In patients with acute respiratory distress syndrome, prone positioning improves oxygenation and reduces mortality. Pressure injuries occur frequently because of prolonged prone positioning in high-risk patients, and preventive measures are limited. This article describes 2 patients who developed minimal pressure injuries despite several prone positionings. Prevention strategies are also described.

Clinical Findings

A 64-year-old man and a 76-year-old woman were admitted to the hospital with respiratory insufficiency. Due to acute respiratory distress syndrome, both patients were intubated and received mechanical ventilation and prone positioning.


Both patients had positive test results for SARS-CoV-2 and a diagnosis of acute respiratory distress syndrome.


Patient 1 was in prone position for 137 hours during 9 rounds of prone positioning; patient 2, for 99 hours during 6 rounds of prone positioning. The standardized pressure injury prevention bundle for prone positioning consisted of skin care, nipple protection with a multilayer foam dressing, a 2-part prone positioning set, and micropositioning maneuvers. For both patients, 2-cm-thick mixed-porosity polyurethane foam was added between skin and positioning set in the thoracic and pelvic areas and a polyurethane foam cushion was added under the head.


Patient 1 developed no pressure injuries. Patient 2 developed category 2 pressure injuries on the chin and above the right eye during deviations from the protocol.


For both patients, the additional application of polyurethane foam was effective for preventing pressure injuries. These case reports support the addition of polyurethane foam to prevent pressure injuries in patients placed in the prone position.

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