Effect of body position on the blood gases and ventilation volume of infants with chronic lung disease before and after feeding. Effects of body position on blood gases and lung mechanics of infants with chronic lung disease during tube feeding. Effect of prone positioning on clinical outcomes in children with acute lung injury: a randomized controlled trial. Effect of nursing in the head elevated tilt position (15 degrees) on the incidence of bradycardic and hypoxemic episodes in preterm infants. The effect of body position on the respiratory rate of infants with tachypnea. Postural effects on pulmonary function and heart rate of preterm infants with lung disease. Prone positioning decreases episodes of hypoxemia in extremely low birth weight infants (1000 grams or less) with chronic lung disease. Pulmonary mechanics and gas exchange: effect of lateral positioning during recovery from respiratory distress syndrome. The effect of positioning on arterial oxygenation in children with atelectasis after cardiac surgery. Does supine positioning increase apnea, bradycardia, and desaturation in preterm infants? Effects of position changes on transcutaneous carbon dioxide tension in neonates with respiratory distress. [Effect of preterm infant position on weaning from mechanical ventilation]. Positioning infants with hyaline membrane disease. Prone position and reduced thoracoabdominal asynchrony in preterm newborns. Lateral positioning of the stable ventilated very-low-birth-weight infant. Effect on transcutaneous oxygen and carbon dioxide. Effect of position on the mechanical interaction between the rib cage and abdomen in preterm infants. Postural effects on gas exchange in infants. Transcutaneous oxygen saturation in sleeping infants: prone and supine. Effect of posture on oxygenation, lung volume, and respiratory mechanics in premature infants studied before discharge. 4A randomized trial of prolonged prone positioning in children with acute respiratory failure.
The effect of body position before and after tube feeding was evaluated in six extremely immature infants who were being mechanically ventilated because of chronic lung disease. Their mean birthweight and gestational age were 722.7 g (range, 540 to 994) and 24.9 weeks (range, 23.9 to 26.0), respectively. This study was performed at a mean postnatal age of 47.5 days (range, 21 to 85 days). The prone position resulted in a significant increase in arterial oxygen saturation before and after feeding, whereas the tidal volume demonstrated an increase only before feeding. Also the prone position showed a significant decrease in heart rate before and after feeding and a tendency to decrease transcutaneous carbon dioxide tension values before feeding. There were no significant differences in minute ventilation despite increased tidal volume in the prone position, most likely due to a decrement of the spontaneous respiratory rate in the prone positioning. We conclude that the prone position may offer an advantage over the supine position in the management of extremely immature infants with chronic lung disease before and after feeding. The effects of body position and feeding on lung mechanics and blood gases in very low birthweight infants with chronic lung disease (CLD) is not fully elucidated.
                Seven very low birthweight infants who were being mechanically ventilated because of CLD were examined. They were enrolled in this study when their feeding volume exceeded 100 mL/kg per day. Each patient was kept on the same position (either prone or supine) during feeding. Feeding was given by a nasogastric tube for over 1 h every 3 h. Blood gases and lung mechanics were evaluated before, 20 min and 40 min after the initiation of the feeding and at the end of the feeding.
                The prone position resulted in a significant increase in arterial oxygen saturation during feeding. The tidal volume in the prone position was significantly larger than in the supine position only before feeding. There were no significant differences in minute ventilation between these positions during the study. Pulmonary resistance was not different in either position, but the static compliance and the work of breathing of spontaneous breaths were improved significantly when the infants were in the prone position. In the supine position, work of breathing increased and static compliance decreased significantly with time, while in the prone position, those values did not change significantly.
                The improvement in lung mechanics may partly explain better oxygenation obtained in the prone position. The prone position could decrease energy expenditure for spontaneous breathing and may shorten the period of ventilatory support for very low birthweight infants with CLD. In uncontrolled clinical studies, prone positioning appeared to be safe and to improve oxygenation in pediatric patients with acute lung injury. However, the effect of prone positioning on clinical outcomes in children is not known.
