Critical Care Trauma Centre



Ensure that patient and health care provider safety standards are met during this procedure including:

  • Risk assessment and appropriate PPE
  • 4 Moments of Hand Hygiene
  • Procedural Safety Pause is performed
  • Two patient identification
  • Safe patient handling practices
  • Biomedical waste disposal policies
  1. Rule out Contraindications
  2. Establish enteral feeding
  3. Assemble Personnel
  4. Perform Safety Pause
  5. Gel Surgical Positioning Pads
  6. Prepare Patient
  7. Place Gel Pads
  8. Position Limbs
  1. Cover Patient With Linen
  2. Sandwich Patient Between Sheets
  3. Slide Patient Away From Ventilator
  4. Complete First Turn
  5. Complete Pronation
  6. Assess Airway
  7. Optimize Proning
  8. Document


Ensure Senior Resident or Consultant is in CCTC before elective proning or supination.  The goal is to plan turns for periods when adequate manpower and airway expertise is available. If a patient needs urgent proning or supination a Senior Resident or Consultant should be present. If required urgently before Senior Resident can arrive, page Anaesthesia for urgent backup in advance of turning.

Significant lip, face and airway edema can develop when the patient is prone. Patients are deeply sedated and usually paralyzed with neuromuscular blocking agents (NMBs). ETT position should be assessed AT THE TEETH, before, during and after proning.  If the patient develops a cuff leak following pronation, recheck the ETT position AT THE TEETH to ensure the tube has not moved.  If air needs to be added more than once, an Xray in the prone position to include the upper airway should be performed to rule out laryngeal placement.





Rule out Contraindications

Identify indications and goals for proning with physician and review any contraindications or relative contraindications including (review with consulting services if appropriate)::

  • Raised intracranial pressure (review with neurosurgery before proning)
  • Massive hemoptysis (requiring intervention)
  • Tracheostomy or tracheal surgery
  • Severe facial trauma
  • Eye trauma or injury
  • Unstable C spine
  • New pacemaker insertion (within 2 days)
  • Pregnancy
  • Anterior chest tube with air leak
  • ECMO
  • Open abdomen/recent abdominal surgery



These contraindications can make patient care more difficult or may potentially complicate another more serious clinical problem.

Decisions to prone should be made on a case-by-case basis. Nurses should be aware of situations where proning may be contraindicated and ensure these issues are taken into consideration.

Other services involved in the care of the patient (e.g., neurosurgery, CVT or thoracic surgery) should be included in decision-making when potential contraindications exist.

If a decision is made to prone in the setting of a potential contraindication, clinical documentation by the physician is required.


Establish Enteral Feeding

Prior to proning, insert a small bowel feeding tube unless enteral feeding is contraindicated.  Refer to Procedure for the Insertion of a Small Bowel Feeding Tube.

If enteral feeding is contraindicated review need for TPN with physician/dietitian.

If proning is required urgently, initiate feeding when repositioned supine.

Maintain reverse Trendelenburg while in the prone position. If reverse trendelenburg cannot be maintained, insert a gastric drainage tube.



Gastric drainage may be impaired in the prone position, particularly if reverse Trendelenburg cannot be maintained.

Gastric secretions are produced on an ongoing basis. If a patient is prone and flat (or head down), there is increased risk for aspiration.

Nutrition is important to a critically ill patient's recovery.  Small bowel feeding may promote better feeding tolerance.





Assemble Personnel  



A minimum of 5 staff members are required to prone a ventilated.


  • "Airway Manager" at head of bed
  • 2 staff members on each side of the bed

Additional staff members may be required if the patient is very large or has complex lines and tubes.

An RRT or physician must be present and assumes responsibility for the airway.

During turning, the person responsible for the airway provides the team direction regarding when to turn.

Ensure there is an RRT and physician available in the unit who is skilled at intubation prior to turning.

Ensure hand hygiene and PPE standards are followed.



Patients with severe ARDS are deeply sedated and often paralyzed during proning. Paralysis increases the risk for join, limb and nerve injury due to altered neuromuscular stability.

Patients who are on neuromuscular blockers should be treated like a spinal cord injured patient and need sufficient personal to maintain proper spine and limb alignment.

Attempting to turn with insufficient numbers of staff increases the risk for patient and staff member harm.

Loss of airway in a patient with severe ARDS is life-threatening. A physician or RRT who is able to reintubate if necessary must be available.


Perform Safety Pause

With team assembled, review the procedural steps to ensure everyone knows the plan.

