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Adverse Events of Prone Positioning in Mechanically Ventilated
Adults With ARDS
Felipe Gonza
´lez-Seguel, Juan Jose
´Pinto-Concha, Nadine Aranis, and Jaime Leppe
Review of the Literature
Data Extraction and Analysis
Study Design
Search Strategy
Introduction
Research Question
Operational Definitions
Eligibility Criteria
Document Selection
Results
Literature Search and Document Characteristics
Adverse Events Related to Prone Positioning
Mitigation Strategies for Adverse Events Related to Prone Positioning
Conclusions
Discussion
BACKGROUND: Prone positioning is a therapy utilized globally to improve gas exchange, minimize
ventilator-induced lung injury, and reduce mortality in ARDS, particularly during the ongoing corona-
virus disease 2019 (COVID-19) pandemic. Whereas the respiratory benefits of prone positioning in
ARDS have been accepted, the concurrent complications could be undervalued. Therefore, this study
aimed to identify the adverse events (AEs) related to prone positioning in ARDS and, secondarily, to
collect strategies and recommendations to mitigate these AEs. METHODS: In this scoping review, we
searched recommendation documents and original studies published between June 2013 and November
2020 from 6 relevant electronic databases and the websites of intensive care societies. RESULTS: We
selected 41 documents from 121 eligible documents, comprising 13 recommendation documents and
28 original studies (involving 1,578 subjects and 994 prone maneuvers). We identified >40 individual
AEs, and the highest-pooled occurrence rates were those of severe desaturation (37.9%), barotrauma
(30.5%), pressure sores (29.7%), ventilation-associated pneumonia (28.2%), facial edema (16.7%), ar-
rhythmia (15.4%), hypotension (10.2%), and peripheral nerve injuries (8.1%). The reported mitigation
strategies during prone positioning included alternate face rotation (18 [43.9%]), repositioning every 2
h (17 [41.5%]), and the use of pillows under the chest and pelvis (14 [34.1%]). The reported mitigation
strategies for performing the prone maneuver comprised one person being at the headboard (23
[56.1%]), the use of a pre-maneuver safety checklist (18 [43.9%]), vital sign monitoring (15 [36.6%]),
and ensuring appropriate ventilator settings (12 [29.3%]). CONCLUSIONS: We identified >40 AEs
reported in prone positioning ARDS studies, including additional AEs not yet reported by previous
systematic reviews. The pooled AE proportions collected in this review could guide research and clini-
cal practice decisions, and the strategies to mitigate AEs could promote future consensus-based
recommendations. Key words: prone position; mechanical ventilation; ARDS; respiratory failure;
adverse events; complications. [Respir Care 2021;66(12):1898–1911. © 2021 Daedalus Enterprises]
1898 RESPIRATORY CARE DECEMBER 2021 VOL 66 NO12
Introduction
ARDS has a mortality rate of 20%–48%,
1-3
and survivors
commonly experience long-term physical, cognitive, and
mental impairments.
4,5
Prone positioning is among the well-
known strategies to counteract ARDS
6-8
andisaninexpen-
sive intervention that requires no complex technology, mak-
ing it feasible worldwide.
9
In particular, early (12–24 h after
ARDS diagnosis) and extended prone positioning (>16 h
per d) demonstrated decreased mortality from 41 to 24% in
the 2013 Proning Severe ARDS Patients (PROSEVA) trial
10
when compared with supine positioning. Subsequently,
prone positioning has been incorporated as a strong recom-
mendation in international practice guidelines of ARDS,
11-14
including the World Health Organization guidelines for the
management of the coronavirus disease 2019 (COVID-19).
15
Although prone positioning is an established therapy
worldwide for improving gas exchange, minimizing ventila-
tor-induced lung injury, and reducing mortality in ARDS,
10,16
the literature demonstrates several adverse events (AEs), such
as unplanned extubation, removal of invasive devices, tran-
sient desaturation, airway obstruction, facial edema, and pres-
sure sores.
10,17-21
Currently, prone positioning has been
widely applied even in awake patients supported with nonin-
vasive ventilation or oxygen therapy
22
; however, patients
who are mechanically ventilated and sedated are more likely
to experience complications related to position changes. Four
systematic reviews with meta-analyses involving up to 11
randomized controlled trials published between 2001 and
2013 (including the PROSEVA trial) revealed that a
significant increase in new pressure sores, airway obstruction,
and unplanned extubation occurred with prone positioning
than with supine positioning.
23-26
Since the publication of the PROSEVA trial, and particu-
larly from the onset of the ongoing pandemic, global recom-
mendations for prone positioning have been given greater
emphasis,
11-14
whichcouldleadtoanincreaseintheinci-
dence and intensity of AEs. This is predominantly relevant
for inexperienced clinicians in prone positioning processes,
who may be compelled to undertake this therapy during the
pandemic.
27
To safely prone ventilated patients with ARDS
in ICUs, minimizing human resource impacts, appropriate
training, simulation, and health system planning must be
undertaken.
28
Numerous guidelines recommend safe tips to
minimize risk
29-31
; however, to implement prone positioning,
clinicians must also recognize and consider the potential
AEs. Whereas the respiratory benefits of prone positioning in
patients with ARDS are widely accepted, the concurrent com-
plications could be undervalued. Although some reviews on
prone positioning have compiled AEs,
21,30,32
there have been
no reviews that specifically included studies after the
PROSEVA trial. Moreover, there are no reviews that fully
collected AEs associated with prone positioning in mechani-
cally ventilated adults with ARDS. Therefore, a scoping
review is a recommended first step to systematically map the
available literature from this landmark point.
33,34
Accordingly, the primary objective of this study was to
identify AEs related to prone positioning in mechanically
ventilated adults with ARDS and, secondarily, to collect
strategies and recommendations to mitigate the AEs during
prone positioning implementation.
