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A 35-year-old intoxicated male 179 cm tall and weighing 110 kg (BMI 34 kg·m−2) presents to the emergency room with a 12-inch hunting knife lodged in his upper thoracic spine after an altercation at a cottage party. Initial examination reveals normal vital signs in the prone position, a reassuring airway and normal screening neurological exam. Initial X-ray studies confirm the knife enters at the level of T3 to T4 and traverses the right side of the spinal canal with the tip of the knife embedded in the T4 vertebral body. The neurosurgeon wishes to take the patient to the operating room for an urgent wound exploration and removal of the foreign body under general anesthesia with careful continuous neurological monitoring throughout the procedure.


What Are Your Concerns When a Patient Is Placed in the Prone Position for a Surgical Procedure?

Proper patient positioning for any medical procedure is an important consideration for a safe and successful outcome. Proper positioning provides for appropriate surgical access and guards against injury due to pressure points and strain on neurological and musculoskeletal structures. The prone position is most commonly required for surgical procedures on the spine, and for selected procedures in neurosurgery, urology, and general surgery. This position is complicated by an increased risk of stretch and pressure injury of nerves, cardiovascular instability, difficulty with ventilation, and problems with providing cardio-pulmonary resuscitation1,2 as compared with the supine position. Airway considerations for patients in the prone position may include difficult access to the airway, migration of the endotracheal tube (ETT) cephalad or caudad with head extension and flexion respectively,3 changes in ETT cuff pressure,4 limited ability to reposition the head and neck for face-mask ventilation (FMV), and the potential development of airway edema.5

This case presents a challenging situation for airway practitioners: securing the airway in an urgent setting in which the patient cannot be easily positioned supine. Limited information is currently available in the literature to assist the airway practitioner with critical decision-making should they encounter this situation.


How Do You Provide Ventilation to a Patient in the Prone Position If Urgently Needed?

Options to manage the airway in a prone patient are similar to those in a supine patient. FMV should be considered the standard and attempted before other measures because the ease of FMV will guide all airway management decisions that follow. However, FMV in the prone patient can be difficult due to limited access to the airway, difficult mask seal due to no occipital support to apply counter pressure to the head,6 and lack of clinical experience performing FMV in a prone patient. It may be necessary to use a two person FMV technique, with one person achieving a mask seal using ...

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