Is prone positioning recommended for adults with moderate-to-severe COVID-19 ARDS?

Prone positioning (lying face down) is a standard treatment for moderate-to-severe acute respiratory distress syndrome (ARDS), including COVID-19 ARDS. It helps improve oxygen levels and lung function. Current guidelines recommend prone positioning for patients on mechanical ventilation, and some evidence suggests that longer sessions (24 hours or more) may offer additional benefits, though with a higher risk of pressure injuries.

What the research says

Prone positioning is recommended for patients with moderate-to-severe ARDS receiving mechanical ventilation ⁹. Studies show that prone positioning improves oxygenation and lung compliance in COVID-19 ARDS, with a more pronounced effect compared to non-COVID ARDS ⁹. A meta-analysis of 10 studies (2,412 patients) found that extended prone positioning (≥24 hours per session) was associated with reduced mortality compared to traditional prone positioning (16-24 hours) (risk ratio 0.76) ⁸¹⁰. However, the certainty of evidence was low to very low ⁸¹⁰. Another meta-analysis of 7 studies (996 patients) showed a nonsignificant trend toward lower mortality with prolonged prone positioning (>24 hours) but a borderline increase in pressure injuries ⁷. In awake, non-intubated patients with COVID-19 ARDS, prone positioning improved oxygenation and was feasible, but the evidence is limited to small studies ¹¹. Overall, prone positioning is beneficial, but the optimal duration remains uncertain, and longer sessions increase the risk of pressure injuries ⁷⁸¹⁰.

What to ask your doctor

• Is prone positioning appropriate for my specific condition and severity of ARDS?
• What is the recommended duration for prone positioning sessions in my case?
• What measures will be taken to prevent pressure injuries during prone positioning?
• Are there any contraindications or risks I should be aware of?
• How will my oxygen levels and lung function be monitored during prone positioning?