Prone Positioning in Acute Respiratory Distress Syndrome

Prone positioning has emerged as a cornerstone intervention in the management of moderate to severe acute respiratory distress syndrome (ARDS), a life-threatening form of respiratory failure characterised by diffuse alveolar injury and profound hypoxaemia. By turning the patient onto their front, gravitational forces redistribute perfusion and ventilation to the dorsal lung regions, recruit collapsed alveoli, improve ventilation–perfusion matching and reduce regional overdistension. In intubated and sedated patients, trials have demonstrated that long sessions of prone positioning (typically exceeding 12 hours per day) combined with lung-protective ventilation and adequate positive end-expiratory pressure significantly reduce mortality in severe ARDS. The manoeuvre also attenuates transpulmonary driving pressure and can mitigate ventilator-induced lung injury by homogenising lung stress. More recently, awake prone positioning has been explored in non-intubated patients receiving high-flow nasal oxygen or noninvasive ventilation; early physiological studies confirm rapid improvements in arterial oxygenation and end-expiratory lung volume, although attention must be paid to patient comfort and monitoring of inspiratory effort to avoid self-inflicted lung injury. Operationally, prone positioning demands coordinated protocols, appropriate staffing and attention to pressure-area care, but its global adoption during the COVID-19 pandemic has underlined its versatility and impact across diverse healthcare settings. As evidence continues to accumulate, prone positioning remains a practical, low-cost, evidence-based therapy for ARDS with wide-ranging implications for critical care worldwide.

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Prone Positioning in Acute Respiratory Distress Syndrome publication trend

The graph below shows the total number of articles in prone positioning in acute respiratory distress syndrome across all publications each year (not limited to Nature Index journals).

Technical terms

Acute respiratory distress syndrome (ARDS): A severe form of respiratory failure marked by diffuse lung inflammation, reduced lung compliance and refractory hypoxaemia.

PaO2/FiO2 ratio: The arterial oxygen tension divided by the fraction of inspired oxygen, used to grade severity of hypoxaemia in ARDS.

Positive end-expiratory pressure (PEEP): The pressure maintained in the lungs at end of expiration during mechanical ventilation to prevent alveolar collapse.

High-flow nasal cannula (HFNC): A device delivering warmed and humidified oxygen at high flow rates, supporting respiratory drive and comfort in hypoxaemic patients.

Self-inflicted lung injury: Lung damage resulting from excessive patient effort and high transpulmonary pressures during spontaneous breathing.

References

1. Physiological effects of awake prone position in acute hypoxemic respiratory failure. Critical Care (2023).
2. Factors for success of awake prone positioning in patients with COVID-19-induced acute hypoxemic respiratory failure: analysis of a randomized controlled trial. Critical Care (2022).
3. The effect of prone positioning on mortality in patients with acute respiratory distress syndrome: a meta-analysis of randomized controlled trials. Critical Care (2014).