Review of the Literature
Study Design
This scoping review of the AEs of prone positioning
was performed according to the Joanna Briggs Institute
framework
34,35
and followed the PRISMA extension for
Scoping Reviews checklist.
36
The protocol was registered
on the International Platform of Registered Systematic
Review and Meta-analysis Protocols database (registra-
tion number: INPLASY2020120020), which is available
at https://doi.org/10.37766/inplasy2020.12.0020. Ethical
approval was not required in this study.
Research Question
The research questions of this scoping review were for-
mulated based on the authors’ concern about the type and
quantity of AEs associated with prone positioning,
Mr Gonza
´lez-Seguel and Ms Aranis are affiliated with the Servicio de
Medicina Fı
´sica y Rehabilitacio
´n and Departamento de Paciente Crı
´tico,
Clı
´nica Alemana Universidad del Desarrollo, Santiago, Chile. Mr
Gonza
´lez-Seguel, Mr Pinto-Concha, Ms Aranis, and Mr Leppe are affili-
ated with the Master Program in Physical Therapy and Rehabilitation,
School of Physical Therapy, Facultad de Medicina, Clı
´nica Alemana
Universidad del Desarrollo, Santiago, Chile. Mr Pinto-Concha is affili-
ated with the Centro de Paciente Crı
´tico Adulto, Clı
´nica INDISA,
Santiago, Chile.
This study was performed under the Master Program in Physical Therapy
and Rehabilitation, School of Physical Therapy, Facultad de Medicina,
Clı
´nica Alemana Universidad del Desarrollo, Santiago, Chile.
The authors have no conflicts to disclose.
Supplementary material related to this paper is available at http://www.
rcjournal.com.
Correspondence: Felipe Gonza
´lez-Seguel PT MSc, Servicio de Medicina
Fı
´sica y Rehabilitacio
´n and Departamento de Paciente Crı
´tico, Facultad
de Medicina, Clı
´nica Alemana Universidad del Desarrollo, Av. Plaza
680, Santiago, Chile. E-mail: feligonzalezs@udd.cl.
DOI: 10.4187/respcare.09194
ADVERSE EVENTS OF PRONE POSITIONING
RESPIRATORY CARE DECEMBER 2021 VOL 66 NO12 1899
especially after the publication of the PROSEVA trial,
10
and even more during the ongoing COVID-19 pandemic.
We structured the research questions using the population,
concept, and context method,
34
searching for AEs related to
prone positioning in mechanically ventilated adult subjects
with ARDS and strategies or recommendations to mitigate
AEs of prone positioning implementation.
Operational Definitions
AEs were defined according to the conceptual frame-
work of the International Classification for Patient Safety
37
as incidents that can be a reportable circumstance, near
miss, no-harm incident, or harmful incident involving an
unintentional and/or unexpected event or occurrence that
may result in injury or death. AEs can be classified as those
associated with the prone positioning maneuver and those
associated with the management of patients while in the
prone position and can be detected during or immediately
following the prone maneuver, including oxygen desatura-
tion, loss of intravascular lines, unscheduled extubation,
and hemodynamic instability, or as a long-term finding,
including peripheral nerve injuries and pressure sores.
30
For
the purposes of extraction, AEs were also considered as
complications or adverse effects and were classified indi-
vidually and by domain group according to type or the bod-
ily system affected. Mitigation strategy was defined as any
measure, effort, or recommendation to minimize or avoid
AEs during the prone positioning maneuver or during the
period when the subject was in the prone position.
30
Search Strategy
Biomedical database searches and hand searching were
performed between October 26, 2020, and November 1,
2020, (JJP-C, FG-S) following stages recommended by the
Joanna Briggs Institute (for more details of the search strat-
egy, (see the supplementary materials at http://www.
rcjournal.com). The main search was carried out in the fol-
lowing biomedical databases: PubMed, CINAHL, Scientific
Electronic Library Online Citation Index (Clarivate, London,
England), Cochrane Library (free access from the Chilean
Ministry of Health), LILACS, and WorldWideScience. The
details of the search strategy used for each database are pre-
sented in Supplementary Material Table S1 (see the supple-
mentary materials at http://www.rcjournal.com). The hand
search was undertaken to acquire recommendation docu-
ments in the websites of scientific societies affiliated with
the World Federation of Intensive and Critical Care.
Eligibility Criteria
Based on the population, concept, and context method, the
following inclusion criteria were established: (1) population:
mechanically ventilated subjects who required prone posi-
tioning due to ARDS; (2) concept: AE reporting; and (3)
context: documents involving subjects in the ICU published
from June 1, 2013, to November 1, 2020. The start of the
study period was established from the publication date of the
PROSEVA trial (included).
10
We included original studies (randomized, controlled tri-
als; nonrandomized trials; prospective and retrospective
observational studies; case reports; and any letter, editorial,
or correspondence with original data) and recommendation
documents that provided advice to avoid or minimize AEs
(including care protocols, guidelines, or any nonoriginal
study providing clinical recommendations). The exclusion
criteria were documents on awake prone positioning (ie,
receiving noninvasive ventilation or high-flow nasal can-
nula), pediatric or neonatal population, animal or experimen-
tal models, unavailable full text, and documents written in
languages other than English or Spanish. Documents that did
not mention the presence or absence of AEs among subjects
who underwent prone positioning were excluded from data
extraction. Additionally, reviews were excluded from data
extraction but were used to look for nonduplicate citations of
pertinent documents.
Document Selection
Two reviewers blinded from each other’s judgment (JJP-C,
NA) independently screened all documents related to prone
positioning in mechanically ventilated adults with ARDS
using the title, abstract, and full text according to the eligibil-
ity criteria previously described. Any disagreements were
resolved by a third reviewer (FG-S). For more details of the
document selection, (see the supplementary materials at
http://www.rcjournal.com).