                To test the hypothesis that at the end of 28 days infants and children with acute lung injury treated with prone positioning would have more ventilator-free days than those treated with supine positioning.
                Multicenter, randomized, controlled clinical trial conducted from August 28, 2001, to April 23, 2004, of 102 pediatric patients from 7 US pediatric intensive care units aged 2 weeks to 18 years who were treated with supine vs prone positioning. Randomization was concealed and group assignment was not blinded.
                Patients were randomized to either supine or prone positioning within 48 hours of meeting acute lung injury criteria, with those patients in the prone group being positioned within 4 hours of randomization and remaining prone for 20 hours each day during the acute phase of their illness for a maximum of 7 days, after which they were positioned supine. Both groups were treated using lung protective ventilator and sedation protocols, extubation readiness testing, and hemodynamic, nutrition, and skin care guidelines.
                Ventilator-free days to day 28.
                The trial was stopped at the planned interim analysis on the basis of the prespecified futility stopping rule. There were no differences in the number of ventilator-free days between the 2 groups (mean [SD], 15.8 [8.5] supine vs 15.6 [8.6] prone; mean difference, -0.2 days; 95% CI, -3.6 to 3.2; P = .91). After controlling for age, Pediatric Risk of Mortality III score, direct vs indirect acute lung injury, and mode of mechanical ventilation at enrollment, the adjusted difference in ventilator-free days was 0.3 days (95% CI, -3.0 to 3.5; P = .87). There were no differences in the secondary end points, including proportion alive and ventilator-free on day 28 (P = .45), mortality from all causes (P>.99), the time to recovery of lung injury (P = .78), organ-failure-free days (P = .88), and cognitive impairment (P = .16) or overall functional health (P = .12) at hospital discharge or on day 28.
                Prone positioning does not significantly reduce ventilator-free days or improve other clinical outcomes in pediatric patients with acute lung injury. We investigated whether nursing in the head elevated tilt position (HETP), compared with the horizontal position, has any effect on the incidence of bradycardic and hypoxemic episodes in preterm infants.
                Twelve spontaneously breathing preterm infants with idiopathic recurrent apnea were studied in a randomized controlled crossover trial. Nine infants were treated with aminophylline. Each spent a total of 24 hours in the horizontal prone position and a total of 24 hours in HETP (prone, 15 degrees). The position was changed in random order every 6 hours. Thoracic impedance, heart rate, and arterial oxygen saturation were recorded continuously. The frequency of isolated hypoxemia (arterial saturation <80%), of isolated bradycardia (heart rate <90 beats per minute), and of mixed events was analyzed and compared without knowledge of the allocated position.
                In total, there were significantly fewer bradycardic and/or hypoxemic episodes (28.2%) in HETP compared with the horizontal position (mean difference, 13.35 episodes/24 hours; 95% confidence interval [CI]: 5.9- 20.8). The decrease was largest for isolated hypoxemic episodes (48.5%; mean difference, 11.74 episodes/24 hours; 95% CI: 6.1-17.4). Isolated bradycardic episodes (mean difference, 2.27 episodes/24 hours; 95% CI: -0.78-5.31) and mixed events were not decreased significantly in HETP.
