Background Acute respiratory distress syndrome (ARDS) is a significant cause of hospitalisation and death in young children. Positioning and mechanical ventilation have been regularly used to reduce respiratory distress and improve oxygenation in hospitalised patients. Due to the association of prone positioning (lying on the abdomen) with sudden infant death syndrome (SIDS) within the first six months, it is recommended that young infants be placed on their back (supine). However, prone positioning may be a non‐invasive way of increasing oxygenation in individuals with acute respiratory distress, and offers a more significant survival advantage in those who are mechanically ventilated. There are substantial differences in respiratory mechanics between adults and infants. While the respiratory tract undergoes significant development within the first two years of life, differences in airway physiology between adults and children become less prominent by six to eight years old. However, there is a reduced risk of SIDS during artificial ventilation in hospitalised infants. Thus, an updated review focusing on positioning for infants and young children with ARDS is warranted. This is an update of a review published in 2005, 2009, and 2012. Objectives To compare the effects of different body positions in hospitalised infants and children with acute respiratory distress syndrome aged between four weeks and 16 years. Search methods We searched CENTRAL, which contains the Acute Respiratory Infections Group's Specialised Register, MEDLINE, Embase, and CINAHL from January 2004 to July 2021. Selection criteria Randomised controlled trials (RCTs) or quasi‐RCTs comparing two or more positions for the management of infants and children hospitalised with ARDS. Data collection and analysis Two review authors independently extracted data from each study. We resolved differences by consensus, or referred to a third contributor to arbitrate. We analysed bivariate outcomes using an odds ratio (OR) and 95% confidence interval (CI). We analysed continuous outcomes using a mean difference (MD) and 95% CI. We used a fixed‐effect model, unless heterogeneity was significant (I2 statistic > 50%), when we used a random‐effects model. Main results We included six trials: four cross‐over trials, and two parallel randomised trials, with 198 participants aged between 4 weeks and 16 years, all but 15 of whom were mechanically ventilated. Four trials compared prone to supine positions. One trial compared the prone position to good‐lung dependent (where the person lies on the side of the healthy lung, e.g. if the right lung was healthy, they were made to lie on the right side), and independent (or non‐good‐lung independent, where the person lies on the opposite side to the healthy lung, e.g. if the right lung was healthy, they were made to lie on the left side) position. One trial compared good‐lung independent to good‐lung dependent positions. When the prone (with ventilators) and supine positions were compared, there was no information on episodes of apnoea or mortality due to respiratory events. There was no conclusive result in oxygen saturation (SaO2; MD 0.40 mmHg, 95% CI ‐1.22 to 2.66; 1 trial, 30 participants; very low certainty evidence); blood gases, PCO2 (MD 3.0 mmHg, 95% CI ‐1.93 to 7.93; 1 trial, 99 participants; low certainty evidence), or PO2 (MD 2 mmHg, 95% CI ‐5.29 to 9.29; 1 trial, 99 participants; low certainty evidence); or lung function (PaO2/FiO2 ratio; MD 28.16 mmHg, 95% CI ‐9.92 to 66.24; 2 trials, 121 participants; very low certainty evidence). However, there was an improvement in oxygenation index (FiO2% X MPAW/ PaO2) with prone positioning in both the parallel trials (MD ‐2.42, 95% CI ‐3.60 to ‐1.25; 2 trials, 121 participants; very low certainty evidence), and the cross‐over study (MD ‐8.13, 95% CI ‐15.01 to ‐1.25; 1 study, 20 participants). Derived indices of respiratory mechanics, such as tidal volume, respiratory rate, and positive end‐expiratory pressure (PEEP) were reported. There was an apparent decrease in tidal volume between prone and supine groups in a parallel study (MD ‐0.60, 95% CI ‐1.05 to ‐0.15; 1 study, 84 participants; very low certainty evidence). When prone and supine positions were compared in a cross‐over study, there were no conclusive results in respiratory compliance (MD 0.07, 95% CI ‐0.10 to 0.24; 1 study, 10 participants); changes in PEEP (MD ‐0.70 cm H2O, 95% CI ‐2.72 to 1.32; 1 study, 10 participants); or resistance (MD ‐0.00, 95% CI ‐0.05 to 0.04; 1 study, 10 participants). One study reported adverse events. There were no conclusive results for potential harm between groups in extubation (OR 0.57, 95% CI 0.13 to 2.54; 1 trial, 102 participants; very low certainty evidence); obstructions of the endotracheal tube (OR 5.20, 95% CI 0.24 to 111.09; 1 trial, 102 participants; very low certainty evidence); pressure ulcers (OR 1.00, 95% CI 0.41 to 2.44; 1 trial, 102 participants; very low certainty evidence); and hypercapnia (high levels of arterial carbon dioxide; OR 3.06, 95% CI 0.12 to 76.88; 1 trial, 102 participants; very low certainty evidence). One study (50 participants) compared supine positions to good‐lung dependent and independent positions. There was no conclusive evidence that PaO2 was different between supine and good‐lung dependent positioning (MD 3.44 mm Hg, 95% CI ‐23.12 to 30.00; 1 trial, 25 participants; very low certainty evidence). There was also no conclusive evidence for supine position and good‐lung independent positioning (MD ‐2.78 mmHg, 95% CI ‐28.84, 23.28; 25 participants; very low certainty evidence); or between good‐lung dependent and independent positioning (MD 6.22, 95% CI ‐21.25 to 33.69; 1 trial, 25 participants; very low certainty evidence). As most trials did not describe how possible biases were addressed, the potential for bias in these findings is unclear. Authors' conclusions Although included studies suggest that prone positioning may offer some advantage, there was little evidence to make definitive recommendations. There appears to be low certainty evidence that positioning improves oxygenation in mechanically ventilated children with ARDS. Due to the increased risk of SIDS with prone positioning and lung injury with artificial ventilation, it is recommended that hospitalised infants and children should only be placed in this position while under continuous cardiorespiratory monitoring. 

