Proning Nonintubated COVID-19 Patients with Acute Respiratory Distress Syndrome

Patricia Kritek, MD


Many patients showed improvement with noninvasive ventilation and prone positioning.


Prone positioning is used to treat mechanically ventilated patients with moderate-to-severe acute respiratory distress syndrome (ARDS). Numerous studies have demonstrated improved oxygenation in the prone position, and mortality benefit was shown in a large randomized, controlled trial (NEJM JW Gen Med Jul 15 2013 and N Engl J Med2013; 368:2159). As the COVID-19 pandemic spread, clinicians became concerned about a potential shortage of ventilators. Many recommended that patients spend time in the prone position in an attempt to avoid or delay intubation. In two brief reports, authors describe single-center experiences with this intervention.


In the first study, investigators in France attempted prone positioning (for as long as tolerated) in 24 COVID-19 patients with acute respiratory failure who had computed tomography scan findings of posterior lung field opacities and acute hypoxemia managed with supplemental oxygen alone. Of the 24 patients, 15 tolerated prone positioning for longer than 3 hours, 5 tolerated it for 1 to 3 hours, and 4 could not sustain the position for 1 hour. At 10 days, 6 patients had improved oxygenation, and 5 required intubation.


In the second study, investigators in Italy attempted prone positioning in 15 COVID-19 patients with ARDS who were supported by noninvasive ventilation. All patients had improved oxygenation during pronation, and 12 maintained that improvement when supinated. Eleven patients had improved comfort in the prone position. At 14 days, 1 patient was intubated, and 1 patient had died.


These two reports demonstrate that proning in nonintubated patients is feasible and safe. Little downside is associated with attempting prone positioning, as it is inexpensive and easy. However, given the limitations of the studies (including lack of controls, small size, and short follow-up), whether this intervention meaningfully affects any patient-centered outcomes is unclear.



Elharrar X et al. Use of prone positioning in nonintubated patients with COVID-19 and hypoxemic acute respiratory failure. JAMA 2020 May 15; [e-pub]. (

Sartini C et al. Respiratory parameters in patients with COVID-19 after using noninvasive ventilation in the prone position outside the intensive care unit. JAMA 2020 May 15; [e-pub]. (


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