Data Extraction and Analysis
The authors (JJP-C, NA, FG-S) collectively developed a
standardized data charting form that included relevant vari-
ables according to the research questions. The data charting
form was iteratively updated as needed, and each author in-
dependently abstracted the information from the recommen-
dation documents (JJP-C, NA) and original studies (JJP-C,
FG-S), including all supplementary materials (for more
details of the data extraction, see the supplementary materi-
als at http://www.rcjournal.com).
We generated summary tables reporting counts and per-
centages for document characteristics, AE proportions, and a
compilation of available mitigation strategies and recommen-
dations to minimize or avoid AEs. To calculate the pooled
proportion of AEs according to the subjects in the prone posi-
tion, we used the proportion of subjects who experienced AE
and divided this value by the total number of subjects who
received prone positioning (according to the data from the
ADVERSE EVENTS OF PRONE POSITIONING
1900 RESPIRATORY CARE DECEMBER 2021 VOL 66 NO12
original studies). To calculate the pooled proportion of AEs
according to the number of prone positioning maneuvers, we
used the proportion of the number of AE occurrences during
the prone maneuver and divided this value by the total num-
ber of positioning change maneuvers performed (according
to the data from the original studies). When possible, we pre-
sented descriptive data as overall or pooled medians (inter-
quartile range [IQR] or minimum-maximum [min-max]).
Results
Literature Search and Document Characteristics
This scoping review was conducted between August
2020 and March 2021. The literature search identified 732
citations from scientific databases and 19 from the manual
searches. After removing duplicates and screening by title
and abstract, 134 full texts were reviewed, yielding 121
eligible documents reporting prone positioning in mechani-
cally ventilated subjects with ARDS. Of these documents,
22 (18.2%) were only used to look for relevant citations, and
58 (47.9%) were not selected due to the lack of AE reporting.
Finally, 41 documents were selected for this review, includ-
ing28originalstudiesand13recommendationdocuments
(Fig. 1). Of these, 39 (95.1%) were written in English and 2
(4.9%) in Spanish. An overview of the document characteris-
tics is presented in Table 1. Remarkably, 19 (46.3%) were
published in 2020, and 15 (36.6%) were focused on COVID-
19-related ARDS. A summary of the main characteristics of
each individual document included in this study is presented
in Supplementary Material Table S2 (see the supplementary
materials at http://www.rcjournal.com).
Adverse Events Related to Prone Positioning
Nine domain groups of AEs were identified in the original
studies (number of studies [percentage]): pressure sores or
skin injuries (13 [46.4%]), invasive devices (11 [39.3%]), re-
spiratory system (9 [32.1%]), cardiovascular system (7
[25.0%]), musculoskeletal system (6 [21.4%]), visual system
(5 [17.9%]), gastrointestinal system (4 [14.3%]), nervous sys-
tem (2 [7.1%]), and others (4 [14.3%]). We identified AEs
related to the prone position in 25 studies comprising a total
of 1,578 subjects who received prone positioning (Table 2),
with a pooled median (IQR) age of 57 y (48–60). With the
data from 17 studies, the pooled median (IQR) total duration
of the prone position was 2 d (0.9–5.0). We also identified
AEs related to the prone positioning maneuver in 6 studies
comprising 994 prone positioning maneuvers (Table 3). The
highest-pooled proportions of AE occurrence were severe
desaturation (37.9%), barotrauma (30.5%), pressure sores
(29.7%), ventilation-associated pneumonia (28.2%), facial
edema (16.7%), and arrhythmia or bradycardia (15.4%). Only
3 studies compared AE occurrence between the supine and
prone groups (Supplementary Material Table S3, see the sup-
plementary materials at http://www.rcjournal.com). Among
the original studies, 15 (53.6%) reported a total of 14 AE
detection methods (Supplementary Material Table S4, see the
supplementary materials at http://www.rcjournal.com). In
addition, we identified only 4 AEs in the case reports: meral-
gia paresthetica,
38,39
intraocular pressure increase,
40
optic neu-
ropathy,
41
and lower cranial nerve paralysis.
42
Mitigation Strategies for Adverse Events Related to
Prone Positioning
Combining data from the original studies and recommen-
dation documents, Table 4 presents literature-based matching
between AEs related to prone positioning and the identified
mitigation strategies. The most frequently reported mitigation
strategies for managing subjects in the prone position were as
follows: alternate face rotation (18 [43.9%]), repositioning
Records identified through
database searching
732
Records screened
503
Full-text assessed for
eligibility
134
Records identified
751
Eligible studies
121
Duplicates removed
248
Excluded
13
Awake prone: 7
Full-text not available: 3
Patients treated outside the ICU: 2
Editorial: 1
Excluded
80
Lack of adverse event reporting: 58
Reviews used for citation chasing: 22
Studies included
41
Original research: 28
Recommendations: 13
Excluded
369
Additional records
from other sources
19
Fig. 1. Flow chart.
