Prone positioning in patients with acute respiratory distress syndrome, translating research and implementing practice change from bench to bedside in the era of coronavirus disease 2019

Published:January 22, 2021DOI:



      Acute respiratory distress syndrome (ARDS) is a relatively common condition of varied aetiology associated with high morbidity and mortality. A range of therapies have been proven to be useful for patients with ARDS, including ventilatory and nonventilatory strategies. Prone positioning is one of the nonventilatory strategies and has been proven to be safe and is associated with significant mortality benefit in patients with moderate to severe ARDS. It is now included in several international guidelines as the standard of care for these cases.


      The aim of the study was to develop, implement, and evaluate a prone positioning program in two nonmetropolitan, nontertiary intensive care units in South East Queensland.


      A Plan–Do–Study–Act quality improvement model was used to implement changes in clinical practice in relation to prone positioning of patients.


      A description of the methods used to promote a complex change strategy is provided in this article.


      In this article, we demonstrate the feasibility of introducing a nonventilatory intervention of prone positioning in the management of patients with moderate to severe ARDS in regional intensive care in South East Queensland. This implementation strategy could be replicated and adopted in other similar intensive care units that do not have the ability to provide tertiary services such as extracorporeal life support.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Australian Critical Care
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Hewson-Conroy K.M.
        • Elliott D.
        • Burrell A.R.
        Quality and safety in intensive care—a means to an end is critical.
        Aust Crit Care. 2010; 23: 109-129
        • Ullman A.J.
        • Ray-Barruel G.
        • Rickard C.M.
        • Cooke M.
        Clinical audits to improve critical care: Part 1 Prepare and collect data.
        Aust Crit Care. 2018; 31: 101-105
        • Pronovost Peter J.
        • Goeschel Christine A.
        • Colantuoni Elizabeth
        • Watson Sam
        • Lubomski Lisa H.
        • Berenholtz Sean M.
        • et al.
        Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study.
        BMJ. 2010; 340: c309
        • Ray-Barruel G.
        • Ullman A.J.
        • Rickard C.M.
        • Cooke M.
        Clinical audits to improve critical care: Part 2: analyse, benchmark and feedback.
        Aust Crit Care. 2018; 31: 106-109
        • The ARDS Definition Task Force
        Acute respiratory distress syndrome: the Berlin definition.
        JAMA. 2012; 307: 2526-2533
        • Cherian S.V.
        • Kumar A.
        • Akasapu K.
        • Ashton R.W.
        • Aparnath M.
        • Malhotra A.
        Salvage therapies for refractory hypoxemia in ARDS.
        Respir Med. 2018; 141: 150-158
        • Bellani G.
        • Laffey J.G.
        • Pham T.
        • Fan E.
        • Brochard L.
        • Esteban A.
        • et al.
        Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries.
        JAMA. 2016 Feb 23; 315: 788-800
        • Xu Z.
        • Shi L.
        • Wang Y.
        • Zhang J.
        • Huang L.
        • Zhang C.
        • et al.
        Pathological findings of COVID-19 associated with acute respiratory distress syndrome.
        Lancet Respir Med. 2020 Apr; 8: 420-422
        • Ñamendys-Silva S.A.
        ECMO for ARDS due to COVID-19.
        Heart Lung. 2020; 49: 348-349
        • Huang C.
        • Wang Y.
        • Li X.
        • Ren L.
        • Zhao J.
        • Hu Y.
        • et al.
        Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.
        Lancet. 2020; 395: 497-506
        • Chen N.
        • Zhou M.
        • Dong X.
        • Qu J.
        • Gong F.
        • Han Y.
        • et al.
        Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study.
        Lancet. 2020; 395: 507-513
        • Ferguson N.D.
        • Fan E.
        • Camporota L.
        • Antonelli M.
        • Anzueto A.
        • Beale R.
        • et al.
        The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material.
        Intensive Care Med. 2012; 38: 1573-1582