                Nursing in a moderately tilted position (15 degrees) reduces hypoxemic events in preterm infants. This intervention is easy to apply, quickly reversible, and can be combined with drugs such as aminophylline. In neonatal disease states where lung compliance is reduced (e.g., inadequate resorption of fetal lung fluid or, surfactant deficiency) an infant's normally low functional residual capacity (FRC) decreases even further. Tachypnea is an efficient compensatory maneuver for the newborn. We evaluated the effect of different bed and body positions on the increased respiratory rate observed in infants with transient tachypnea of the newborn (TTN), infant respiratory distress syndrome (RDS), and bronchopulmonary dysplasia (BPD). Seventeen infants were studied (TTN, n = 6; RDS, n = 6; BPD, n = 5) in four different positions: supine flat, supine elevated, prone flat, and prone elevated. Respiratory rate and heart rate were evaluated in each position. Analysis of variance for the three patient groups showed a lower respiratory rate when the bed was elevated 20-30 degrees compared to flat (P = 0.0001), in the prone posture compared to supine (P = 0.031), and no significant difference in heart rate. The lowest mean respiratory rate occurred when patients were in the prone elevated position. The significant improvement in tachypnea seen in the prone and elevated positions was likely related to improved FRC resulting from reduced cephalad stress on the diaphragm from the abdomen. Positioning neonatal patients with respiratory insufficiency was a simple and safe therapeutic maneuver with prompt and demonstrable benefit. nan Extremely low birth weight infants with chronic lung disease (CLD) have frequent episodes of desaturation (hypoxemia). We quantified oxygenation and episodes of hypoxemia in 55 infants (birth weight < or = 1000 gm) with CLD in the supine versus prone position, for 1-hour time intervals. Oxygen saturation was measured with the Nellcor N-200 pulse oximeter and a computer program. Prone positioning increased oxygen saturation from 92.0% to 94.1% (p < 0.001) and significantly decreased episodes of hypoxemia to oxygen saturation levels of less than 90%, 85%, and 80% (p < 0.001). Our findings support prone positioning for the extremely low birth weight infant with CLD in an intensive care setting. Sixteen stable intubated premature infants without a clinically significant patent ductus arteriosus were studied during recovery from respiratory distress syndrome in order to determine the effects of left and right lateral, as compared to supine, positioning. Pulmonary mechanics were measured for spontaneous breaths 5 and 15 minutes after positioning, and arterial blood gases 15 minutes after positioning. Infants were randomized to 1 of 2 position sequences: (1) supine, left, supine, right or (2) supine, right, supine, left. No significant differences were detected between positions for dynamic compliance, tidal volume/kg, and total, inspiratory and expiratory pulmonary resistance. Likewise, no significant differences in PaO2 or PaCO2 were detected between the positions. The sequence of positions did not affect the pulmonary mechanics of spontaneous breaths or arterial blood gases. This suggest that short-term lateral positioning as well as supine positioning can be utilized without deleterious effects on pulmonary mechanics and gas exchange in neonates recovering from respiratory distress syndrome. To determine the effect of body position on arterial oxygenation in children with unilateral atelectasis after cardiac surgery.
                Prospective, quasi-experimental, random assignment.
                Midwestern university-affiliated tertiary pediatric medical center.
                25 children who underwent cardiac surgery and who presented with unilateral atelectasis within 2 weeks of operation. Age range was one month to 10 years (mean 34 months).
                The partial pressure of oxygen.
                Data collection was initiated within 24 hours of the diagnosed unilateral atelectasis. Arterial blood gases were drawn from intraarterial lines after subjects were placed for 15 minutes in the supine, right lateral, and left lateral decubitus positions (atelectatic lung dependent or nondependent), the order being randomized.
                Analysis of variance for repeated measures was used in the data analysis. The mean PaO2 for the supine, nondependent, and dependent positions were 115, 118, and 112, respectively. No statistical differences at p less than 0.05 level of significance were demonstrated for the body positions under study. Age and degree of atelectasis were analyzed as covariates to determine the possible correlation with the PaO2 and the change in PaO2. Age inversely correlated with the PaO2, r = -0.24 (p less than 0.05), indicating the older subjects had a lower PaO2. The degree of atelectasis demonstrated correlation with the change in PaO2, r = -0.26 (p less than 0.05) indicating the subjects with greater degree of atelectasis had a lesser change in PaO2.
                These results differ from similar studies on the effect of positioning in adult subjects. This finding suggests that the effect of positioning of children who have had cardiac surgery should be evaluated on an individual basis with close monitoring for changes in clinical condition and oxygen saturation and periodic arterial oxygen blood sampling until further studies can provide conclusive direction. The purpose of this study was to determine the effects of prone and supine positioning on the cardiorespiratory stability of preterm infants with apnea and bradycardia.