ADVERSE EVENTS OF PRONE POSITIONING
RESPIRATORY CARE DECEMBER 2021 VOL 66 NO12 1901
every 2 h (17 [41.5%]), the use of pillows under the chest and
pelvis (14 [34.1%]), one upper limb abducted next to the
head (11 [26.8%]), the use of a facial or head padding (11
[26.8%]), the use of protective measures for eyes (11
[26.8%]), placing the subject in a swimming position (10
[24.4%]), placing the subject in the reverse Trendelenburg
position (10 [24.4%]), and free abdomen to minimize abdom-
inal pressure (10 [24.4%]) (Table 5). Unexpectedly, no origi-
nal study or recommendation document reported early
mobilization (ie, neuromuscular electrical stimulation or pas-
sive mobilization) as a mitigation strategy for prone
positioning of mechanically ventilated subjects. The manual
prone positioning maneuver was the most common maneu-
ver, reported in 14 (34.1%) documents. The most frequently
reported mitigation strategies for performing the prone ma-
neuver were one person being at the head of the subject (23
[56.1%]), the use of a pre-maneuver safety checklist (18
[43.9%]), vital sign monitoring (15 [36.6%]), ensuring appro-
priate ventilator settings (12 [29.3%]), rotation opposite to the
catheter side (10 [24.4%]), pre-oxygenation with 100% O
2
(10 [24.4%]), and interruption of enteral nutrition (10
[24.4%]) (Table 6). The overall median (min-max) number
Table 1. Overview of Included Documents Reporting Adverse Events Related to Prone Positioning in Subjects With ARDS
Characteristics Original Studies Recommendations Overall
no. ¼28, no. (%) no. ¼13, no. (%) no. ¼41, no. (%)
Year of publication
2017–2020
*
19 (67.9) 11 (84.6) 30 (73.2)
2013–2016 9 (32.1) 2 (15.4) 11 (26.8)
Region
Europe
†
16 (57.1) 7 (53.8) 23 (56.1)
United States 9 (32.1) 2 (15.4) 11 (26.8)
Asia
‡
3 (10.7) 2 (15.4) 5 (12.2)
Brazil 0 2 (15.4) 2 (4.9)
Design
Retrospective observational study
§
15 (53.6) N/A 15 (36.6)
Case report
||
8 (28.6) N/A 8 (19.5)
Prospective observational study 4 (14.3) N/A 4 (9.8)
Randomized controlled trial 1 (3.6) N/A 1 (2.4)
Clinical practice guideline N/A 5 (38.5) 5 (12.2)
National guideline N/A 3 (23.1) 3 (7.3)
Clinical commentary N/A 2 (15.4) 2 (4.9)
Care protocol N/A 2 (15.4) 2 (4.9)
Checklist N/A 1 (7.7) 1 (2.4)
Target population
Non-COVID-19-related ARDS 17 (60.7) 9 (69.2) 26 (63.4)
COVID-19-related ARDS 11 (39.3) 4 (30.8) 15 (36.6)
Extracorporeal membrane oxygenation
¶
2 (7.1) 0 2 (4.9)
Morbid obesity with ARDS
¶
1 (3.6) 0 1 (2.4)
Exacerbation of interstitial lung disease
¶
1 (3.6) 0 1 (2.4)
Journal or source scope
Critical care and intensive care medicine 16 (57.1) 7 (53.8) 23 (56.1)
Medicine miscellaneous 2 (7.1) 3 (23.1) 5 (12.2)
Pulmonary and respiratory medicine 3 (10.7) 0 3 (7.3)
Surgery 2 (7.1) 0 2 (4.9)
Anesthesiology 1 (3.6) 1 (7.7) 2 (4.9)
Physical therapy and rehabilitation 1 (3.6) 1 (7.7) 2 (4.9)
Nursing 1 (3.6) 1 (7.7) 2 (4.9)
Nutrition and dietetics 1 (3.6) 0 1 (2.4)
Dermatology 1 (3.6) 0 1 (2.4)
N/A ¼not applicable.
* Includes one study published online in 2020, yet currently publication date is 2021.
64
†
Documents from European countries included France (no. ¼7), United Kingdom (no. ¼7), Spain (no. ¼4), Germany (no. ¼2), Italy (no. ¼2), and Denmark (no. ¼1).
‡
Documents from Asian countries included India (no. ¼2), Japan (no. ¼1), China (no. ¼1), and Saudi Arabia (no. ¼1).
§
Includes one secondary analysis
65
and one ancillary study,
66
both originated from PROSEVA trial data.
||
Includes a research letter with 2 case reports.
38
¶
Also included in the category: non-SARS-CoV-2–related ARDS.
COVID-19 ¼coronavirus disease 2019
ADVERSE EVENTS OF PRONE POSITIONING
1902 RESPIRATORY CARE DECEMBER 2021 VOL 66 NO12
of staff members involved in the prone positioning maneuver
was 5 (3–8) in the original studies and 5 (3–7) in the recom-
mendations, mainly including physicians, nurses, and
respiratory therapists. Additionally, the training of staff mem-
bers involved in the management of subjects placed in the
prone position was reported in only 11 (39.3%) original
Table 2. Adverse Events Related to Prone Positioning in Subjects With ARDS
Adverse Event Studies Contributing Data, no. Subjects With
Adverse Event,
†
n95% CI
Pressure sores (by body site)
‡
Pressure sores in general 7 195/656 (29.7) 26.2–33.2
Face (ie, chin, cheekbone) 7 113/595 (19.0) 15.8–22.1
Chest 4 40/443 (9.0) 6.4–11.7
Lower limb (ie, foot, heel, knee, trochanter) 4 29/449 (6.5) 4.2–8.7
Ears 2 9/120 (7.5) 2.8–12.2
Back of head 1 6/191 (3.1) 0.7–5.6
Back 1 2/189 (1.1) 0–2.5
Sacrum 1 40/196 (20.4) 14.8–26.1
Pressure sores (by severity grade)
Grade I 2 17/205 (8.3) 4.5–12.1
Grade II 2 20/205 (9.8) 5.7–13.8
Grade III 2 0/205 (0) 0
Grade IV 2 3/205 (1.5) 0–3.1
Invasive devices
Removal of venous or arterial lines 7 4/452 (0.9) 0–1.7
Unscheduled extubation 5 32/413 (7.7) 5.2–10.3
Displacement of endotracheal tube 4 9/466 (1.9) 0.7–3.2
Airway obstruction 2 11/272 (4.0) 1.7–6.4
Respiratory system
Severe desaturation (SpO2<85%) 3 162/428 (37.9) 33.3–42.4
Ventilation-associated pneumonia 2 96/340 (28.2) 23.5–33.0
Pneumothorax 2 3/104 (2.9) 0–6.1
Barotrauma 1 11/36 (30.6) 15.5–45.6
Cardiovascular system
Cardiac arrest 5 19/559 (3.4) 1.9–4.9
Hypotension 3 40/393 (10.2) 7.2–13.2
Arrhythmia or bradycardia 2 42/273 (15.4) 11.1–19.7
Musculoskeletal system
Peripheral nerve injuries in general 4 15/185 (8.1) 4.2–12.0
Brachial plexus injury 3 4/174 (2.3) 0.1–4.5
Ulnar nerve injury 1 6/83 (7.2) 1.7–12.8
Radial nerve injury 1 3/83 (3.6) 0–7.6
Sciatic nerve injury 1 3/83 (3.6) 0–7.6
Median nerve injury 1 2/83 (2.4) 0–5.7
Back pain 1 1/11 (9.1) 0–26.1
Visual system
Eye hemorrhage or edema 3 8/226 (3.5) 1.1–5.9
Gastrointestinal system
Vomit 1 1/66 (1.5) 0–4.5
Hemoptysis 1 6/237 (2.5) 0.5–4.5
Nervous system
Transient increase in intracranial pressure 2 2/102 (2.0) 0–4.7
Others
§
Facial, periorbital, or tongue edema 3 17/102 (16.7) 9.4–23.9
Bleeding 1 1/66 (1.5) 0–4.5
* Counting studies that collected data on adverse events, regardless of whether an event occurred.
