Proning as Part of Your COVID-19 Bundle

Chiumello et al., 2006

How can lying on your stomach help with COVID-19?
Body Mechanics + Physiology

There’s a yoga term called “back breathing” where deep breathing occurs when your back is on top and your chest is below. In medicine, this is called “prone positioning.”

It is simply easier to take deeper breaths when lying on your belly (or variation) because thoracic compliance is increased by reducing chest wall restriction.

Thoracic compliance depends on the ratio of tidal volume to the elastic recoil pressure (i.e. plateau pressure). Two grouping of factors determine lung compliance: elasticity of the lung tissue and surface tensions at air water interfaces (lung surfactants).

Lungs with low compliance or “stiff lungs” can be caused by a variety of factors including:

* Alterations in the ribs (i.e. fractures)
* Ossification of the costal cartilage
* Obesity
* Muscular or neural changes to intercostal muscles (i.e. paralysis or strain/pain)
* Position (prone/supine)
* Structural abnormalities (i.e. kyphosis or scoliosis)
* Increased intra-abdominal pressure
* Age
* Examples: COPD, Emphysema, pulmonary fibrosis, tobacco smokers

Patients requiring PEEP (non or invasive ventilation) also have an added benefit while in prone position to assist in lung recruitment of atelectasis.

Who to Prone? Probably Everyone with COVID-19

Patients Discharged with Mild Hypoxia

These are patients who are being discharged with mild hypoxia of 88-93%RA depending on their pre-existing conditions and work of breathing. These patients should be discharged with home oxygen tanks, incentive spirometers, home pulse oximetry meters.

In a pre-COVID-19 world, these patients would most likely be admitted for observation at a minimum.

(TheoreticalBreathing exercises utilizing prone positioning may provide easier breaths and/or used as preventative measures by exercising the lungs. Deep breathing exercises can help cough up secretions. *It’s what I did for my own at home care.  To be clear, no evidence to support this.

Click here for my At Home Breathing Exercises Handout available for

download. English and Spanish versions available!

I believe in proning so much that I created these exercises in combination with my knowledge of Iyengar Yoga for my own COVID-19 recovery when I experienced mild shortness of breath and hypoxia 92-93%. I found a lot of relief with these exercises which I have shared privately but with encouragement, here it is:

Feel free to use and distribute it. No need to ask for permission, it’s given. 


Below is the tweet that started it all:


Patients Requiring Oxygen and/or PEEP including “Happy Hypoxics”

These are patients who require a hospital admission because their oxygen requirements are much higher and/or work of breathing is increased.

“Happy Hypoxics” are patients who walk in and say they feel “fine” but their oxygen saturations are low, HR normal, RR may be slightly or more increased. Regardless, their mentation is normal and intact. These are also patients where delayed intubation may be beneficial despite having low oxygen saturations (i.e. 65%-85%RA) with corresponding low PaO2 on blood gas samples. They require oxygen at the minimum. Inclusion of PEEP may be required; high flow nasal cannula (HFNC) or continuous positive airway pressure (CPAP).

Other patients may be in this category and are “Unhappy Hypoxics” but may be waiting for a ventilator depending on your resources.

Proning these patients may have an immediate increase of measured oxygen saturation and most are able to tolerate lying on their bellies. They should stay in this position for as long as they can. These are generally your walkie talkies – so they have the ability to move around on their own.

You should still check up on them, and often. Especially your “Unhappy Hypoxics.”

Intubated Patients

Patients intubated with COVID-19 will benefit from prone position to assist with lung recruitment of atelectasis as discussed earlier. Patients who are on ECMO also will benefit from proning.

These patients require 12-16+ hours of proning.

Proning teams are probably the best method for ICU or EDICU settings because it requires a lot of coordination with several HCWs. A lot can go wrong.

Here’s a video from a UK ECMO team on how to manually prone patients. There are proning beds/equipment but may be unrealistic during a pandemic.

Alternative Proning Positions
What if your patient is unable to tolerate lying on their bellies?

* Pregnancy mattresses – Mattresses with cutouts for larger bellies.
* Lying down in a lateral position or sideways.
* Sitting on a chair with legs a little wider and leaning forward against a bed. I thought about this for awhile while I have been sick and had mild hypoxia with extreme fatigue. This was the easiest position I could sustain for a long period of time.

Illustration by Yasmina Alexandra Nysten


We don’t have a lot of great research on this. Currently a lot of this is theoretical and/or anecdotal. This means, we’re making educated guesses!

We need more research on this, especially with our awake proning and breathing exercises with proning. Prior to this COVID-19 pandemic, I don’t think any of us thought something as simple as body positioning would have such a large effect seen in patients by bedside clinicians. We really need further research on proning.

Some of these positions I came up with while recovering from COVID-19 including shortness of breath with hypoxia 92-93%RA with tachycardia. I’ve been practicing Iyengar yoga regularly for 8 years and decided to combine my knowledge of both yoga, pranayama (breathing exercises) and nursing. No proper research done.


Chiumello, D., Cressoni, M., Racagni, M., Landi, L., Li Bassi, G., Polli, F., Carlesso, E., & Gattinoni, L. (2006). Effects of thoraco-pelvic supports during prone position in patients with acute lung injury/acute respiratory distress syndrome: a physiological study. Critical care (London, England), 10(3), R87.

GST. (2018, May 8). GST-Proning the intensive care patient [Video]. YouTube.

Ding, L., Wang, L., Ma, W. et al. Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study. Crit Care 24, 28 (2020).

Marino, P. (2007). The ICU Book (3rd ed.). Lippincott Williams & Wilkins.

Morales, D. [@RNCSantander’. (2020, March 22). Puede ser util [Tweet]. Twitter.

Sun, Q., Qiu, H., Huang, M. et al. Lower mortality of COVID-19 by early recognition and intervention: experience from Jiangsu Province. Ann. Intensive Care 10, 33 (2020).

OpenAnesthesia. (2020).


Cite this post as
Dirsa, Yun Cee. April 28, 2020. Proning as Part of Your COVID-19 Bundle. Resus Nurse Podcast and Blog. Date retrieved June 22, 2021.

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