23)
11 (8-15)

2 (1-3)
2016

application of cylindrical cushions under the thorax and the iliac

4 (13)

crests had been limited to patients with limited neck mobility or

with a tracheostomy.
28 (15-40)

The main variables associated with an increased oc-

(n = 22)

10 (7-12)

3 (2-4)
2015

0 (0)

currence of pressure sores in our population were as fol-

lows: the length of time spent in PP (single cycle and
overall time) and the repetition of PP sessions. The median
14 (11-44)
(n = 14)

9 (7-11)
2014

length of PP for each session was higher in the group with

2 (1-4)
0 (0)

pressure sores (11; IQR, 1-8) compared with the other

group (9; IQR, 7-12; P = .04), just like the median number
of sessions applied (3 vs 2; P = .03). Our results highlight
(n = 16)

18 (8-64)
8 (6-11)

1 (1-5)
2013

0 (0)

an increase in oxygenation within the use of the PP.

PaO2/FiO2 ratio measured with the patient in the supine
position before and after the first PP session increased from
17 (13-21)
(n = 8)

7 (7-9)

2 (2-3)
2012

1 (13)

108 (80-148) to 144 (96-200) mm Hg (P = .001). It is cru-

cial to remember that the improvement of the PO2/FiO2
mm Hg ratio value on its own does not represent a reliable
(n = 13)

11 (7-14)

parameter to evaluate the possible benefits of PP. Guérin

8 (6-8)

1 (1-2)
2011

2 (15)

and colleagues3 have shown how the PP compared with

the supine position markedly reduces the overinflated lung
areas while promoting alveolar recruitment. These effects
(n = 3)

7 (9-13)

7 (6-24)
2010

1 (1-2)
2 (67)

may contribute to prevent the well-known ventilator-

induced lung injury by homogenizing the distribution of
stress and strain within the lung. Guérin and colleagues3
20 (11-31)
(n = 11)

11 (7-12)
2009

3 (2-3)

also suggest sessions not shorter than 16 hours. Other ar-

4 (36)

ticles suggest that the PP maneuver should be performed

by not less than 5 trained and skilled operators.11,14,22
(n = 14)

9 (6-12)

10 (7-14)

Moreover, to guarantee the defined length pronation session

1 (1-2)
2008

3 (21)

and to ensure the simultaneous presence of 5 health profes-

sionals (generally 1 physician and 4 nurses) during the study,
the procedure was generally performed in the late afternoon
with the restoration of supine position in the following morn-
19 (10-40)
(N = 170
[100%])
Sample

9 (7-12)
Total

2 (1-3)
23 (14)

ing, according to patients' clinical conditions. This decision

limited any position modification during night shifts, char-
Abbreviation: IQR, interquartile range.

acterized by a reduction of the health care personnel. De-

spite dedicated beds being made available in the past years
Patients with pressure sores,

Total time in prone position,

(Rotoprone, Arjo Huntleigh), all PP maneuvers in the study

Prone positioning cycles,
Prone positioning/cycle,

were performed with a manual technique.

median (IQR), h

median (IQR), h

Kruskal-Wallis test.
median (IQR)

LIMITATIONS
TABLE 2

n (%)

χ Test.

This is a retrospective single-center study, so our conclu-

a 2

sions have some biases related to the individual center. In

44 Dimensions of Critical Care Nursing Vol. 39 / No. 1

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.