Review online Procedural Safety Pause

Review emergency response and ensure appropriate personnel and equipment is available prior to turning including:

  • Accidental extubation (reintubation equipment available, bag-mask)
  • Rapid supination plan in the event of cardiac arrest
  • Accidental loss of other lines and tubes (e.g., central venous, arterial or dialysis lines, chest tubes)





Gel Surgical Positioning Pads

If available, obtain a set of gel positioning pads. These include gel rolls, donuts, gel sheets and head donuts.  Although these are still available we have been using them less frequently with success. Careful skin inspection is needed as these can increase the chance of developing blisters or friction injury.

If not available, pillows and nerve protectors can be used.

Gel Pads

Figure 1: Gel Positioning Pads



To prolong the life of these pads, the manufacturer recommends a 4 step cleaning process.

  1. Spray or wipe with disinfectant (e.g., Caviwipe). Avoid alcohol containing products.
  2. Wipe excess cleaner off with a cloth (after an appropriate dry time)
  3. Rinse with water
  4. Dry thoroughly



Gel positioning pads can be used to help raise the chest and pelvis off the bed. This reduces pressure points and abdominal pressures.  Reduction in abdominal pressures may improve ventilation.

Gel pads are not mandatory. These are used in the OR for positioning.


Prepare Patient

1. Turn patient to one side and apply ECG leads to the patient's back. When finished, remove all chest electrodes

2. Examine patient's chest to identify areas vulnerable to pressure (e.g., subclavian or jugular lines). Integrate strategies to alleviate pressure on these point.

3. Reposition all lines and tubes that are located above the patient's waist straight upward toward the head of the bed.

4. Reposition all lines and tubes

that are located below the waist (e.g., bladder catheter, femoral lines, fecal drainage systems and chest tubes) straight down toward the foot of the bed.


5.  RRT to evaluate ETT securement and identify ETT distance marking AT THE TEETH prior to turning.



Smooth repositioning is accomplished by careful planning.

ECG electrodes, chest tubes and central venous catheters can lead to significant skin breakdown if the patient lies on them.

Placing all lines and tubes in an upward and downward line from the patient facilitates turning. This maneuver prevents the lines from getting tangled or from getting caught underneath the patient (where they cause skin breakdown).

With lines and tubes directed upward and downward, the patient can be freely turned in a way that is similar to the principles of a rotisserie.


Place Gel Pads (Or Pillows)

If being used, obtain 3 long gel rolls, and place one across chest just above level of axilla, one across iliac crest, and one across the thighs (if available).  Pillows can be used if gel pad is not available.

DO NOT place middle roll below iliac crest or femoral nerve compression can occur.

Gel Pad Application

Figure 2: Applying Gel Rolls to Torso



Gel pads help to raise the patient off the bed and provide pressure relief.  Raising the chest and pelvis relieves and tension from the abdominal viscera and may help to improve ventilation.

Raising the chest also lowers the arm position to relax the shoulder (this prevents brachial plexus compression).


Position Limbs for Turning

Turn patient prone and supine with their face looking in the direction of the ventilator.


  • Position arms along the side of the body with fingers pointing toward toes
  • Keep arms as close to body as possible


  • While patient is supine, cross feet at the ankles by placing the foot OPPOSITE to the ventilator on top




These positions protect the arms from injury and make turning easier.


Cover Patient with Linen

Place two lift sheets over the patient's chest and midsection.

Cover the lifter and entire patient with a sheet. The sheet should cover from the head to foot of the bed.

Fold the section of the sheet that is above the shoulders so that the patient's head is not covered up.


Figure 3: Apply Lifters


The top linen will become the new bottom linen following proning. This linen will facilitate turning and make the bed in the same step.

The head must be uncovered to observe the airway. When fully open, the sheet needs to extend to the head and foot of the bed to serve as a bottom sheet.


Sandwich Patient Between Sheets

Grab both the top and bottom sheets together. Along both sides of patient, tightly roll the sheets together like a jelly roll to sandwich patient firmly between the sheets.

Note in the Figure 4 below the patient's head is exposed.

Jelly Roll

Figure 4: Rolling Top and Bottom Sheets to Sandwich Patient



Sandwiching the patient between the sheets helps maintain alignment and protect limbs during turning.

The "jelly rolls" help facilitate turning while keeping patient secure.


Slide Patient Away from Ventilator

Slide the patient to the side of the bed away from the ventilator.



The patient will be turned to face the ventilator. This provides the most "slack" for the ventilator tubing.

Moving the patient away from the ventilator ensures sufficient bed surface for pronation.


