Effectiveness of Prone Positioning in Nonintubated Intensive Care Unit Patients With Moderate to Severe Acute Respiratory Distress Syndrome by Coronavirus Disease 2019

Manuel Taboada, MD, PhD; Mariana González, MD; Antía Álvarez, MD; Irene González, MD; Javier García, MD; María Eiras, MD; María Diaz Vieito, MD; Alberto Naveira, MD; Pablo Otero, MD; Olga Campaña, MD; Ignacio Muniategui, MD; Ana Tubio, MD; Jose Costa, MD; Salomé Selas, MD; Agustín Cariñena, MD; Adrián Martínez, MD; Sonia Veiras, MD, PhD; Francisco Aneiros, MD; Valentín Caruezo, MD; Aurora Baluja, MD, PhD; Julian Alvarez, MD, PhD


Anesth Analg. 2020;132(1):25-30. 

In This Article

Abstract and Introduction


Background: In the treatment for severe acute respiratory distress syndrome (ARDS) from coronavirus disease 2019 (COVID-19), the World Health Organization (WHO) recommends prone positioning (PP) during mechanical ventilation for periods of 12–16 h/d to potentially improve oxygenation and survival. In this prospective observational study, we evaluated the ability of long PP sessions to improve oxygenation in awake intensive care unit (ICU) patients with moderate or severe ARDS due to COVID-19.

Methods: The study was approved by the ethics committee of Galicia (code No. 2020–188), and all patients provided informed consent. In this case series, awake patients with moderate or severe ARDS by COVID-19 admitted to the ICU at University Hospital of Santiago from March 21 to April 5, 2020 were prospectively analyzed. Patients were instructed to remain in PP as long as possible until the patient felt too tired to maintain that position. Light sedation was administered with dexmedetomidine. The following information wascollected: number and duration of PP sessions; tissue O2 saturation (StO 2) and blood gases before, during, and following a PP session; need of mechanical ventilation; duration of ICU admission; and ICU outcome. Linear mixed-effects models (LMM) were fit to estimate changes from baseline with a random effect for patient.

Results: Seven patients with moderate or severe ARDS by COVID-19 were included. All patients received at least 1 PP session. A total of 16 PP sessions were performed in the 7 patients during the period study. The median duration of PP sessions was 10 hours. Dexmedetomidine was used in all PP sessions. Oxygenation increased in all 16sessions performed in the 7 patients. The ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO 2/FIO 2) significantly increased during PP (change from baseline 110 with97.5% confidence interval[CI], 19–202) and, after PP, albeit not significantly (change from baseline 38 with97.5% CI, −9.2 to 85) compared with previous supine position. Similarly, tissue oxygenation underwent a small improvement during PP (change from baseline 2.6%with 97.5% CI, 0.69–4.6) without significant changes after PP. Two patients required intubation. All patients were discharged from the ICU.

Conclusions: We found that PP improved oxygenation in ICU patients with COVID-19 and moderate or severe ARDS. PP was relatively well tolerated in our patients and may be a simple strategy to improve oxygenation trying to reduce the number ofpatients in mechanical ventilation and the length of stay in the ICU, especially in COVID-19 pandemic.


Since the emergence of the 2019 novel coronavirus (SARS-CoV-2) infection in December 2019, the coronavirus disease 2019 (COVID-19) has rapidly spread across the globe. The clinical spectrum of patients with COVID-19 ranges from asymptomatic or mild symptoms to critical disease with a high risk of mortality. In particular, of the incidence of acute respiratory distress syndrome (ARDS) in patients hospitalized with COVID-19 can range from 17% to 30% (1–2). Some of these patients with ARDS (20%–30%) may develop respiratory failure 10–11 days after the onset of symptoms requiring intensive care unit (ICU) admission and mechanical ventilation.[1,2]

In treatment for severe ARDS associated with COVID-19, 1 option is prone positioning (PP) during mechanical ventilation. The World Health Organization (WHO) recommends its use for periods of 12–16 h/d because it may improve oxygenation and survival.[3,4]

The objective of this prospective observational study was to evaluate the effectiveness of the PP sessions to improve oxygenation and assess the incidence of tracheal intubation and mechanical ventilation in patients with moderate or severe ARDS by COVID-19.