How lying in a prone position helps with COVID-19 infection?

How lying in a prone position helps with COVID-19 infection?

Last Reviewed : 01/07/2021
How lying in a prone position helps with COVID-19 infection?



  • Prone position was earlier used to improve oxygenation in patients with ARDS, a severe lung condition
  • Recent studies suggest that it can be used in conscious and non-ventilated COVID-19 patients
  • Frequent position changing and monitoring for any worsening of symptoms is crucial for its effectiveness

Most of the patients infected with SARS-CoV-2, a virus that causes COVID-19, develop mild symptoms, which usually resolves with symptomatic treatment and supportive care. In contrast, other patients with underlying comorbidities develop severe disease and sometimes even cause the death of the patient. Acute respiratory distress syndrome (ARDS) is a life-threatening complication of COVID-19 affecting 17% of COVID-19 patients with a high mortality rate of 30%- 40%.


The Role of Prone Positioning

Scientists around the world are researching various treatment strategies for COVID-19 and its associated complications. Prone positioning is being studied as an adjunctive treatment strategy in patients to improve oxygenation. Long before the COVID-19 pandemic, prone position was used as adjunctive therapy in patients with ARDS, a disease that is commonly seen in hospitalized and severe COVID-19 patients. ARDS is a serious lung disease that occurs secondary to infection, trauma, and aspiration. Its patients present with severe breathing difficulty and decreased oxygen levels in the blood due to inflamed lungs and fluid leakage into the air sacs (alveoli). The symptoms impair the transfer of oxygen into the blood capillaries. Prone positioning helps by improving lung recruitability and increasing lung volumes. Studies showed that patient lying in a prone position for long periods showed a decrease in the mortality rate in ventilated ARDS patients. Recent studies suggest that the prone position can improve oxygenation in conscious and non-ventilated patients. The majority of our lung tissue is present in the back of our chest. On the front side of the chest, major organs like heart and its major blood vessels occupy a large volume. When we lie in the prone position, lungs are aerated better than when lie in the supine position or on our back. As lungs receive more oxygen in the prone position, they improve faster.

More Findings

A few observational studies showed that COVID-19 patients with moderate to severe ARDS responded well to invasive ventilation when done in prone positioning. Proning Severe ARDS or PROSEVA trial suggests the early use of prone ventilation in patients with moderate to severe ARDS to improve oxygenation and reduce mortality. Hence, experts recommend prone ventilation as the international guideline to manage COVID-19. Intensive Care Society (ICS) guidelines recommend the use of prone position in COVID-19 patients with breathing difficulties but with careful monitoring of blood oxygen levels. Positions should be frequently changed to avoid the side effects associated with prolonged prone positioning. The side effects associated with prone positioning are pressure wounds, gastroesophageal reflux, increased salivation, periorbital and facial edema, and skin injuries.

According to the ICS guidelines, the prone position can be done if:

  • Suspected/Confirmed COVID-19
  • FiO2>28%
  • Requires basic respiratory support in the form of oxygen therapy
  • Can change the positions independently
  • Able to communicate and co-operate with the procedure


Here are key contraindications to note:

  • Persistent breathing difficulty or respiratory distress
  • Hemodynamic instability (BP<90 mmHg)
  • Arrhythmia
  • Agitation/Altered mental status
  • Immediate need for intubation
  • Unstable spine/thoracic surgery/recent abdominal surgery
  • Morbid obesity or pregnancy
  • Neurological problems like frequent seizures
  • Facial injuries
  • Pressure sores/ulcers

Patients should be constantly monitored for oxygen saturation and the worsening of symptoms. Continue prone position with frequent position changing every 1-2 hours, if symptoms improve and oxygen saturation is between 92%-96%. Discontinue if no improvement or respiratory distress or worsening of symptoms or deteriorating saturation levels are observed. Although the prone position has been proven to be useful in a few studies, more evidence and randomized controlled trials are required in this subject.

Even though prone position is more beneficial in severe and critically ill COVID-19 patients, it also helps in individuals with mild to moderate disease. In some individuals with a big belly or other medical conditions, lying in prone position may not be feasible. These individuals should avoid lying in prone position which may cause more harm than benefits.



(n.d.). EMCrit Blog - Emergency Department Critical Care & Resuscitation.

The prone position in COVID-19 affected patients - Full text view - (n.d.).

Prone position in management of COVID-19 patients; a commentary. (n.d.). PubMed Central (PMC).


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