ICU Map

Prone Positioning Protocol for Severe ARDS

From eligibility screening and team preparation to 16-hour proning cycles and response evaluation.

RecognizeAssessDecideDifferentialInterveneReassess
Severe ARDS / Refractory Hypoxemia (P/F < 150)
Assessment StepVerify severe ARDS and proning indication; PROSEVA used PaO2/FiO2 <150, FiO2 >=0.6 and PEEP >=5 cmH2OExplore Topic
Confirm lung-protective ventilation and severe hypoxemia. PROSEVA confirmed its enrollment criteria after 12–24 h in the participating ICU, but current guideline use should be driven by severe ARDS and local protocol rather than an invented PEEP >=10 threshold.
Decision PointScreen for absolute & relative contraindications
Absolute: unstable spinal fracture, open abdomen, severe facial trauma. Relative: acute elevated ICP, severe refractory shock, second/third trimester pregnancy.
Clinical ActionExecute pre-proning safety checklist
Confirm ETT position and secure tape; pause enteral feeding and aspirate stomach; apply eye lubricant and tape eyelids; pre-oxygenate with FiO2 1.0; assemble minimum 4-person team.
Clinical ActionTurn patient prone: maintain session for >= 16 consecutive hours
Position head in neutral/swimmer's position with alternating head turns q2h; place chest and pelvic padding to allow uninhibited abdominal excursion.
Reassessment / LoopCheck ABG & mechanics at 4 hours into proning session
Responders demonstrate PaO2/FiO2 rise >= 20 mmHg or PaCO2 decrease >= 1 mmHg without deterioration in driving pressure.
Reassessment / LoopTurn supine at 16–20 hours: reassess supine PaO2/FiO2 after 4 hours
Evaluate whether oxygenation improvement persists in the supine position on moderate ventilator settings.
Differential Branches (2)
1Branch
Clinical ActionPaO2/FiO2 >= 150 maintained supine on PEEP <= 10 & FiO2 <= 0.6
Discontinue daily proning cycles. Continue lung-protective ventilation in the supine position.
2Branch
Critical AlertPaO2/FiO2 drops < 150 after 4 hours supine
Initiate next 16-hour proning cycle. Continue daily cycles until sustained improvement or treatment failure criteria met.

An educational representation of clinical reasoning, not a diagnostic algorithm or personalized medical advice — always apply clinical judgment and institutional protocols.

Caution

Escalate — Red Flags & Critical Warnings

  • Accidental extubation in the prone position — place patient supine immediately and perform emergency airway management.
  • Sudden bradycardia or severe hypotension during turning — return patient to supine position immediately and evaluate for line displacement or RV failure.

Related Bedside Clinical Problems (9)

Bedside Presentations
Sudden Hypoxemia

Bedside triage of acute desaturation: signal verification, immediate danger screening (DOPE / tension pneumothorax), oxygen escalation ladder, and mechanism-based differential.

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Acute Hypercapnia & Ventilatory Failure

Triaging rising PaCO2: distinguishing acute uncompensated acidemia from chronic compensation, identifying central vs pump vs dead-space failure, and titrating noninvasive ventilation.

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Sudden Ventilator Deterioration & High Airway Pressures

Algorithmic troubleshooting of acute patient-ventilator collapse: the DOPE framework, peak vs plateau pressure differentiation, auto-PEEP evaluation, and manual bagging separation.

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Linked Deep-Dive Topics (4)

Reference Knowledge
Acute Respiratory Distress Syndromerespiratory

Acute, diffuse inflammatory lung injury causing hypoxemia and bilateral infiltrates not fully explained by cardiac failure or fluid overload.

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Invasive Mechanical Ventilationrespiratory

Complete clinical topic overview. For the full 10-level interactive course, visit Master MV. Covers core ventilator modes, respiratory mechanics (Cstat, Raw, driving pressure), waveform dyssynchrony analysis, VILI prevention, and liberation protocols.

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Hypoxemic Respiratory Failurerespiratory

Pathophysiologic mechanisms (shunt vs V/Q mismatch), dynamic ROX index trajectories, P-SILI prevention, and evidence-based oxygen escalation ladders.

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Respiratory Failure: Basic Principlesrespiratory

Core taxonomy (Types I–IV), alveolar gas exchange physiology, work-of-breathing mechanics, and escalation thresholds in acute respiratory failure.

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Evidence status

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References & Guidelines

PROSEVA

New England Journal of Medicine, 2013

RCT