†
Proportion of subjects who experienced the adverse event due to prone positioning divided by the total number of subjects who received prone positioning, from original studies contributing data.
‡
Two other body sites (head and penis) were reported in one study.
67
In this study, it only includes subjects presenting skin injuries; therefore, data of this adverse event were not used for this table.
§
Meralgia paresthetica, intraocular pressure increase, optic neuropathy, and lower cranial nerves paralysis are not presented in this table as they were only informed in case reports.
ADVERSE EVENTS OF PRONE POSITIONING
RESPIRATORY CARE DECEMBER 2021 VOL 66 NO12 1903
studies and was suggested by 8 (61.5%) recommendation
documents.
Discussion
We identified >40 individual AEs within 9 domains
from the original studies, despite almost half of the eligi-
ble studies not reporting any AEs. To our knowledge,
this is the first scoping review to specifically and com-
prehensively collect AEs related to prone positioning in
mechanically ventilated subjects with ARDS. We identi-
fied studies reporting AEs according to the number of
subjects placed in the prone position (no. ¼25) and the
number of prone maneuvers (no. ¼6). Moreover, from
the original studies and recommendation data, we identi-
fied >30 strategies to mitigate AEs during the prone
position and almost 20 strategies to perform the prone
positioning maneuver.
Our findings can be contrasted with previous systematic
reviews that, as a secondary aim, have also reported the occur-
rence of AEs in subjects placed in the prone position.
23-26
Considering the AEs reported by systematic reviews, the
reported data up to the publication of the PROSEVA trial,
and our scoping review, the pooled proportions were similar
in terms of pressure sores, ventilator-associated pneumonia,
cardiac arrest, pneumothorax, arrhythmia, airway obstruction,
unplanned extubation, removal of venous or arterial lines, and
endotracheal tube displacement (Supplementary Material
Table S5,see the supplementary materials at http://www.
rcjournal.com). Remarkably, we identified similar overall
values, showing a lower proportion of AEs in our scoping
review, except for ventilator-associated pneumonia and ar-
rhythmia, which were slightly higher.
Owing to the wide coverage of scoping reviews, we iden-
tified additional AEs from nonrandomized controlled trials
and compared the data with preceding randomized con-
trolled trials.
23-26
From single studies, we identified back
pain,
43
barotrauma,
44
vomit,
45
hemoptysis,
10
and bleeding
45
as AEs. Additionally, we found relevant AEs reported in at
least 2 original studies that were not informed by previous
reviews.
23,24
For instance, pressure sores were reported by
severity grade in 2 studies,
17,46
highlighting grades I and II
(with redness and blisters) as the most prevalent (8.3% and
9.8%, respectively) and showing fewer grades in subjects
who received suitable nutritional intake.
46
Severe desatura-
tion was reported in 3.4% of all prone positioning maneu-
vers
47,48
and in 37.9% of subjects while in the prone
position.
10,49,50
In the PROSEVA trial, 65.4% of subjects
presented with severe desaturation (pulse oximetry satura-
tion <8 5%) during prone positioning compared to 71.6%
in the supine group.
10
We believe that the proportion of
AEs that occurred during the maneuver should be calcu-
lated separately from those that occurred while the subjects
were in the prone position. Remarkably, acquired periph-
eral nerve injury associated with the use of prone position-
ing has been rarely reported and is likely undervalued.
However, in 2 recent reports,
51,52
it was surprising that
13.1%–14.5% of subjects with COVID-19 had peripheral
nerve injury after prone positioning, including injuries to
the brachial plexus, ulnar, radial, sciatic, and median
nerves. In our review, only 4 studies reported a pooled
Table 3. Adverse Events Related to the Positioning Change Maneuver in Subjects With ARDS
Adverse Event Studies Contributing Data, no. Maneuvers With Adverse Events
†
, no. (%) 95% CI
Invasive devices
Disconnection of ventilator lines 3 5/920 (0.5) 0.1–1.0
Removal of venous or arterial lines 3 1/250 (0.4) 0–1.2
Removing of nasogastric tube 2 2/441 (0.5) 0–1.1
Unscheduled extubation 2 0/441 (0) 0
Airway obstruction 1 2/74 (2.7) 0–6.4
Respiratory system
Severe desaturation (SpO2<85%) 2 15/441 (3.4) 1.7–5.1
Cardiovascular system
Hypotension 1 7/74 (9.5) 2.8–16.1
Arrhythmia or bradycardia 1 3/74 (4.1) 0–8.5
Cardiac arrest 1 1/74 (1.4) 0–4.0
Gastrointestinal system
Vomit 1 5/526 (1.0) 0.1–1.8
Other
Bleeding
‡
1 10/74 (13.5) 5.7–21.3
* Counting studies that collected data on adverse events, regardless of whether an event occurred.