        • Kallet R.H.
        A comprehensive review of prone position in ARDS.
        Respir Care. 2015; 60: 1660-1687
        • Henderson W.R.
        • Griesdale D.E.G.
        • Dominelli P.
        • Ronco J.J.
        Does prone positioning improve oxygenation and reduce mortality in patients with acute respiratory distress syndrome?.
        Canc Res J. Jul-Aug 2014; 21: 213-215
        • Guerin C.
        • Beuret P.
        • Constantin J.M.
        • Bellani G.
        • Garcia-Olivares P.
        • Roca O.
        • et al.
        A prospective international observational prevalence study on prone positioning of ARDS patients: the APRONET (ARDS Prone Position Network) study.
        Intensive Care Med. 2018; 44: 22-37
        • Ponseti E.J.
        • Millán A.V.
        • Chinchilla D.O.
        Analysis of complications of prone position in acute respiratory distress syndrome: quality standard, incidence and related factors.
        Enfermería Intensiva. 2017; 28: 125-134
        • Moore Z.
        • Patton D.
        • Avsar P.
        • McEvoy N.L.
        • Curley G.
        • Budri A.
        • et al.
        Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the COVID-19 emergency.
        J Wound Care. 2020; 29: 312-320
        • Girard R.
        • Baboi L.
        • Ayzac L.
        • Richard J.-C.
        • Guérin C.
        • Group P.T.
        The impact of patient positioning on pressure ulcers in patients with severe ARDS: results from a multicentre randomised controlled trial on prone positioning.
        Intensive Care Med. 2014; 40: 397-403
        • Mitchell D.A.
        • Seckel M.A.
        Acute respiratory distress syndrome and prone positioning.
        AACN Adv Crit Care. 2018; 29: 415-425
        • Jabbour M.
        • Newton A.S.
        • Johnson D.
        • Curran J.A.
        Defining barriers and enablers for clinical pathway implementation in complex clinical settings.
        Implement Sci. 2018; 13: 139
        • Craswell A.
        • Massey D.
        • Wallis M.
        • Sriram D.
        • Gray N.A.
        • Kotwal S.
        • et al.
        Current practice in dialysis central venous catheter management: multi-disciplinary renal team perspectives.
        Nephrology. 2020; 25: 406-412
        • Grol R.
        • Wensing M.
        What drives change? Barriers to and incentives for achieving evidence-based practice.
        Med J Aust. 2004; 180: S57-S60
        • Grol R.
        • Grimshaw J.
        From best evidence to best practice: effective implementation of change in patients' care.
        Lancet. 2003; 362: 1225-1230
        • Gattinoni L.
        • Carlesso E.
        • Taccone P.
        • Polli F.
        • Guerin C.
        • Mancebo J.
        Prone positioning improves survival in severe ARDS: a pathophysiologic review and individual patient meta-analysis.
        • Griffiths M.J.
        • McAuley D.F.
        • Perkins G.D.
        • Barrett N.
        • Blackwood B.
        • Boyle A.
        • et al.
        Guidelines on the management of acute respiratory distress syndrome.
        BMJ Open Respir Res. 2019; 6: e000420
        • Barnes T.
        • Zochios V.
        • Parhar K.
        Re-examining permissive hypercapnia in ARDS: a narrative review.
        Chest. 2018; 154: 185-195
        • Cannon J.W.
        • Gutsche J.T.
        • Brodie D.
        Optimal strategies for severe acute respiratory distress syndrome.
        Crit Care Clin. 2017; 33: 259-275
        • Kamo T.
        • Aoki Y.
        • Fukuda T.
        • Kurahashi K.
        • Yasuda H.
        • Sanui M.
        • et al.
        Optimal duration of prone positioning in patients with acute respiratory distress syndrome: a protocol for a systematic review and meta-regression analysis.
        BMJ Open. 2018; 8: e021408
        • Bloomfield R.
        • Noble D.W.
        • Sudlow A.
        Prone position for acute respiratory failure in adults.
        Cochrane Database Syst Rev. 2015;
        • Fan E.
        • Del Sorbo L.
        • Goligher E.C.
        • Hodgson C.L.
        • Munshi L.
        • Walkey A.J.
        • et al.
        An official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice guideline: mechanical ventilation in adult patients with acute respiratory distress syndrome.
        Am J Respir Crit Care Med. 2017; 195: 1253-1263