                A total of 22 preterm infants with symptomatic apnea and bradycardia (gestational age of 26.9 +/- 1.8 weeks and birth weight of 865 +/- 235 gm) were monitored for 24 hours (in four sequential 6-hour blocks) for apnea, bradycardia, and oxygen desaturation in alternating positions (prone or supine) following randomization. Postconceptional age at the time of study was 31.9 +/- 3.0 weeks. Respiratory rate, heart rate, and transcutaneous oxygen saturation were continuously monitored. All episodes of apnea (> or = 10 seconds), bradycardia (< 100 beats per minute), and oxygen desaturation (< 90%) were recorded on an event monitor. Episodes of apnea, bradycardia, and oxygen desaturation were defined as clinically significant if the following criteria were met: apnea, > or = 15 seconds; bradycardia, < 90 beats per minute; and oxygen desaturation, < 80%. All other recorded episodes were considered mild. The episodes were analyzed for statistical significance using the paired t-test.
                No significant differences (p > 0.05) in the incidence of clinically significant apnea, bradycardia, or desaturation between supine and prone positions were seen in these preterm infants.
                Our results suggest that the cardiorespiratory stability of preterm infants is not significantly compromised by supine positioning. Routine neonatal care includes frequent position changes. Recent research has concluded that positions other than supine may result in beneficial physiologic responses. Specifically, several studies suggest that neonates may ventilate more effectively in a prone rather than in a supine position. This study tested the hypothesis that transcutaneous carbon dioxide tension (TcPCO2) would be lower in the prone than in the supine position in neonates with respiratory distress. Fourteen ventilated infants were studied. TcPCO2 was measured and recorded in prone, supine, and right-side-lying positions for each subject. There were no statistically significant differences in mean TcPCO2 values between the three positions (F = .45; df 2,39; P = .64). The relationship between TcPCO2 and PaCO2 values was stable (r = .88) during the studies. The results indicate that changing a neonate's position does not significantly alter transcutaneous carbon dioxide tension. To determine the effects of prone positioning on cardiorespiratory stability and weaning outcome of preterm infants during weaning from mechanical ventilation.
                From January to December 1999, a sample of 42 preterm infants, with birthweight < 2,000 g, mechanically ventilated in the first week of life, were randomly divided, in the beginning of the weaning process, into two groups according to the position: supine position (n = 21) or prone position (n = 21). Heart rate, respiratory rate, transcutaneous oxygen saturation and ventilatory parameters were recorded every one hour. Length of the weaning process and complications were also assessed.
                In both groups the mean gestational age was 29 weeks, most of the patients presented very low birthweight and respiratory distress syndrome. The mean length of the weaning process was 2 days. There were no differences between the groups regarding respiratory rate, heart rate and transcutaneous oxygen saturation, however, oxygen desaturation episodes were more frequent in supine position (p = 0.009). Ventilatory parameters decreased faster and reintubation was less frequent in the prone group (4% versus 33%). No adverse effects of prone positioning were observed.
                These results suggest that prone position is a safe and beneficial procedure during weaning from mechanical ventilation and may contribute to weaning success in preterm infants. nan To assess the effect of prone and supine positions on breathing pattern variables, thoracoabdominal motion and peripheral oxygen saturation of hemoglobin of premature newborn infants recovering from respiratory distress syndrome, while breathing spontaneously and in rapid eye movement sleep.
                This was a quasi-experimental study. Twelve preterms weighing > 1,000 g at enrollment were studied in both positions, in random order. Respiratory inductive plethysmography was used to analyze breathing pattern (tidal volume, respiratory rate, minute ventilation, mean inspiratory flow) and thoracoabdominal motion (labored breathing index, phase relation in inspiration, phase relation in expiration, phase relation in total breath and phase angle). Pulse oximetry was used to evaluate peripheral oxygen saturation. Student's t test for paired samples or the Wilcoxon test were used for statistical analysis. Significance was set at p < 0.05.
