Prone Positioning in Patients with COVID ARDS

Across twitter and internet blogs, intensive care physicians have remarked that prone positioning has helped improve lung function in patients with acute respiratory distress syndrome (ARDS) from COVID-19.

Below is an excellent video from NEJM about prone positioning. This process is very involved, requiring multiple people and careful attention to all tubes and lines attached to the patient.

Source: NEJM

A comprehensive review about the physiology and therapeutic benefits of prone positioning is outlined here: In brief, when you are prone, there is a more even distribution of alveoli size throughout your lungs and you are able to ventilate more effectively (get more air into your lungs). The perfusion of blood throughout the lungs is relatively unchanged, so the net effect is that more blood in your lungs can get more oxygen.

Source: Richard Kallet. Respiratory Care 2015.

The PROSEVA trial in 2013 demonstrated that prone positioning reduces mortality in patients with severe ARDS. In this study, patients underwent their first pronation within ~55 minutes after random assignment into a group, remained in a position for ~17 hours before flipping positions, and had ~4 flipped positions during their hospitalization. See for more details.

Prone positioning improves survival
Source: Guerin et al NEJM 2013.

The March interim report for the clinical management of acute respiratory infection recommends early proning for patients with COVID ARDS. See

Source: WHO

There are reports on twitter, blogs, and papers that prone positioning has been helpful. In Xie et al. Intensive Care Medicine 2020 (, the authors remark:

Source: Xie et al. Intensive Care Medicine 2020.

In Huang et al.’s experience, 53.8% of their patients had improvement with prone ventilation (28/52, p= 0.04). Source:

In Giuseppe Natalini’s experience in Italy (

Source: Giuseppe Natalini 2020.

Critical care physicians in Seattle have noted the same thing.

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