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Updated: Nov 10, 2025
An Educational Video Demonstration of How to Prone a Critically Ill Intubated Patient
Published on: November 30, 2022
Prone position in intubated, mechanically ventilated patients with COVID-19: a multi-centric study of more than 1000
Thomas Langer1,2, Matteo Brioni3, Amedeo Guzzardella4
1Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.
Insights
Prone positioning improved oxygenation in invasively ventilated Coronavirus disease-19 (COVID-19) patients. While not affecting mortality, this technique enhanced oxygen levels, suggesting benefits for ventilation-perfusion matching in severe respiratory failure.
Area of Science:
- Critical Care Medicine
- Pulmonology
- Infectious Diseases
Background:
- Limited data exist on prone positioning for invasively ventilated Coronavirus disease-19 (COVID-19) patients.
- The first wave of the COVID-19 pandemic saw widespread use of mechanical ventilation for respiratory failure.
Purpose of the Study:
- To investigate the utilization and effects of prone positioning in intubated COVID-19 patients.
- To analyze the impact of prone position on oxygenation and ventilation parameters in this cohort.
Main Methods:
- Retrospective, multicenter cohort study of 1057 adult COVID-19 patients requiring invasive mechanical ventilation across 24 Italian ICUs.
- Data collected on ICU admission, daily prone positioning use, and patient outcomes.
- Respiratory effects analyzed in a subset of 78 patients, defining Oxygen and Carbon Dioxide Responders.
Main Results:
- Prone positioning was used in 61% of patients, who had more severe disease and higher mortality (45% vs. 33%).
- Prone position significantly increased the PaO2/FiO2 ratio, indicating improved oxygenation, but did not alter respiratory system compliance or ventilatory ratio.
- 78% of patients were Oxygen Responders, showing improved oxygenation; Non-Responders had worse outcomes. 47% were Carbon Dioxide Responders, with similar mortality to Non-Responders.
Conclusions:
- Prone positioning is widely adopted for mechanically ventilated COVID-19 patients with respiratory failure.
- The majority of patients experienced improved oxygenation during prone positioning, likely due to enhanced ventilation-perfusion matching.
Background:
Limited data are available on the use of prone position in intubated, invasively ventilated patients with Coronavirus disease-19 (COVID-19). Aim of this study is to investigate the use and effect of prone position in this population during the first 2020 pandemic wave.
Methods:
Retrospective, multicentre, national cohort study conducted between February 24 and June 14, 2020, in 24 Italian Intensive Care Units (ICU) on adult patients needing invasive mechanical ventilation for respiratory failure caused by COVID-19. Clinical data were collected on the day of ICU admission. Information regarding the use of prone position was collected daily. Follow-up for patient outcomes was performed on July 15, 2020. The respiratory effects of the first prone position were studied in a subset of 78 patients. Patients were classified as Oxygen Responders if the PaO2/FiO2 ratio increased ≥ 20 mmHg during prone position and as Carbon Dioxide Responders if the ventilatory ratio was reduced during prone position.
Results:
Of 1057 included patients, mild, moderate and severe ARDS was present in 15, 50 and 35% of patients, respectively, and had a resulting mortality of 25, 33 and 41%. Prone position was applied in 61% of the patients. Patients placed prone had a more severe disease and died significantly more (45% vs. 33%, p < 0.001). Overall, prone position induced a significant increase in PaO2/FiO2 ratio, while no change in respiratory system compliance or ventilatory ratio was observed. Seventy-eight % of the subset of 78 patients were Oxygen Responders. Non-Responders had a more severe respiratory failure and died more often in the ICU (65% vs. 38%, p = 0.047). Forty-seven % of patients were defined as Carbon Dioxide Responders. These patients were older and had more comorbidities; however, no difference in terms of ICU mortality was observed (51% vs. 37%, p = 0.189 for Carbon Dioxide Responders and Non-Responders, respectively).
Conclusions:
During the COVID-19 pandemic, prone position has been widely adopted to treat mechanically ventilated patients with respiratory failure. The majority of patients improved their oxygenation during prone position, most likely due to a better ventilation perfusion matching.
Trial Registration:
clinicaltrials.gov number: NCT04388670.
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