Critically ill patients who require ventilatory assistance are at risk for further lung injury from higher airway pressures and tidal volumes produced by mechanical ventilation. Prone positioning (laying the patient on his stomach) is used to improve ventilation-to-perfusion capacity and thereby decrease lung injury, but there has been no research to support its use in children. A nurse-led team of researchers conducted a multicenter clinical trial to determine whether keeping patients in the prone position rather than supine (on their backs) would result in fewer days of mechanical ventilation. They randomized critically ill pediatric patients ranging in age from two weeks to 18 years to be placed in either the prone or supine position.
Patients in the prone-position group remained in that position for 20 hours each day (for a maximum of seven days), while those assigned to the supine-position group remained in the supine position. All patients were assessed daily while supine, and the clinical teams followed strict protocols for sedation, ventilator management and weaning, and extubation. The primary outcome measure was ventilator-free days; others were mortality all from causes, organ failure, lung injury, and freedom from ventilation by day 28. The study was stopped at the interim analysis point, when 94 patients (47 in each group) had completed the 28-day study period, because there were no differences between the two groups in any of the outcome measures. Although most of the patients in the prone-position group showed improved oxygenation, that result was not associated with better outcomes.
Lead researcher Martha Curley, from Children's Hospital Boston, says that, "This is good news because we now know that critically ill children can be safely cared for in any position of comfort-prone or supine-and that changes in blood oxygen levels associated with the prone position do not equal improved outcomes."
Curley M, et al. JAMA 2005;294(2):229-37.