                A total of 9,167 respiratory cycles were analyzed. The prone position was associated with significant reductions in labored breathing index (-0.84+/-0.69; p = 0.001; 95%CI -1.29 to -0.40), phase relation in inspiration (-27.36+/-17.55; p = 0.000; 95%CI -38.51 to -16.20), phase relation in expiration (-32.36+/-16.20; p = 0.000; 95%CI -42.65 to -22.06) and phase relation in total breath (-30.20+/-14.76; p = 0.000; 95%CI -39.59 to -20.82). There were no significant differences between the two positions in any of the other variables analyzed.
                The prone position resulted in a significant reduction in thoracoabdominal asynchrony, without affecting breathing pattern or peripheral oxygen saturation. Eighteen stable very-low-birth-weight (VLBW) mechanically ventilated infants with chronic lung disease were studied to examine the effects of right and left lateral positioning in contrast to supine positioning on transcutaneous (tc) oxygen (tcPO2) and carbon dioxide measurements (tcPCO2). The neonates were studied at a median postnatal age of 31 days (range, 17 to 57 days) and had median birth weights and gestational ages of 975 g (range, 570 to 1360 g) and 27.5 weeks (range, 24 to 30 weeks), respectively. Median fraction of inspiratory oxygen was 0.32 (range, 0.23 to 0.40). The sequence of study positions was randomly determined. Sleep state as well as tcPO2 and tcPCO2 were recorded every 30 s for five minutes. A significant difference in mean tcPO2 or tcPCO2 was not detected for any of the positions. Lateral positioning may facilitate the development of midline behavior in VLBW infants. Care givers are often reluctant to position infants in side lying, however, because of concerns that ventilation or oxygenation might be compromised. We conclude that placing the stable VLBW mechanically ventilated infant in a side-lying position has no deleterious effects on oxygenation and ventilation, as measured by tcPO2 and tcPCO2, and therefore should be encouraged. To determine the influence of body position on chest wall and pulmonary function, we studied the ventilatory, pulmonary mechanics, and thoracoabdominal motion profiles in 20 preterm infants recovering from respiratory disease who were positioned in both the supine and prone position. Thoracoabdominal motion was assessed from measurements of relative rib cage and abdominal movement and the calculated phase angle (an index of thoracoabdominal synchrony) of the rib and abdomen Lissajous figures. The ventilatory and pulmonary function profiles were assessed from simultaneous measurements of transpulmonary pressure, airflow, and tidal volume. The infants were studied in quiet sleep, and the order of positioning was randomized across patients. The results demonstrated no significant difference in ventilatory and pulmonary function measurements as a function of position. In contrast, there was a significant reduction (-49%) in the phase angle of the Lissajous figures and an increase (+66%) in rib cage motion in prone compared with the supine position. In addition, the degree of improvement in phase angle in the prone position was correlated to the severity of asynchrony in the supine position. We speculate that the improvement in thoracoabdominal synchrony in the prone position is related to alterations of chest wall mechanics and respiratory muscle tone mediated by a posturally related shift in the area of apposition of the diaphragm to the anterior inner rib cage wall and increase in passive tension of the muscles of the rib cage. This study suggests that the mechanical advantage associated with prone positioning may confer a useful alternative breathing pattern to the preterm infant in whom elevated respiratory work loads and respiratory musculoskeletal immaturity may predispose to respiratory failure. In adults with unilateral lung disease, pulmonary gas exchange is better when the patients is positioned with the good lung dependent. We studied the effects of body position on gas exchange in 10 infants with unilateral lung disease by measuring transcutaneous oxygen and carbon dioxide pressures in the supine and right and left lateral positions. We also performed krypton lung scans and measured changes in thoracic gas volumes in four of the infants. Transcutaneous oxygen pressure (mean +/- S.E.) was greater with the good lung uppermost (82 +/- 7.6 mm Hg) than with the good lung dependent (73 +/- 7 mm Hg) (P less than 0.02) or in the supine position (78 +/- 7 mm Hg). There were no changes in transcutaneous carbon dioxide pressure. The proportion of ventilation to the good lung was greater with the good lung uppermost than with the