Conduct First Turn

The "Airway Manager" is responsible for determining when to turn. Prior to turning, review the expectations for when to turn (for example, "we will turn when I say 3 in a 1, 2, 3 count").

Review the plan for the turn as follows:

  • Log roll using spinal precautions
  • Hold tightly onto jelly roll at each side to secure patient
  • Turn patient onto side only
  • Following turn, airway manager to adjust ETT and tubing in preparation for final turn



By taking a moment to review the steps, all members of the team have the same expectation. This ensures both patient and staff safety and makes the process much more efficient.


Complete the Pronation



The "Airway Manager" is responsible for determining when to turn. Prior to turning, review the expectations for this second turn.


Review the plan for the turn as follows:

  • Slowly turn the patient prone
  • Hold tightly onto jelly roll at each side to secure patient
  • "Airway Manager" to provide feedback on speed of turn according to airway needs
  • Support ETT
  • Maintain neck alignment



Airway positioning must take priority for pronation speed. The pronation step poses the greatest risk for the ETT.


Assess Airway

Following proning, RRT to reassess:

  • ETT distance AT THE TEETH
  • Cuff leak
  • Pressure points around ETT and securement device
  • Check for any kinks in tubing
  • Breath sounds, ventilator parameters

Lifting team to assist RRT to establish airway patency. The head and shoulders may need to be lifted and supported in order for ventilator tubing to hang freely.

NOTE: The need to add air more than once to the cuff on the ETT can indicate either damage to the pilot/cuff or migration of the tube into the larynx.  An xray can be repeated in the supine position

Note: The head must be turned from side-to-side every two hours.  Edema will settle in dependent areas and can lead to asymmetrical facial swelling, swelling of the eyes and eyelids and periorbital region.

When using Anchor Fast(TM), check ETT securement frequently and monitor pressure points closely, especially along the plastic ETT holder.  Alternate methods of securement may be required.



The ETT may have moved during turning.

Optimal head and neck placement requires individualized adjustment.

Repositioning helps to distribute edema fluid, alleviate pressure points and assess patient for areas at risk.


Optimize Position

Adjust the patient to minimize risk for both pressure injuries and nerve entrapment. 

Optimal prone placement will include:

  • Q 2 H head repositioning
  • Ongoing assessment and pressure relief of vascular devices and tubes
  • Patient not lying on tubing or devices
  • No ECG electrodes on chest
  • No EEG leads on dependent side of head
  • Eyes moist and lids closed at all times
  • Pressure relief for knees. The donut shaped gel pads can be placed under each knee cap
  • Feet should be maintained in dorsiflexion (ankle at 90 degrees, no downward toe pointing)
  • Dorsiflexion can be maintained by placing a gel roll under the lower shin to raise ankles off bed
  • For large breasted women, position breast laterally to reduce pressure on nipples/breast tissues
  • Male genitalia should hang freely; iliac roll helps to raise pelvis (Note: patient is deeply sedated and usually on NMB)
  • Foley positioned between patient's legs
  • Shoulder should be relaxed and "dropped" below chest"; avoid "shrugging" positions as this can lead to frozen shoulder/brachial plexus injury.
  • Alternate arm positions. Dropping the arm below the bed surface (e.g. on padded bedside table) can help relax the shoulder; this can usually be done one arm at a time)
  • A swimmer's crawl position (one arm above head and opposite arm at side) can be tried
  • Protect against ulnar nerve injury with nerve protectors or gel pads; reposition frequently
  • Reverse Trendelenburg

Should be able to slide a hand under patient's abdomen (may be difficult if very obese)



Patients who are proned for ARDS will be maintained in a prone position for 16 hours before supination.

During pronation, pressure points must be altered with head turning, tilting, limb adjustments etc. every two hours.

Although not studied in clinical trials, patients who are on rotational bed might benefit from a very gently 10 degree rotation as a strategy for pressure relief. If a rotational bed is available this strategy may be explored and assessed on an individual patient basis.



Document response to turning, pressure relief strategies and any assessment findings that are not WDL.




Developed: August 2, 2013

Updated: June 3, 2015, February 3, 2016, October 30, 2018

Brenda Morgan RN BScN MSc CNCC, CCTC


1. Claude Guérin, M.D., et al. (2013). Prone positioning in severe acute respiratory distress syndrome. New Engl J Med; 368:2159-2168 June 6, 2013. DOI: 10.1056/NEJMoa1214103

2. William Harvey Hospital, Ashford Kent, UK. Proning Video.