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Awake Proning of COVID-19 Patients 

Clinical Decision Making Tool 







  Known or suspected COVID-19 

  Requiring FiO2 ? 28% to maintain SpO2 ? 92% 

     (or 88-92% if risk of hypercapnic respiratory failure) 

  No contraindications present 


  Haemodynamic instability (SBP &lt; 90mmHg) 

or arrhythmias 

  Need for immediate intubation 

  Anticipated airway issues 

  Unstable spine / thoracic injuries 

  Recent abdominal surgery 

  Inability to co-operate (agitation, delirium) 

Continue Supine 



  Obvious respiratory distress (RR &gt; 30) 

  Facial injury 

  Neurological issues (seizures) 

  Morbid obesity (BMI &gt; 40) 

  Pregnancy (2nd or 3rd trimesters) 

  Pressure injuries 

  Unable to adjust position independently 

Continue Supine &amp; Escalate to Medical Team 


Continue Proning (See Figure 1) 

  Change position every 2hrs 

as tolerated 

  When supine, sit as upright 

as possible 

  Monitor closely (especially 

after each position change) 

  Wean oxygen as able 


  Check oxygen therapy set-up 

  Increase oxygen support 

  Change / modify position 

  MET call as appropriate 

Discontinue if: 

  Clinically deteriorating 

  Not tolerating position 

Multidisciplinary Decision Made to Initiate Proning  

(Medical / Physiotherapy / Nursing) 

  Consider number of staff required 

  Have pillows for support (minimum 3) 

  Brief / educate patient 

  Secure oxygen therapy and ensure adequate tubing length 

  Ensure other attachments are unobstructed 

  Sedation must not be administered to facilitate proning 

Complete / Assist Proning Manoeuvre 

  Maximise patient comfort 

  Manage attachments 

  Reassure patient 


  Oxygen saturations for 15 mins 

o SpO2 92-96% (or 88-92% if risk of 

hypercapnic respiratory failure) 

  Tolerating position with nil obvious distress 

 YES        NO       



Awake Proning of COVID-19 Patients 

Proning Implementation 

This patient may benefit from spending time in the prone position 

There is some evidence that the prone position (lying on their stomach) for conscious   

COVID-19 patients requiring basic respiratory supports may be of benefit in terms of: 

- Improving oxygenation 

- Improving V/Q matching 

- Recruitment of posterior lung segments 

- Avoiding need for intubation / escalation of care 


Figure 1: Awake Proning Process 


If the patient fulfils criteria for proning, where possible, encourage the patient to  

switch positions every 30 minutes to 2 hours as needed; the more time they can spend 

prone the better: 

1. Prone 


         2. Lying on Right Side 






4. Lying on Left Side 








        3. Sitting  







Adapted from Intensive Care Society Guidelines (Bamford et al., 2020) 

Authors: Simone Dafoe, Rocky Callisto 

  Central Adelaide Local Health Network. All rights reserved 



Awake Proning of COVID-19 Patients 

Patient Information 

Proning is when you lay flat on your stomach for a 

prolonged time 

We may ask you to lay in the following positions to help: 

- Get oxygen into your lungs      - Lower your risk of getting severely ill 

- Reduce your breathlessness   - Assist you to recover quicker 





















Try staying in each position for 30mins to 2 hours 

If comfortable, the longer you can spend on your stomach 

the longer the benefits 

1. Lying on Stomach 2. Lying on Right Side 

4. Lying on Left Side 3. Sitting 


Practical Tips for Rolling 

1. Move body to opposite side of bed 

2. Turn head in direction of turn 

3. Reach across with arm 

4. Bend knee and push off foot 

5. Rearrange pillows until you are comfortable