†
Proportion of the number of occurrences of adverse events during the positioning change maneuver to prone or supine divided by the total positioning change maneuvers performed, from studies contrib-
uting data.
‡
Reported in only one study of subjects with extracorporeal membrane oxygenation.
ADVERSE EVENTS OF PRONE POSITIONING
1904 RESPIRATORY CARE DECEMBER 2021 VOL 66 NO12
Table 4. Literature-Based Matching Between Adverse Events Related to Prone Positioning and Identified Mitigation Strategies
Pressure
Sores
Peripheral
Nerve
Injuries*
VAP Facial
Edema
Eye
Injuries
†
Lower
Cranial
Nerves
Paralysis
Vomit or
Hemoptysis
Transient
Increase
in ICP
Invasive Devices
Displacements
‡
Airway
Obstruction Barotrauma Severe
Desaturation
Hemodynamic
Instability
§
Strategies during prone position
Swimming position
||
Incomplete prone positioning (135–180)
Reverse Trendelenburg
¶
One upper limb abducted next to the head
Upper limbs placed alongside the body
Slide scapula up the back with slight
shoulder shrug
Head placement over the upper edge of the
bed
One lower limb with hip and knee semi-
flexed
Upper limbs placed up straight beside the
head
Keep all joints in a neutral anatomical
position
Avoid neck hyperextension
Avoid extension of the shoulder
Avoid arm abduction >70
Avoid depression of the shoulder girdle
Avoid nonphysiologic limbs movements
Pillows under chest and pelvis
Pillow under shinbone minimizing equinus
foot
Alternate face rotation
Repositioning every 2 h
Facial or head padding
Protective measures for eyes
Free abdomen
Bony prominences padding
Hand rolls
Hourly joint movement and skin marks
observation
Suitable mattress and bed-related
characteristics
(Continued)
ADVERSE EVENTS OF PRONE POSITIONING
RESPIRATORY CARE DECEMBER 2021 VOL 66 NO12 1905
Table 4. Continued
Pressure
Sores
Peripheral
Nerve
Injuries*
VAP Facial
Edema
Eye
Injuries
†
Lower
Cranial
Nerves
Paralysis
Vomit or
Hemoptysis
Transient
Increase
in ICP
Invasive Devices
Displacements
‡
Airway
Obstruction Barotrauma Severe
Desaturation
Hemodynamic
Instability
§
Strategies to perform the prone positioning
maneuver
One person at the head of subject**
Rotation opposite to the catheter side
Rotation toward the ventilator side
Pre-maneuver safety checklist
Vital sign monitoring
Ensuring appropriate ventilator settings
Pre-oxygenation with 100% O
2
Sedated and paralyzed
Airway suction prior to procedure
Interruption of enteral nutrition
Discontinue nonessential infusions and
monitoring
Arms alongside the body
Palms facing inward or anteriorly
Palms under the buttocks
Avoid nonphysiologic limb movements
* Peripheral nerve injuries include brachial plexus injury, ulnar nerve injury, radial nerve injury, sciatic nerve injury, median nerve injury, back pain, and meralgia paresthetica.
†
Eye injuries include eye hemorrhage or edema, intraocular pressure increase, and optic neuropathy.
‡
Invasive devices removal or displacements include removal of venous or arterial lines, unscheduled extubation, displacement of endotracheal tube, disconnection of ventilator lines, and removal of nasogastric tube.
§
Hemodynamic instability includes cardiac arrest, hypotension, and arrhythmia.
||
Swimming position definition (also called swim position or swimmer position) varies depending on the reference; mainly it is described as one arm raised (elbow flexed 90and shoulder abducted 45–80) and head rotated toward the raised arm; the other arm is
positioned alongside the body with the palms facing inward or upward.
¶
For reverse Trendelenburg position, the following degrees of inclination were reported: 10,25
–30, and 30.
**
One person at the head of subject/bed dedicated to ensure the endotracheal tube, ventilator, and nasogastric tube, directing, coordinating, and supervising the procedure.
VAP ¼ventilation-associated pneumonia
ICP ¼intracranial pressure
ADVERSE EVENTS OF PRONE POSITIONING
1906 RESPIRATORY CARE DECEMBER 2021 VOL 66 NO12
proportion of any peripheral nerve injury (8.1%),
43,49,52,53
which could indicate an underestimation in other studies.
We found relevant mitigation strategies for AEs related
to body position in subjects placed in the prone position.
The swimming position was reported in 7 (53.8%) recom-
mendations but was performed in only 3 (10.7%) original
studies, whereas the complete prone positioning (180)was
mentioned in only one recommendation but was performed
in 7 (25.0%) studies. Although the PROSEVA trial used
complete prone positioning with arms placed alongside the
body, we also observed a trend in the recommendation of
the swimming position; however, there is heterogeneity in
its description, with the majority of documents describing it
as placing the face toward the abducted and flexed
arm,
29,30,54
whereas others describing it as placing the face
toward the straight arm.
