A new protocol for prone positioning— a technique commonly used to treat COVID-19 patients

New option for how people with Covid-19 are cared for on NHS wards.


Proning is extremely beneficial in COVID-19 patients. It is a medically accepted position to improve breathing comfort and oxygenation. Like in other conditions, prone positioning for COVID-19 involves turning a patient with precise, safe motions from their back onto their abdomen, so the patient is lying face down.

Proning has been used for several decades. Still, clinicians have limited guidance on the optimal use of the maneuver and requisite monitoring.

Now, researchers from the University of Bristol, in collaboration with clinicians at the Royal United Hospital in Bath, conducted a literature review of the maneuver to develop a standard protocol for the prone positioning. The team wanted to design a way through which alternative positioning of people with severe lung infections could improve their oxygen levels.

They started by reviewing five studies that give them details of the technique, which involved patients being cared for while lying on their fronts.

Two of the five studies tested the protocol in patients with non-invasive ventilation, and three described a protocol but did not test it in patients. Using the data from these five articles and relevant clinical guidelines, the study showed as well as being cost-effective, when patients are positioned prone, their oxygenation improves dramatically. While the studies did not provide conclusive evidence to suggest a consensus on optimal duration in the COVID-19 population, studies that compared duration show a trend towards more extended periods being of greater benefit.

Dr. Emily Henderson, an Honorary Consultant Geriatrician at the Royal United Hospital Bath and Senior Lecturer at the University of Bristol and the study’s senior author, said: “Working on the frontline throughout the pandemic, I have sadly seen a large number of older adults, in particular, die as a result of severe Covid-19 infection. Prone positioning is often used in intensive care settings and was a successful strategy that we trialled during the pandemic.”

“We were struck by how little research there was to guide who this might benefit from this and how it could be adopted into practice safely. We are delighted to have developed a protocol for this potential adjuvant treatment. We look forward to exploring whether this, in addition to the drug treatments being developed and tested in large trials, may improve survival and outcomes. This strategy has particular utility for older people who are often looked after in NHS ward environments with Covid-19 infection.”

Danielle Brazier, an academic physiotherapist at the University of Bristol, added: “Prone positioning for people with Covid-19 is a promising option, but there’s a lot that needs to be considered prior to and during the procedure. We have designed a simple protocol to guide clinicians caring for people with Covid-19 infection. It was great to work with a multidisciplinary team of academics and clinicians to develop this guide.”

Journal Reference:
  1. Brazier, D.E., Perneta, N., Lithander, F.E., et al. Prone Positioning of Older Adults with COVID-19: A Brief Review and Proposed Protocol. J Frailty Aging (2021). DOI: 10.14283/jfa.2021.30
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