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Diminishing Utilization of Prone Positioning for Severe ARDS Patients After COVID-19

Updated: Oct 31, 2023

Prone positioning has emerged as a pivotal, evidence-based therapy for patients grappling with Acute Respiratory Distress Syndrome (ARDS). The onset of the COVID-19 pandemic saw a widespread adoption of prone positioning for managing patients afflicted with COVID-19-associated ARDS. This was a significant stride towards leveraging a historically underutilized therapy. However, past analyses on the implementation of evidence-based ICU care unveil a concerning trend; the use of such therapies can diminish in the absence of targeted support. The question hence arises: has the heightened use of prone positioning during the early pandemic phase been sustained?

A retrospective observational study was conducted, diving into the trends of prone positioning utilization in COVID-19 ARDS patients from March 2020 to December 2022. The data was extracted from the electronic medical records (EMR) of five hospitals under the Johns Hopkins Health System (JHHS) in the Baltimore-Washington, DC region. The study encompassed adult patients with suspected or confirmed COVID-19 cases, receiving invasive mechanical ventilation (IMV), and met the criteria for proning within the initial 72 hours of mechanical ventilation initiation [1].

Proning rates by study period
Proning rates by study period

A total of 656 patients were identified over three years (341 in 2020, 224 in 2021, and 91 in 2022), with over half (53%) meeting the severe ARDS criteria. The incidence of early proning was comparable in 2020 and 2021 (56.2% and 56.7% respectively) but saw a substantial decline to 27.5% in 2022. This represented a 51% reduction in the use of prone positioning in 2022 compared to 2020, with a relative risk (RR) of 0.49 (95% CI, 0.33–0.72; p < 0.001). This significant reduction persisted even in adjusted models with an adjusted RR of 0.59 (95% CI, 0.42–0.82; p = 0.002). During COVID-19 surge periods, there was a 7% increase in the utilization of proning, as indicated by an adjusted RR of 1.07 (95% CI, 1.02–1.13; p = 0.01).

Comparative Analysis of Prone Positioning Utilization across Three Years
Comparative Analysis of Prone Positioning Utilization across Three Years

The findings underscore a concerning downtrend in the use of prone positioning for managing severe ARDS in COVID-19 patients, necessitating prompt interventions to revive and uphold the application of this evidence-based therapy.

In your practice, have you observed a decline in the utilization of prone positioning for patients with severe ARDS

  • 0%Yes (Please elaborate on any contributing factors)

  • 0%No

  • 0%Not sure


  1. Hochberg, Chad H. MD, MHS1; Psoter, Kevin J. PhD2; Eakin, Michelle N. PhD1; Hager, David N. MD, PhD1. Declining Use of Prone Positioning After High Initial Uptake in COVID-19 Adult Respiratory Distress Syndrome*. Critical Care Medicine 51(11):p 1547-1551, November 2023 Link

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