55
Currently, there is no completely
safe and suitable positioning of the body that will ensure
the minimization of nerve injury in every patient, but some
Table 5. Mitigation Strategies to Manage Subjects While in the Prone Position
Strategies Original Studies Recommendations Overall
no. ¼28, no. (%) no. ¼13, no. (%) no. ¼41, no. (%)
Prone whole-body position
Swimming position
*
3 (10.7) 7 (53.8) 10 (24.4)
Reverse Trendelenburg
†
6 (21.4) 4 (30.8) 10 (24.4)
Complete prone positioning (180) 7 (25.0) 1 (7.7) 8 (19.5)
Incomplete prone positioning (135–180) 1 (3.6) 1 (7.7) 2 (4.9)
Limbs and head position
One upper limb abducted next to the head 3 (10.7) 8 (61.5) 11 (26.8)
Upper limbs placed alongside the body 8 (28.6) 0 8 (19.5)
Avoid neck hyperextension 2 (7.1) 3 (23.1) 5 (12.2)
Slide scapula up the back with slight shoulder shrug 1 (3.6) 3 (23.1) 4 (9.8)
Avoid extension of the shoulder 1 (3.6) 3 (23.1) 4 (9.8)
Head placement over the upper edge of the bed 3 (10.7) 1 (7.7) 4 (9.8)
Arm abduction of 801 (3.6) 2 (15.4) 3 (7.3)
Avoid arm abduction >700 2 (15.4) 2 (4.9)
Avoid depression of the shoulder girdle 0 2 (15.4) 2 (4.9)
One lower limb with hip and knee semi-flexed 1 (3.6) 1 (7.7) 2 (4.9)
Upper limbs placed up straight beside the head 1 (3.6) 0 1 (2.4)
Keep all joints in a neutral anatomical position 0 1 (7.7) 1 (2.4)
Avoid nonphysiologic limbs movements 1 (3.6) 0 1 (2.4)
Pillows use
Pillows under chest and pelvis 7 (25.0) 7 (53.8) 14 (34.1)
Pillow under shinbone minimizing equine position 4 (14.3) 3 (23.1) 7 (17.1)
A triangular pillow under the anterior iliac crests 1 (3.6)
‡
0 1 (2.4)
Care measures
Alternate face rotation 11 (39.3) 7 (53.8) 18 (43.9)
Repositioning every 2 h 11 (39.3) 6 (46.2) 17 (41.5)
Facial or head padding
§
6 (21.4) 5 (38.5) 11 (26.8)
Protective measures for eyes 4 (14.3) 7 (53.8) 11 (26.8)
Free abdomen 5 (17.9) 5 (38.5) 10 (24.4)
Bony prominences padding 4 (14.3) 4 (30.8) 8 (19.5)
Hand rolls 0 3 (23.1) 3 (7.3)
Repositioning every 1 h 1 (3.6) 1 (7.7) 2 (4.9)
Hourly joint movement and skin marks observation 1 (3.6) 1 (7.7) 2 (4.9)
Bed-related characteristics
Alternating-pressure mattress 3 (10.7) 1 (7.7) 4 (9.8)
Prone positioner
||
0 3 (23.1) 3 (7.3)
Suitable mattress 1 (3.6) 1 (7.7) 2 (4.9)
* Swimming position definition (also called swim position or swimmer position) varies depending on the reference; mainly it is described as one arm raised (elbow flexed 90and shoulder abducted within
45–80) and head rotated toward the raised arm; the other arm is positioned alongside the body with the palms facing inward or upward.
†
For reverse Trendelenburg position, the following degrees of inclination were reported: 10,25
–30, and 30.
‡
Reported in only one study of subjects with extracorporeal membrane oxygenation.
62
§
Includes half a crescent jelly, sponge donuts, C-letter–shaped pad, facial padding if the subject has a tracheostomy, and bite block (for macroglosia).
||
Includes Vollman Prone Positioner (Hill-Rom), RotoProne bed, and the continuous lateral rotation therapy.
ADVERSE EVENTS OF PRONE POSITIONING
RESPIRATORY CARE DECEMBER 2021 VOL 66 NO12 1907
authors promote an understanding of the principles of a
safe position and encourage the maintenance of a high clin-
ical suspicion of potential brachial plexus injury during the
prone position, especially for unconscious and paralyzed
patients.
54
To reduce the risk and impact of brachial plexus
injury, some guidelines recommend the swimming posi-
tion, avoiding excessive rotation, neck extension, shoulder
extension or subluxation, arm abduction beyond 70with
elbow extension, and external rotation of the shoulder
beyond 60.
54
Regarding the application of thoraco-pelvic
supports (pillows under the chest and pelvis), 7 (25.0%)
studies and 7 (53.8%) recommendations reported mini-
mizing the intra-abdominal pressure. Controversially,
Chiumello et al
56
demonstrated that these supports decrease
chest wall compliance, increase pleural pressure, and
slightly deteriorate hemodynamics without any advantage
in gas exchange, along with a higher likelihood of pressure
sores. Regardless of the main position of the entire body,
the reverse Trendelenburg
57
position has been reported as a
recommended strategy to mitigate face pressure sores, venti-
lator-associated pneumonia, facial edema, eye injuries, lower
cranial nerve paralysis, vomiting, transient increase in intra-
cranial pressure, and severe desaturation (Table 4) and is
even better if combined with alternating face rotation and
repositioning every 2 h. Despite the well-known safety and
benefits of passive mobilization and neuromuscular electrical
stimulation in sedated subjects,
58-61
no study has reported
early mobilization as a mitigation strategy, which is likely
vital to minimize nerve injuries and ICU-acquired weakness
after prone positioning.
