Guidance for: Prone positioning in adult critical care. 2019. (accessed 9 February 2022)

Bloomfield R, Noble DW, Sudlow A. Prone position for acute respiratory failure in adults. Cochrane Database Syst Rev. 2015; 2015:(11)

Pressure injury prevention: PIP tips for prone positioning. 2020. (accessed 10 February 2022)

Demarré L, Verhaeghe S, Annemans L, Van Hecke A, Grypdonck M, Beeckman D. The cost of pressure ulcer prevention and treatment in hospitals and nursing homes in Flanders: A cost-of-illness study. Int J Nurs Stud. 2015; 52:(7)1166-1179

Gefen A, Ousey K. Update to device-related pressure ulcers: SECURE prevention. COVID-19, face masks and skin damage. J Wound Care. 2020a; 29:(5)245-259

Gefen A, Ousey K. COVID-19, fever and dressings used for pressure ulcer prevention: monthly update. J Wound Care. 2020b; 29:(8)430-431

Gefen A, Alves P, Ciprandi G Device-related pressure ulcers: SECURE prevention. J Wound Care. 2020; 29:S1-S52

Guest J, Fuller G, Vowden P Cohort study evaluating pressure ulcer management in clinical practice in the UK following initial presentation in the community: costs and outcomes. BMJ Open. 2018;

Girard R, Baboi L, Ayzac L, Richard JC, Guérin C The impact of patient positioning on pressure ulcers in patients with severe ARDS: results from a multicentre randomised controlled trial on prone positioning. Intensive Care Med. 2014; 40:(3)397-403

Guan W, Ni Z, Hu Y Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020; 382:(18)1708-1720

Heale R, Twycross A. What is a case study?. Evid Based Nurs. 2018; 21:(1)7-8

Hocková B, Riad A, Valky J Oral complications of ICU patients with COVID-19: case-series and review of two hundred ten cases. J Clin Med. 2021; 10:(4)

Jiang ST, Fang CH, Chen JT, Smith RV. The face of COVID-19: facial pressure wounds related to prone positioning in patients undergoing ventilation in the intensive care unit. Otolaryngol Head Neck Surg. 2021; 164:(2)300-301

Joanna Briggs Institute Levels of Evidence and Grades of Recommendation Working Party. Supporting document for the Joanna Briggs Institute levels of evidence and grades of recommendation. 2014. (accessed 14 February 2022)

Luck L, Jackson D, Usher K. Case study: a bridge across the paradigms. Nurs Inq. 2006; 13:(2)103-109

Mahalingam S, Gao L, Nageshwaran S, Vickers C, Bottomley T, Grewal P. Improving pressure ulcer risk assessment and management using the Waterlow scale at a London teaching hospital. J Wound Care. 2014; 23:(12)613-622

Martel T, Orgill DP. Medical device–related pressure injuries during the COVID-19 pandemic. J Wound Ostomy Continence Nurs. 2020; 47:(5)430-434

Mölnlycke Healthcare. Z-flo fluidised positioner (instructions for use). 2019. (accessed 10 February 2022)

Moore Z, Patton D, Avsar P Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the COVID-19 emergency. J Wound Care. 2020; 29:(6)312-320

National Institute for Health and Care Excellence. Pressure ulcers: prevention and management. Clinical guideline CG179. 2014. (accessed 10 February 2022)

Peko L, Barakat-Johnson M, Gefen A. Protecting prone positioned patients from facial pressure ulcers using prophylactic dressings: A timely biomechanical analysis in the context of the COVID-19 pandemic. Int Wound J. 2020; 17:(6)1595-1606

Percy P. Initial observations on pressure ulcers and COVID-19. Wounds UK. 2020; 16:(4)45-47

Perrillat A, Foletti JM, Lacagne AS, Guyot L, Graillon N. Facial pressure ulcers in COVID-19 patients undergoing prone positioning: how to prevent an underestimated epidemic?. J Stomatol Oral Maxillofac Surg. 2020; 121:(4)442-444

Shearer SC, Parsa KM, Newark A Facial pressure injuries from prone positioning in the COVID-19 era. Laryngoscope. 2021; 131:(7)E2139-E2142

Shelhamer MC, Wesson PD, Solari IL Prone positioning in moderate to severe acute respiratory distress syndrome due to COVID-19: a cohort study and analysis of physiology. J Intensive Care Med. 2021; 36:(2)241-252

Singh C, Tay J, Shoqirat N. Skin and mucosal damage in patients diagnosed with COVID-19. J Wound Ostomy Continence Nurs. 2020; 47:(5)435-438

Sleiwah A, Nair G, Mughal M, Lancaster K, Ahmad I. Perioral pressure ulcers in patients with COVID-19 requiring invasive mechanical ventilation. Eur J Plast Surg. 2020; 43:(6)727-732

Stephen-Haynes J, Maries M. Pressure ulcers and the prone position. Br J Nurs. 2020; 29:(12)

Worsley PR, Spratt F, Bader DL. COVID-19: challenging tissue viability in both patients and clinicians. J Tissue Viability. 2020; 29:(3)153-154

Facial ulcers in patients with COVID-19 admitted to ICU: review of the evidence

24 February 2022
Volume 31 · Issue 4



Many patients with COVID-19 admitted to intensive care undergo prone positioning. These patients are at risk of developing facial pressure ulcers (PUs). This study aimed to identify evidence-based recommendations to prevent or reduce their incidence.


A multi-case study was undertaken using secondary data published between November 2020 and April 2021 discussing facial PUs in patients with COVID-19. CINAHL and MEDLINE electronic databases were analysed. Sixteen publications met the inclusion criteria. The overall quality of evidence was low.


Studies reported a high incidence of facial PUs. The evidence suggests key preventive areas are skin assessment, pressure-redistribution surfaces, eye coverings, education, medical devices and prophylactic dressings. Recommendations included skin cleaning and moisturising, eye coverings, replacing endotracheal tube holders and using hydrocolloid or film dressings.


Considering the severe implications for patients and healthcare systems caused by facial PUs, ICUs should develop strategies to prevent and minimise them.

In December 2019, the first cases of pneumonia from a novel coronavirus were identified in Wuhan, China, and the pathogen was later named as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). According to official figures ( up to 1 March 2021, 4 182 009 people had tested positive in the UK, 439 352 of them requiring hospital admission. At the peak of COVID-19 admissions by the end of January 2021, more than 4000 occupied an intensive care unit (ICU) level 3 bed, those reserved for patients requiring either advanced respiratory support or two or more organ system support. Patients with COVID-19 often present with acute respiratory distress syndrome (ARDS), requiring management in the prone position for up to 16 hours, several times, which presents a challenge for health professionals to maintain skin integrity (Worsley et al, 2020).

Prone positioning is a postural therapy where the patient lies in a horizontal position facing down, which aims to enhance the oxygenation and lung compliance of patients who develop moderate or severe ARDS, a condition experienced by 67-85% of critically ill COVID-19 patients admitted to ICU (Moore et al, 2020; Stephen-Haynes and Maries, 2020). The APRONET analysis, a prospective international study performed between April 2016 and January 2017 in 141 ICUs from 20 countries, revealed that 32.9% of patients with serious ARDS were ventilated in the prone position for prolonged periods of time, increasing their risk of facial pressure ulcers (PUs) (Moore et al, 2020).

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