The Effects of Early and Repeated Prone Positioning in Pediatric Patients with Acute Lung Injury

Study Objective: To describe the physiologic changes and to evaluate the safety of placing pediatric patients with acute lung injury (ALI) prone for 20 h/d during the acute phase of their illness.

Design: Single-center prospective case series.

Setting: Tertiary-level pediatric ICU.

Patients: Consecutive patients with bilateral pulmonary parenchymal disease requiring intubation and mechanical ventilation with a PaO(2)/fraction of inspired oxygen (FIO(2)) ratio </= 300 mm Hg.

Interventions: Patients were enrolled as soon as possible after meeting criteria and were placed in a prone position for 20 h/d daily until clinical improvement or death occurred.

Measurements And Results: Twenty-five pediatric patients who had ALI/ARDS, ranging in age from 2 months to 17 years, were placed in a prone position within 19 h of meeting the study criteria for a median time of 4 days, which accounted for 47% of their time receiving mechanical ventilation. Eighty-four percent of patients (n = 21) were categorized as overall responders to prone positioning because they experienced more days of increases of >/= 20 mm Hg in PaO(2)/FIO(2) ratio or a decrease of >/= 10% in oxygenation index when shifted from a supine to a prone position during the study period. During the 107 patient-days and 214 positioning cycles, no critical incidents occurred. Furthermore, no patient experienced a persistent decrease in oxygen saturation as measured by pulse oximetry (SpO(2)) of > 10% from values obtained when in the supine position, failed to keep their SpO(2) at > 85%, or experienced an increased respiratory rate of > 40 breaths/min when prone. Using the COMFORT score, patients were objectively rated to be equally comfortable in both the supine and prone positions. Patients also were able to resume spontaneous ventilation and to progress toward endotracheal extubation while in the prone position. Iatrogenic injury associated with prolonged prone positioning included stage II pressure ulcers in six patients (24%).

Conclusions: The pediatric patients in this series demonstrated improvements in oxygenation without serious iatrogenic injury after prone positioning. This study provides a foundation for a prospective randomized study investigating the effect of early and repeated prone positioning on clinical outcomes in pediatric patients with ALI.