Intensive Care Medicine

, Volume 40, Issue 3, pp 397–403 | Cite as

The impact of patient positioning on pressure ulcers in patients with severe ARDS: results from a multicentre randomised controlled trial on prone positioning

  • Raphaele Girard
  • Loredana Baboi
  • Louis Ayzac
  • Jean-Christophe Richard
  • Claude GuérinEmail author
  • for the Proseva trial group



Placing patients with severe acute respiratory distress syndrome (ARDS) in the prone position has been shown to improve survival as compared to the supine position. However, a higher frequency of pressure ulcers has been reported in patients in the prone position. The objective of this study was to verify the impact of prone positioning on pressure ulcers in patients with severe ARDS.


This was an ancillary study of a prospective multicentre randomised controlled trial in patients with severe ARDS in which the early application of long prone-positioning sessions was compared to supine positioning in terms of mortality. Pressure ulcers were assessed at the time of randomisation, 7 days later and on discharge from the intensive care unit (ICU), using the four-stage Pressure Ulcers Advisory Panel system. The primary end-point was the incidence (with reference to 1,000 days of invasive mechanical ventilation or 1,000 days of ICU stay) of new patients with pressure ulcers at stage 2 or higher from randomisation to ICU discharge.


At randomisation, of the 229 patients allocated to the supine position and the 237 patients allocated to the prone position, the number of patients with pressure ulcers was not significantly different between groups. The incidence of new patients with pressure ulcers from randomisation to ICU discharge was 20.80 and 14.26/1,000 days of invasive mechanical ventilation (P = 0.061) and 13.92 and 7.72/1,000 of ICU days (P = 0.002) in the prone and supine groups, respectively. Position group [odds ratio (OR) 1.5408, P = 0.0653], age >60 years (OR 1.5340, P = 0.0019), female gender (OR 0.5075, P = 0.019), body mass index of >28.4 kg/m2 (OR 1.9804, P = 0.0037), and a Simplified Acute Physiology Score II at inclusion of >46 (OR 1.2765, P = 0.3158) were the covariates independently associated to the acquisition of pressure ulcers.


In patients with severe ARDS, prone positioning was associated with a higher frequency of pressure ulcers than the supine position. Prone positioning improves survival in patients with severe ARDS and, therefore, survivors who received this intervention had a greater likelihood of having pressure ulcers documented as part of their follow-up. There are risk groups for the development of pressure ulcers in severe ARDS, and these patients need surveillance and active prevention.


ARDS Pressure ulcer Prone position Supine position 


Conflicts of interest

The authors declare no conflict of interest.

Supplementary material

134_2013_3188_MOESM1_ESM.doc (32 kb)
Supplementary material 1 (DOC 31 kb)
134_2013_3188_MOESM2_ESM.doc (38 kb)
Supplementary material 2 (DOC 38 kb)


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Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2013

Authors and Affiliations

  • Raphaele Girard
    • 1
    • 2
    • 3
  • Loredana Baboi
    • 1
    • 2
    • 3
  • Louis Ayzac
    • 1
    • 2
    • 3
  • Jean-Christophe Richard
    • 1
    • 2
    • 3
  • Claude Guérin
    • 1
    • 2
    • 3
    Email author
  • for the Proseva trial group
  1. 1.Réanimation MédicaleHôpital de la Croix-RousseLyonFrance
  2. 2.Service d’HygièneCentre Hospitalier Lyon-SudSaint-Genis LavalFrance
  3. 3.Centre Coordination et de Lutte contre les Infections Nosocomiales Sud-EstHôpital Henri GabrielleSaint-Genis LavalFrance

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