Prone Position: A Saviour to Covid-19


The purpose of the positioning is very well known as the preventive, curative, and rehabilitative aspects of the health. We often position the client as per the need or as required therapeutically. The Health care workers are  well- versed with the different kinds of positions which is been used for long times for the comfort and safety aspects for the client's treatment and their betterment.1 One of these positions considering the prone position which is been increasingly in the treatment of patients with acute respiratory distress syndrome (ARDS) and this maneuver is now considered a simple and safe method to improve oxygenation in this COVID outbreak as a pandemic9. One of the research studies show if a patient with the acute respiratory distress syndrome (ARDS) is placed on his belly the ventilation is improved due to changes in pleural pressure by the body of the client itself, considering other as the prone positioning may promote pulmonary secretion drainage in patients with specific diseases as well.2 This has also been observed that the oxygenation was often preserved once the patient returned to the supine position giving the fact that the alveoli have reopened they are more likely to stay open.3,4

The pandemic outbreak of coronavirus with a huge number of affected patients requiring respiratory support, create a situation to overload the intensive care units which are a big threat in health care teams.5Considering the Non-invasive ventilation which can be possible in general wards and become an alternative for some of the patients. There is feasibility, If we club this NIV with the pronation6 will be a help to drain airway secretions and improves the gas exchange and the rate of survival in acute respiratory disease syndrome(ARDS)7, published online by National center of biotechnological information and national library of medicine 8
Some of the good effects of prone (face-down) position over Supine (face-up) in oxygenation:
1.     Reducing ventral-dorsal transpulmonary pressure difference: In supine, the dorsal pleural pressure is greater than the ventral pressure exceeds by the weight of lungs leads to the over-inflation to the ventral lungs9,10,11 as compared to the dorsal area results in dorsal atelectasis on the other hand in prone the dorsal-ventral transpulmonary the pressure is reduced and making the ventilation homogeneous prevents the collapsing of lungs.9,12,13
2.     Reduced the compression at lungs: During ARDS the person lying at supine, the pressure by the heart as it compresses the medial posterior lung parenchyma and the diaphragm on the other hand compresses the posterior- caudal lung parenchyma leads to hypoxemia and lung associated injury risks comparatively if the patient is in supine the heart puts the pressure on the sternum and the diaphragm relieves the  caudal pressure14,15 leads to good ventilation and prevents lung injuries.
3.     Improved lung perfusion: In supine the ventilation-perfusion mismatch as the lung collapse and blood flow are both greatest in the dependant areas of the lungs comparatively in prone position there is a match in the ventilation perfusion due to the majority of blood first goes to the previously dependant areas as the alveoli’s are beginning to reopen and then to the newly dependant alveoli’s as they begin to collapse leads to better ventilation.16
Conclusion: It was previously hypothesized that prone positioning allows the redistribution of the blood flows equally based on the gravitational gradient. Most of the studies indicating, that the blood flow pattern changes when we turn the patient in face-down position.17,18It is preferable that implementing prone position for the ventilation early in the course of ARDS within the first 36 hours and maintains the prone position for 18-20 consecutive hours with position changes as needed and also keeping in mind the contraindications in some of the cases as well19. So during this pandemic of COVID 19 it is great to help as per the different studies that prone positioning works as a savior for the patients suffering from breathing difficulties


1.      https://www.slideshare.net/babithadevu/comfort-positions comfort positions, October 2016

2.      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173887/Does prone positioning improves oxygenation and reduces mortality in patients with acute respiratory distress syndrome? William R Henderson, MD, Donald EG Griesdale, MD MPH, Paolo Dominelli, MSc, and Juan J Ronco, MD

3.      Chatte G, Sab J-M, Dubois J-M, Sirodot M, Gaussorgues P, Robert D. Prone position in mechanically ventilated patients with severe acute respiratory failure. Am J RespirCrit Care Med. 1997;155:473–8. [PubMed] [Google Scholar]
4.      22. Pelosi P, Tubiolo D, Mascheroni D, et al. Effects of the prone position on respiratory mechanics and gas exchange during acute lung injury. Am J RespirCrit Care Med. 1998;157:387–93. [PubMed] [Google Scholar]
5.      Cabrini  L, Landoni  G, Bocchino  S,  et al.  The long-term survival rate in patients with acute respiratory failure treated with noninvasive ventilation in ordinary wards.   Crit Care Med. 2016;44(12):2139-2144. DOI:10.1097/CCM.0000000000001866PubMedGoogle ScholarCrossref
6.      Ding  L, Wang  L, Ma  W, He  H.  Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center a prospective cohort study.   Crit Care. 2020;24(1):28. DOI:10.1186/s13054-020-2738-5PubMedGoogle ScholarCrossref
7.      Guérin  C, Reignier  J, Richard  JC,  et al; PROSEVA Study Group.  Prone positioning in severe acute respiratory distress syndrome.   N Engl J Med. 2013;368(23):2159-2168. DOI:10.1056/NEJMoa12141
8.      Respiratory Parameters in Patients With COVID-19 After Using Noninvasive Ventilation in the Prone Position Outside the Intensive Care Unit Chiara Sartini, MD1; Moreno Tresoldi, MD2; Paolo Scarpellini, MD3; et al

9.      https://erj.ersjournals.com/content/20/4/1017Prone position in acute respiratory distress syndrome. Pelosi, L. Brazzi, L. Gattinoni European Respiratory Journal 2002 20: 1017-1028; DOI: 10.1183/09031936.02.00401702

  1. Pelosi P, Brazzi L, Gattinoni L. Prone position in acute respiratory distress syndrome. EurRespir J 2002; 20:1017.
  2. Gattinoni L, Mascheroni D, Torresin A, et al. Morphological response to positive end expiratory pressure in acute respiratory failure. Computerized tomography study. Intensive Care Med 1986; 12:137.
  3. Douglas WW, Rehder K, Beynen FM, et al. Improved oxygenation in patients with acute respiratory failure: the prone position. Am Rev Respir Dis 1977; 115:559.
  4. Cornejo RA, Díaz JC, Tobar EA, et al. Effects of prone positioning on lung protection in patients with acute respiratory distress syndrome. Am J RespirCrit Care Med 2013; 188:440.
  5. Agostoni E, Mead J. Statics of the respiratory system. In: Handbook of Physiology, Macklem P, Mead J (Eds), American Physiologic Society, Bethesda 1986. p.387.

15.  Pelosi P, Croci M, Calappi E, et al. Prone positioning improves pulmonary function in obese patients during general anesthesia. AnesthAnalg 1996; 83:578.

16.  Nyrén S, Mure M, Jacobsson H, et al. Pulmonary perfusion is more uniform in the prone than in the supine position: scintigraphy in healthy humans. J ApplPhysiol (1985) 1999; 86:1135.
17.  Lamm WJ, Graham MM, Albert RK. Mechanism by which the prone position improves oxygenation in acute lung injury. Am J RespirCrit Care Med 1994; 150:184.
18.  Henderson AC, Sá RC, Theilmann RJ, et al. The gravitational distribution of ventilation-perfusion ratio is more uniform in prone than supine posture in the normal human lung. J ApplPhysiol (1985) 2013; 115:313.
19.  Samanta S, Samanta S, Wig J, Baronia AK. How safe is the prone position in acute respiratory distress syndrome at late pregnancy? Am J Emerg Med 2014; 32:687.e1.

Anu Grover 
Simulation Lab Training Officer 
National Reference Simulation Center 

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