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
Design: Single-center prospective case
Setting: Tertiary-level pediatric ICU.
Patients: Consecutive patients with bilateral
pulmonary parenchymal disease requiring intubation and mechanical
ventilation with a Pao2/fraction of inspired
oxygen (Fio2) 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
Pao2/Fio2 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
(Spo2) of > 10% from values obtained
when in the supine position, failed to keep their
Spo2 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%).
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