1. Smart, Hiske MA(Nur), RN, Hons B Soc Sc (Nur), PGDip (WHTR) UK, IIWCC

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Patients with COVID-19 and acute respiratory distress syndrome who are placed in a prone position add to nursing challenges and workload. The risk for skin injury among these patients is high, and prevention should be prioritized in the nursing process. For optimal patient care, nurses must understand the exact respiratory mechanism initiated by the prone position and the associated risk for pressure injuries (PIs) not addressed in general PI prevention initiatives.


The rationale for proning is compelling; lung physiology and gas transfer are positively altered in this position.1 When supine, the most dorsal parts of the lung remain nearly gasless because of lung anatomy and the wide allowance for chest wall expansion. In the prone position, the bed becomes fixed resistance for the chest wall, limiting its expansion and leading to better distribution of inhaled gas. As a result, the dorsal parts of the lung open up, adding ventilation quality. This increases plateau pressure and reduces tidal volume, with the largest volume of the lungs actively adding to oxygenation surface.1 By achieving close to optimal oxygenation without exceeding the positive end-expiratory pressure, lung barotrauma and hyperinflation are prevented with better clinical outcomes achieved for acute respiratory distress syndrome.


In prone positioning, the swimming position may be best for PI prevention.2 The recovery position (Simms position)3 is also an option to optimize gas exchange; it is similar to the swimming position with only a leg adaptation on the facial side (Figure 1). If the swimming arm is positioned perpendicular to the eye line (hand to eye), it prevents overextension of the brachial plexus.1 By flexing the leg slightly on the same side as the flexed elbow,3 patient body weight is distributed over a wider area of the bed surface and directed away from the midline of the body. The major benefit of this position combination is its practicality for repositioning schedules.

Figure 1 - Click to enlarge in new windowFigure 1. PRONE POSITIONINGAchieved with microelevation under knee and opposite shoulder to protect groin and chest areas without direct pressure on bony prominences; spine is in sufficient alignment.Reprinted with permission of J. Mathai.

See the following section for a suggested procedure to achieve head repositioning and neutral neck alignment4 and the Table for helpful tips. Two providers are suggested for prone positional changes, especially when the patient is intubated (Figure 2).

Table PRONE POSITION... - Click to enlarge in new windowTable PRONE POSITIONING CHECKLIST
Figure 2 - Click to enlarge in new windowFigure 2. HEAD ROTATIONA, Head positioning; B, slight head lift; C, start of rotation; D, head support to complete rotation; E, rest position on other side of the face; F, if patient is correctly positioned on the cheek, the ear will be partly visible.Reprinted with permission of J. Mathai.



1. Ensure that the endotracheal tube (ETT) holder is removed before the patient is proned,5 because the adhesive tube holder wings will add pressure when trapped between the face and the bed surface.


2. Securely tape the ETT of the patient in place without a holder;5 oxygen tubing should be under no tension.


3. Align the patient's arms and legs next to their body to form a straight line.


4. Turn the head using two hands (one under the cheek), lifting the head without causing cervical tension. Slowly rotate until positioned on the opposite cheek. The second person controls the ETT once the face rotates midway (facing the bed).


5. Complete the head positioning. Ensure the neck is in a neutral position aligned with the spine, the hand is positioned in line with the eyes, the elbow has a 90[degrees] angle, and the palm is on the bed.


6. Flex the knee on the same side as the face slightly; ensure the foot is positioned to protect the Achilles tendon.


7. Position a thin pillow under the flexed knee to create a microspace around the genital area.


8. Position a thin pillow lengthwise under the shoulder opposite the face to lift the chest on the bedside away from direct pressure.


9. Check the ear is free from pressure after the slight shoulder lift. This redistributes pressure toward the cheek and achieves neutral alignment of the cervical spine.


10. Apply a moisturizer/skin barrier on the exposed cheek in preparation for the next turn.5



Attention to neutral head positioning4 and regular facial skin care5 may promote skin integrity for patients required to be in the prone position for prolonged periods. Microadjustments to alleviate pressure on the front of the body can protect vulnerable areas without compromising the lifesaving hemodynamic stability achieved with prone positioning.




1. Guerin C, Albert RK, Beitler J, et al. Prone position in ARDS patients: why, when, how and for whom. Intensive Care Med 2020;46:2385-96. [Context Link]


2. National Pressure Injury Advisory Panel. Pressure injury prevention: PIP tips on prone positioning. 2020. Last accessed May 11, 2021. [Context Link]


3. The Free Dictionary. Recovery position. Last accessed May 11, 2021. [Context Link]


4. Snodgrass SJ, Rhodes HR. Cervical spine posteroanterior stiffness differs with neck position. J Electromyogr Kinesiol 2012;22(6):829-34. [Context Link]


5. Team V, Team L, Jones A, Teede H, Weller CD. Pressure injury prevention in COVID-19 patients with acute respiratory distress syndrome. Front Med (Lausanne) 2021;7:558696. [Context Link]