Critical Care Trauma Centre



  1. Assemble Personnel
  2. Perform Safety Pause
  3. Prepare Patient
  4. Position Limbs
  5. Cover Patient With Linen
  6. Sandwich Patient Between Sheets
  1. Slide Patient Toward Ventilator
  2. Complete First Turn
  3. Complete Supination
  4. Assess Airway
  5. 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 avaialble. 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 occur during prone positioning. Patients are deeply sedated and usualy paralyzed with NMBs. ETT position should be assessed AT THE TEETH, before, during and after proning or supination.  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.


Refer to Procedure for Turning a Ventilated Patient Prone in CCTC.





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)





Prepare Patient

1. Remove gel pads from under patient knees and ankles.

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

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.


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 prone, cross feet at the ankles by placing the foot ON THE SAME SIDE of 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 back 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 1: Apply Lifters


The top linen will become the new bottom linen following supination. 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 2 below the patient's head is exposed.

Jelly Roll

Figure 2: 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 Toward Ventilator

Slide the patient to the side of the bed closest to the ventilator.



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

Moving the patient toward the ventilator ensures sufficient bed surface for supination.


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 (facing ventilator)
  • 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 Supination



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


Review the plan for the turn as follows:

  • Slowly turn the patient supine
  • 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 during turning.


Assess Airway

Following supination, 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


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



The ETT may have moved during turning.




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




Developed: August 2, 2013

Updated: June 3, 2015, Feburary 3, 2016

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