TABLE 3 Oxygenation Levels and Mechanical Ventilation Setup Before, During, and After
Prone Position
PRE-Supine Step, Median (Interquartile Range)
PO2, mm Hg 74 (61-80)b
FiO2 0.65 (0.55-0.90)
PO2/FiO2, mm Hg 108 (80-148)b
PEEP, cm H2O 15 (12-16)
Respiratory rate, rr/min 21 (12-29)
Tidal volume, mLc 299 (122-417)
Abbreviations: PEEP, positive end-expiratory pressure; PP, prone position.
a
Repeated-measures analysis of variance test.
b
Student t test: PRE-supine step vs 1 h-PP, END-PP step, and POST-supine step, P < .001.
c
Data available only for 300 cycles.
fact, the physicians were free to decide whether to imple-
ment the PP, selecting only patients suitable to improve
their oxygenation and able to tolerate the repositioning.
Furthermore, in several patients, the mechanical ventila-
tion setup (PEEP, tidal volume) was modified during the
PP. Physicians were free to modify FiO2, PEEP, and tidal
volume according to blood gas analysis and respiratory
mechanics modification. Finally, the small sample size does
not allow a proper evaluation of the effect of PP on clinical
outcomes, mortality, or length of ICU stay.
CONCLUSIONS
This retrospective study has shown that the PP in ARDS
patients, as previously suggested by literature, can be ap-
plied in an experienced center using a specific protocol to
limit the occurrence of complications. As recommended
by recent studies, the length for any PP session should be
at a minimum of 16 hours.
RECOMENDATIONS FOR PRACTICE
Literature recommends prone positioning for patients with
severe ARDS (PO2/FiO2 < 150 mm Hg). Each session
should last at least 16 hours. Prolonged time of application
leads to better outcomes. To limit complications, the pro-
nation protocol should include strategies for skin protec-
tion, primary and secondary methods for central line
fixation, pillow utilization and displacement, and the cor-
rect position of patients' face. As suggested by published
literature, the maneuver should be performed by at least
5 trained and skilled health care operators.
Acknowledgments
The authors would like to thank Mrs Patrizia Procopio,
MSN, RN; Mrs Elena Dettori, MSN, RN; Mrs Luisa
Katherine Barreda, MSN, RN; and Mr Angelo Taraddei,
MSN, RN, for their support and assistance during data
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Prone Position and Complications
1 h-PP Step END-PP Step POST-Supine Step Pa
84 (69-107) 88 (71-105) 77 (63-92) <.001
0.60 (0.50-0.80) 0.55 (0.45-0.70) 0.60 (0.50-0.75) .331
144 (96-200) 158 (110-213) 131 (95-175) <.001
15 (12-17) 15 (12-17) 15 (12-17) .768
21 (12-30) 22 (12-30) 22 (12-29) .657
288 (120-420) 317 (154-423) 317 (116-417) .134
collection. The authors also thank all the local ICU physi-
cians, nurses, residents, and students for their continuous,
extraordinary efforts in caring for these complex patients.
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with acute respiratory distress syndrome: a systematic review
and meta-analysis. CMAJ. 2014;186:E381-E390.
3. Guérin C, Reignier J, Richard JC, et al. Prone positioning in se-
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ABOUT THE AUTHORS
Alberto Lucchini, RN, is head nurse at the General Intensive Care Unit,
ASST Monza, San Gerardo Hospital, Italy. He is the coordinator of the
master's degree program in intensive and critical care nursing at
Milano-Bicocca University, Italy.
46 Dimensions of Critical Care Nursing Vol. 39 / No. 1
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Stefano Bambi, PhD, MSc, RN, CCN, is a staff nurse at the Medical &
Surgical Intensive Care Unit, Careggi Teaching Hospital, Florence, Italy. He
was formerly a lecturer in emergency and critical care nursing at University
of Florence (Italy).
Elisa Mattiussi, MSc, RN, CCN, is a professor-in-charge at School of Nursing,
Department of Medical and Biological Sciences, Udine University, Italy.
Stefano Elli, RN, is currently employed at the General Intensive Care Unit,
Emergency Department, San Gerardo Hospital, and University of
Milan-Bicocca, Italy.
Laura Villa, RN, CCN, is a staff nurse at General Intensive Care Unit, ASST
Monza, San Gerardo Hospital.
Herman Bondi, RN, CCN, is a staff nurse at General Intensive Care Unit,
ASST Monza, San Gerardo Hospital.
Roberto Rona, MD, is director of general intensive care unit, ASST
Monza, San Gerardo Hospital.
Roberto Fumagalli, MD, is director and a full professor at Department of
Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda Hospital,
University of Milan-Bicocca, Milan, Italy.
Giuseppe Foti, MD, is director and an associate professor at the
Emergency Department, ASST Monza, San Gerardo Hospital.
This study was performed at the General Intensive care Unit, Emergency
Department and Intensive Care, San Gerardo Hospital, ASST Monza, Via
Pergolesi 33, Monza (MB), Milan-Bicocca University, Italy.
The authors have disclosed that they have no significant relationships
with, or financial interest in, any commercial companies pertaining to
this article.
Address correspondence and reprint requests to: Alberto Lucchini, RN,
General Intensive Care Unit, San Gerardo Hospital, ASST Monza, Via
Pergolesi 33, Monza (MB), Italy (alberto.lucchini@unimib.it; a.
lucchini@asst-monza.it).
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.