good lung dependent (P less than 0.01) or in the supine position (P less than 0.02) (64 +/- 3, 46 +/- 6, and 59 +/- 7 per cent, respectively). There were no significant changes with position in functional residual capacity, tidal volume, or dynamic lung compliance. We conclude that oxygenation in infants with unilateral lung disease is best with the good lung uppermost--the reverse of what has been observed in adults. Pulse oximetry was used to measure transcutaneous arterial oxygen saturation in infants aged 2 to 11 months prone and supine in quiet sleep. Groups of healthy infants (n = 34), infants with upper respiratory tract infections (n = 13), and infants with generalised moderately severe lower respiratory tract infections (n = 17) were studied. No clinically important differences were demonstrated in any of these groups, although there was a small advantage in the prone position in the group with lower respiratory tract infection. The effect of posture on infants with more severe lower respiratory tract infection and during active sleep has yet to be determined. To determine if the prone versus the supine posture was associated with higher oxygenation levels in prematurely born infants before discharge, whether any such effect was explained by alterations in lung volume or respiratory mechanics, and if the changes were greater in oxygen-dependent infants.
                Twenty infants (10 oxygen-dependent), median gestational age 30 (range: 27-32) weeks, were studied at a median postconceptional age of 35 weeks (range: 32-38 weeks).
                On 2 successive days, infants were studied both supine and prone; each posture was maintained for 3 hours. Oxygen saturation was continuously monitored and at the end of each 3-hour period; compliance and resistance of the respiratory system and functional residual capacity (FRC) were measured.
                Overall, the median oxygen saturation and FRC were significantly higher in the prone position; compliance of the respiratory system and resistance of the respiratory system were not significantly affected by posture. Differences in oxygen saturation and FRC were significantly higher in the prone posture in the oxygen-dependent, but not the nonoxygen-dependent infants.
                Superior oxygenation in the prone posture in oxygen-dependent premature infants studied before discharge could be explained by higher lung volumes. To compare the effect of the prone position (PP) vs supine position (SP) on oxygenation in children with acute respiratory failure (ARF).
                Prospective, randomized controlled trial.
                A 36-bed pediatric critical-care unit in a tertiary-care, university-based children's hospital.
                Ten children (mean [SD] age, 5 +/- 3.6 years) with ARF with a baseline oxygenation index (OI) of 22 +/- 8.5.
                Following a period of stabilization in the SP, baseline data were collected and patients were randomized to one of two groups in a two-crossover study design: group 1, supine/prone sequence; group 2, prone/supine sequence. Each position was maintained for 12 h. Lung mechanics and acute response to inhaled nitric oxide were examined in each position.
                OI was significantly better in the PP compared to the SP over the 12-h period (analysis of variance, p = 0.0016). When patients were prone, a significant improvement in OI was detected (7.9 +/- 5.3; p = 0.002); this improvement occurred early (within 2 h in 9 of 10 patients) and was sustained over the 12-h study period. Static respiratory system compliance and resistance were not significantly affected by the position change. Inhaled nitric oxide had no effect on oxygenation in either position. Urine output increased while prone, resulting in a significantly improved fluid balance (+ 6.6 +/- 15.2 mL/kg/12 h in PP vs + 18.9 +/- 13.6 mL/kg/12 h in SP; p = 0.041). No serious adverse effects were detected in the PP.
                In children with ARF, oxygenation is significantly superior in the PP than in the SP. This improvement occurs early, remains sustained for a 12-h period, and is independent of changes in lung mechanics.
The prone position was significantly superior to the supine position in terms of oxygenation. However, as most participants were ventilated preterm infants, the benefits of prone positioning may be most relevant to these infants. In addition, although placing infants and children in the prone position may improve respiratory function, the association of SIDS with prone positioning means that infants should only be placed in this position while under continuous cardiorespiratory monitoring.