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Updated: Aug 6, 2026
An Educational Video Demonstration of How to Prone a Critically Ill Intubated Patient
Published on: November 30, 2022
Prone positioning can be safely performed in critically ill infants and children
Lori D Fineman1, Michelle A LaBrecque, Mei-Chiung Shih
1Pediatric Cardiac Intensive Care, University of California San Francisco Children's Hospital, USA.
Insights
Prone positioning is safe for critically ill children with acute lung injury, showing no significant impact on ventilation, nutrition, or pain management. However, it requires more staff and time for repositioning.
Area of Science:
- Pediatric critical care medicine
- Respiratory physiology
- Clinical trial methodology
Background:
- Acute lung injury (ALI) in children presents significant management challenges.
- Prone positioning is a recognized intervention for improving oxygenation in ALI.
- Its effects on various aspects of care in pediatric ALI require detailed examination.
Purpose of the Study:
- To evaluate the impact of prone positioning on airway management, mechanical ventilation, enteral nutrition, pain and sedation, and staff utilization in pediatric ALI patients.
- To assess the safety and feasibility of prolonged prone positioning in this population.
Main Methods:
- Secondary analysis of a multi-center, randomized controlled trial comparing supine and prone positioning in 102 pediatric patients with ALI.
- Data collected included airway management, mechanical ventilation parameters, enteral nutrition, pain/sedation scores, staff time, and adverse events over 28 days.
- Patients were managed with standardized protocols for ventilation, sedation, nutrition, and skin care.
Main Results:
- Prone positioning did not significantly affect endotracheal tube leak, inadvertent extubation rates, or the initiation/advancement of enteral feeds.
- Pain and sedation scores, as well as comfort medication use, were similar between prone and supine groups.
- While no critical events occurred during repositioning, prone positioning required more staff and time, and two cases of endotracheal tube obstruction were noted.
Conclusions:
- Prone positioning is a safe intervention for critically ill pediatric patients with ALI.
- Prolonged management in the prone position is feasible without compromising key aspects of care.
- Increased resource utilization (staff and time) is a consideration for implementing prone positioning protocols.
Objective:
To describe the effects of prone positioning on airway management, mechanical ventilation, enteral nutrition, pain and sedation management, and staff utilization in infants and children with acute lung injury.
Design:
Secondary analysis of data collected in a multiple-center, randomized, controlled clinical trial of supine vs. prone positioning.
Setting:
Seven pediatric intensive care units located in the United States.
Patients:
One hundred and two pediatric patients (51 prone and 51 supine) with acute lung injury.
Interventions:
Patients randomized to the supine group remained supine. Patients randomized to the prone group were positioned prone per protocol during the acute phase of their illness for a maximum of 7 days. Both groups were managed using ventilator and sedation protocols and nutrition and skin care guidelines.
Measurements And Main Results:
Airway management and mechanical ventilatory variables before and after repositioning, enteral nutrition management, pain and sedation management, staff utilization, and adverse event data were collected for up to 28 days after enrollment. There were a total of 202 supine-prone-supine cycles. There were no differences in the incidence of endotracheal tube leak between the two groups (p = .30). Per protocol, 95% of patients remained connected to the ventilator during repositioning. The inadvertent extubation rate was 0.85 for the prone group and 1.03 for the supine group per 100 ventilator days (p = 1.00). There were no significant differences in the initiation of trophic (p = .24), advancing (p = .82), or full enteral feeds (p = .80) between the prone and supine groups; in the average pain (p = .81) and sedation (p = .18) scores during the acute phase; and in the amount of comfort medications received between the two groups (p = .91). There were no critical events during a turn procedure. While prone, two patients experienced an obstructed endotracheal tube. One patient, supported on high-frequency oscillatory ventilation, experienced persistent hypercapnea when prone and was withdrawn from the study. The occurrence of pressure ulcers was similar between the two groups (p = .71). Compared with the supine group, more staff (p
Conclusions:
Our data show that prone positioning can be safely performed in critically ill pediatric patients and that these patients can be safely managed while in the prone position for prolonged periods of time.
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