Risk management of enteral nutrition-related complications in patients undergoing prone-position ventilation: a narrative review

Prone position ventilation (PPV) is a strategy for improving oxygenation in patients with severe hypoxemia, particularly those with acute respiratory distress syndrome. By redistributing transpulmonary pressure, improving ventilation-perfusion matching, and optimizing respiratory mechanics, prone positioning can improve oxygenation and clinical outcomes in selected critically ill patients. However, patients undergoing prone-position ventilation often present with severe disease, hypermetabolism, prolonged mechanical ventilation, and increased nutritional requirements. Early enteral nutrition is generally preferred when hemodynamic status is stable because it helps maintain intestinal mucosal integrity, supports immune function, and reduces the risk of nutrition-related deterioration. Despite these benefits, enteral nutrition during prone-position ventilation remains clinically challenging. Prone positioning, deep sedation, analgesia, neuromuscular blockade, delayed gastric emptying, impaired gastrointestinal motility, and increased intra-abdominal pressure may contribute to feeding intolerance and enteral nutrition-related complications, including high gastric residual volume, vomiting, gastroesophageal reflux, aspiration, diarrhea, feeding interruption, and ventilator-associated pneumonia (VAP). These complications may compromise nutritional delivery, prolong mechanical ventilation, and adversely affect prognosis. This review summarizes the pathophysiological mechanisms, major risk factors, clinical assessment indicators, and preventive management strategies for enteral nutrition-related complications in patients undergoing prone-position ventilation. Particular attention is given to glycemic control, intra-abdominal pressure monitoring, medication-related gastrointestinal dysfunction, nutritional biomarkers, endotracheal tube cuff pressure, feeding route selection, gastric residual volume assessment, post-pyloric feeding, prokinetic therapy, and positioning management. By integrating evidence and clinical practice considerations, this review aims to provide a practical framework for risk identification, early prevention, dynamic monitoring, and multidisciplinary management of enteral nutrition-related complications during prone-position ventilation.