The following clinical guidelines for prone positioning are based on clinical studies, evidence based research and best practices in ICUs with extensive experience in prone positioning critically ill patients.

Clinical research has shown the effectiveness of prone therapy in improving oxygenation (Gattinoni 2001) in ARDS patients. Two more recent studies, one utilizing the RotoProne™ Therapy System, have demonstrated that prone therapy may reduce mortality in ARDS patients when implemented early and applied for longer periods of time.(Mancebo 2006, Davis 2007) Although outcomes will vary and there can be no assurance for a specific patient, proning in general has been shown to:

  • Enhance the mobilization of pulmonary secretions, thus optimizing the effectiveness of    physiotherapy techniques.(Chatte 1997)
  • Reduce the risk of iatrogenic lung injury resulting from mechanical ventilation.(Broccard 1997)
  • Reduce the risk of ventilator-acquired pneumonia.(Brazzl 1999)

Patient Response to Prone Therapy:

Approximately 75% of ARDS/ALI patients may respond with improved oxygenation.(Ware 2000) However, the length of prone time required for patient response may vary. Patients are categorized as responders based on the fol­lowing criteria: (Chatte 1997, Jollet 1998)

  • Increase in PaO2 of more than 10mmHg after 30 minutes of prone positioning.
  • Increase in PaO2/ FiO2 ratio of more than 20 or 20% within two hours of patient being turned from supine to prone

Patients are categorized as non-responders based on the following criteria:(Chatte 1997, Jollet 1998)

  • PaO2 was unchanged after prone positioning

Note: If the initial attempt at prone positioning does not elicit a positive response with regards to oxygenation, this does not preclude additional attempts with prone positioning to improve oxygenation. There have been reports of patients who did not respond on the initial attempt that did respond at subsequent attempts of prone positioning showing an improvement in PaO2.(McAuley 2002)

Frequency and Duration of Prone Therapy:

There are no standard guidelines to delineate optimal duration or frequency of prone positioning. Although there is increased risk of serious skin breakdown and other serious complica­tions with prolonged proning, patients can remain in the prone position for as long as they tolerate the position, up to 20 hours daily. (Jollet 1998, Stocker 1997)

Length of prone time and frequency of prone/supine episodes may vary from patient to patient. Consult with the treating physician to obtain orders on frequency and duration of prone positioning and follow any facility-established protocols.

Early Intervention Factors:

Initiating therapy early (within 24 hours) in the course of ARDS may help to improve patient outcomes. (Pappert 1994, Vollman 1997) There is evidence to support proning the patient as soon as the patient meets the criteria for ARDS.(Pappert 1994)

It is important to train and educate the ICU staff on the early recognition of signs and symptoms of pulmonary complications, the practical application of prone positioning and the use of a specific therapy system. For the RotoProne™ Therapy System, it is recommended to place the patient within 24 hours of the P/F ratio trending below 200.

Prior to Initiation of Prone Therapy:

  • The clinician should collaborate with a multidisciplinary committee and physician to determine the need for Prone Therapy.
  • The clinician should inform the patient and the patient’s family about the therapy and rationale for prone positioning. (See the Patient and Family Information About the RotoProne™ Therapy System)
  • A physician’s order is required to initiate prone positioning as an intervention.