Prone Position in Intubated, Mechanically Ventilated Patients With COVID-19

A Multi-Centric Study of More Than 1000 Patients

Thomas Langer; Matteo Brioni; Amedeo Guzzardella; Eleonora Carlesso; Luca Cabrini; Gianpaolo Castelli; Francesca Dalla Corte; Edoardo De Robertis; Martina Favarato; Andrea Forastieri; Clarissa Forlini; Massimo Girardis; Domenico Luca Grieco; Lucia Mirabella; Valentina Noseda; Paola Previtali; Alessandro Protti; Roberto Rona; Francesca Tardini; Tommaso Tonetti; Fabio Zannoni; Massimo Antonelli; Giuseppe Foti; Marco Ranieri; Antonio Pesenti; Roberto Fumagalli; Giacomo Grasselli


Crit Care. 2021;25(128) 

In This Article


At the end of 2019, an outbreak of pneumonia of unknown etiology started from Wuhan, Hubei, China and subsequently spread worldwide. Italy was hit at the end of February 2020 and, as of the end of July 2020, more than 250,000 infections and more than 35,000 deaths had been reported.[1] A novel beta-coronavirus, named Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2), was identified as the cause of the epidemic,[2] and the resulting disease was called Coronavirus Disease 2019 (COVID-19). COVID-19 has a broad spectrum of clinical presentations, ranging from asymptomatic to extremely severe forms. A significant proportion of infected subjects develops the acute respiratory distress syndrome (ARDS)[3,4] and requires invasive mechanical ventilation and admission to an intensive care unit (ICU).[4,5]

In patients developing refractory hypoxemia despite invasive mechanical ventilation, the application of rescue therapies such as extracorporeal gas exchange, inhaled nitric oxide and prone positioning is frequently required.[6] Previous experience in patients with moderate-to-severe ARDS from different causes showed that early application of prone position is associated with a significant survival benefit.[7–9] In patients with ARDS, prone positioning should favour the re-expansion of collapsed lung parenchyma in dorsal lung regions, and reduction in aeration in ventral ones, leading both to lung recruitment and more homogenous lung aeration. While distribution of ventilation is certainly influenced by the postural change, lung perfusion is usually considered less dependent on gravity.[10,11] Nevertheless, the net effect is usually a better ventilation-perfusion matching in prone position, resulting in improved gas exchange. Moreover, the more homogenous distribution of ventilation should reduce the risk of ventilator-induced lung injury.

Given the high number of COVID-19 patients with respiratory failure treated outside the ICU, there has been an increasing interest in the use of prone position in awake, spontaneously breathing patients.[12–16] On the contrary, limited data are available on the use of prone position in intubated, invasively ventilated patients.[17,18]

Aims of the present study are: (1) to describe the frequency of use of prone positioning and the clinical characteristics and outcomes of patients undergoing prone positioning in a large cohort of critically ill, mechanically ventilated patients with COVID-19; and (2) to describe, in a subgroup of patients, the pathophysiological effects of prone positioning.