Table 6. Mitigation Strategies to Perform the Prone Positioning Maneuver
Strategies Original Studies Recommendations Overall
no. ¼28, no. (%) no. ¼13, no. (%) no. ¼41, no. (%)
Practical execution maneuver
Manual prone positioning maneuver 12 (42.9) 2 (15.4) 14 (34.1)
Cornish Pastry technique (envelope maneuver)
*
1 (3.6) 6 (46.2) 7 (17.1)
Tortoise Turning and Positioning System Prone
†
1 (3.6) 0 1 (2.4)
Safety strategies
One person at the head of subject
‡
16 (57.1) 7 (53.8) 23 (56.1)
Pre-maneuver safety checklist 10 (35.7) 8 (61.5) 18 (43.9)
Vital sign monitoring 12 (42.9) 3 (23.1) 15 (36.6)
Rotation opposite to the catheter side 8 (28.6) 2 (15.4) 10 (24.4)
Interruption of enteral nutrition 2 (7.1) 8 (61.5) 10 (24.4)
Discontinue nonessential infusions and monitoring 2 (7.1) 5 (38.5) 7 (17.1)
Rotation toward the ventilator side 1 (3.6) 5 (38.5) 6 (14.6)
Respiratory strategies
Ensuring appropriate ventilator settings 9 (32.1) 3 (23.1) 12 (29.3)
Pre-oxygenation with 100% O
2
4 (14.3) 6 (46.2) 10 (24.4)
Sedated but paralyzed when necessary 4 (14.3) 5 (38.5) 9 (22.0)
Sedated and paralyzed 2 (7.1) 1 (7.7) 3 (7.3)
Airway suction prior to procedure 3 (10.7) 5 (38.5) 8 (19.5)
Limbs positioning
Arms along the body 2 (7.1) 4 (30.8) 6 (14.6)
Palms facing inward or anteriorly 1 (3.6) 3 (23.1) 4 (9.8)
Palms under their buttocks 1 (3.6) 1 (7.7) 2 (4.9)
Avoid nonphysiologic limbs movements 1 (3.6) 0 1 (2.4)
Participating health staff members
Physician
§
6 (21.4) 7 (53.8) 13 (31.7)
Nurse 4 (14.3) 7 (53.8) 11 (26.8)
Respiratory therapist 3 (10.7) 5 (38.5) 8 (19.5)
Physiotherapist 1 (3.6) 4 (30.8) 5 (12.2)
Anesthetist 1 (3.6) 3 (23.1) 4 (9.8)
Occupational therapist 1 (3.6) 0 1 (2.4)
Medical student 1 (3.6) 0 1 (2.4)
* The Cornish Pastry technique (also called envelope maneuver) is described as a prone positioning maneuver that uses double sheets cocooning the subject inside (one below and one above).
†
The Tortoise Turning and Positioning System prone (M€
olnlycke Health Care, Gothenburg, Sweden) consists of 2 low-pressure air-filled pads and 2 fluidized positioners to support and off-load the sub-
ject.
49
‡
One person at the head of subject/bed dedicated to ensure the endotracheal tube, ventilator, and nasogastric tube, directing, coordinating, and supervising the procedure.
§
Physician: including senior physicians and critical care specialists.
ADVERSE EVENTS OF PRONE POSITIONING
1908 RESPIRATORY CARE DECEMBER 2021 VOL 66 NO12
AEs related to prone maneuvers can be mitigated by fol-
lowing at least 20 strategies identified in our scoping
review, including using a pre-maneuver safety checklist,
monitoring vital signs, ensuring appropriate ventilator set-
tings, and having a leader (physician or respiratory thera-
pist) at the head of the subject, which have also been
previously reported.
30
The number of staff members is also
important, as it influences the occurrence of AEs during the
maneuver.
30
Themediannumberidentifiedwas5staff
members, but this number depends on each team’s experi-
ence level and the subject type. For those with extracorpor-
eal membrane oxygenation or morbid obesity requiring
prone positioning, the number of members reported ranged
from 4–8
47,62
and 5–6,
45
respectively.
Although preceding meta-analyses support the signifi-
cant reduction in overall mortality of subjects with ARDS
treated with prone positioning,
23-26
the risk of AEs should
be carefully considered during the decision-making pro-
cess, especially in ICUs with less experience.
23,27
Whereas
most AEs can be severe but immediately corrected, others
may be less prevalent but may require long-term care. In
this scoping review, several mitigation strategies related to
maintaining safe body positions were collected, emphasiz-
ing the prevention of AEs originating from incorrect body
and limb positions that could be maintained over time.
Future clinical trials should incorporate the screening of
long-term AEs, which we believe are still underestimated,
as well as peripheral nerve and eye injuries, which could be
determinants of the quality of life of survivors. In addition,
future studies should report the presence and absence of
AEs in both the prone and supine groups to minimize
design-related bias.
This review is not exempted from limitations. The find-
ings of this scoping review cannot be generalized beyond
subjects with ARDS treated in the ICU with prone position-
ing. Due to the emerging need to obtain recent information
on prone positioning, we did not include documents pub-
lished before 2013. However, we captured useful data on
AEs that became available after the landmark PROSEVA
trial. We did not identify new randomized or controlled
clinical trials reporting AEs related to prone positioning
between 2013 and 2020, limiting the comparison of AE
occurrence between the prone and supine groups. Due to
the observational nature of the original studies included, the
causality of AE occurrence likewise cannot be confirmed.
Moreover, additional confounding and mediator factors
could explain an AE,
63
and the prone position itself could
be a mediator of the greater severity experienced by a
patient presenting with an event. Finally, no cause-effect
analysis had been performed between the mitigation strat-
egies and the occurrence of AEs, nor did we explore the
relationships between the length of prone positioning ses-
sions and AEs. However, the findings of our review could
serve as precursors for future studies.
Conclusions
Several AEs related to prone positioning in mechanically
ventilated subjects with ARDS were identified, involving
additional AEs not yet reported by previous systematic
reviews. The pooled AE proportions reported in this scop-
ing review might guide research and clinical practice deci-
sions, especially for ICU teams with little to no experience
in the management of patients who need prone positioning.
The strategies for mitigating AEs that have been collected
in this scoping review could promote future consensus-
based recommendations.
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