Positioning for acute respiratory distress in hospitalised infants and children

Approximately 2% of the global population lives above 1500 m, where low atmospheric pressure, decreased oxygen levels, harsh cold and dry conditions, strong radiation, and the effects of climate change present significant health challenges. Residents of these high-altitude areas display physiological adaptions, including smaller body size, enlarged ribs, improved oxygen delivery in hypoxic conditions, and adjustments in oxygen utilization and metabolism. Both acute and chronic hypoxia prevalent in such regions can trigger various diseases by stimulating hypoxia-inducible factors, boosting inflammatory responses, and impairing mitochondrial function.Acute Respiratory Distress Syndrome (ARDS) - a critical respiratory condition associated with high morbidity and mortality - occurs more frequently among the health risks in these environments. Hypoxia is a critical predisposing and aggravating factor for high-altitude ARDS. Despite similarities with its low-altitude counterpart, ARDS in high-altitude areas displays unique pathophysiology and clinical manifestations due to the specific environmental conditions.This review aims to shed light on how high-altitude environments influence the diagnosis and treatment of ARDS, providing a comprehensive understanding of the distinct challenges inherent to these regions.

https://medscimonit.com/download/inPress/idArt/939935

Understanding Acute Respiratory Distress Syndrome in High-Altitude Environments: A Comprehensive Review of Diagnosis and Treatment.

Prolonged inspiratory to expiratory (I:E) ratio ventilation may improve arterial oxygenation or gas exchange and respiratory mechanics in patients with obesity. We performed a randomised study to compare the effects of the conventional ratio ventilation (CRV) of 1:2 and the equal ratio ventilation (ERV) of 1:1 on arterial oxygenation and respiratory mechanics during spine surgery in overweight and obese patients. Fifty adult patients with a body mass index of ≥25 kg/m2 were randomly allocated to receive an I:E ratio either l:2 (CRV; n = 25) or 1:1 (ERV; n = 25). Arterial oxygenation and respiratory mechanics were recorded in the supine position, and at 30 minutes and 90 minutes after placement in the prone position. The changes in partial arterial oxygen pressure (PaO2) over time did not differ between the groups. The changes in partial arterial carbon dioxide pressure over time were significantly different between the two groups (P = 0.040). The changes in mean airway pressure (Pmean) over time were significantly different between the two groups (P = 0.044). Although ERV provided a significantly higher Pmean than CRV during surgery, the changes in PaO2 did not differ between the two groups.

/pdf/effects-of-ventilatory-strategy-on-arterial-oxygenation-and-4smqbu36ph.pdf

Effects of ventilatory strategy on arterial oxygenation and respiratory mechanics in overweight and obese patients undergoing posterior spine surgery

VV-ECMO combined with prone position ventilation in the treatment of Pneumocystis jirovecii pneumonia

Abstract Introduction Postoperative pulmonary complications (PPCs) are prevalence in geriatric patients with hip fractures. Low oxygen level is one of the most important risk factors for PPCs. Prone position has been proven efficacy in improving oxygenation and delaying the progress of pulmonary diseases especially in patients with acute respiratory distress syndrome induced by multiple etiologies. The application of awake prone position (APP) has also attracted widespread attention in recent years. A randomized controlled trial (RCT) will be carried out to measure the effect of postoperative APP in a population of geriatric patients undergoing hip fracture surgery. Methods This is a RCT. Patients older than 65 years old admitted through the emergency room and diagnosed with an intertrochanteric or femoral neck fracture will be eligible for enrollment and randomized to control group with routine postoperative management of orthopedics or APP group with additional prone position for the first three consecutive postoperative days (PODs). Patients receiving conservative treatment will not be eligible for enrollment. We will record the difference in patient’s room-air-breathing arterial partial pressure of oxygen (PaO 2 ) values between the 4 th POD (POD 4) and emergency visits, morbidity of PPCs, mortality and ICU stays during hospitalization, length of hospitalization. The rates of PPCs, readmissions and mortality will be followed up for 90 PODs. Discussion We describe the protocol for a single-center RCT that will evaluate the efficacy of postoperative APP treatment in reducing pulmonary complications and improving oxygenation in geriatric patients with hip fracture. Ethics and dissemination: This protocol was approved by the independent ethics committee (IEC) for Clinical Research of Zhongda Hospital, Affiliated to Southeast University and is registered on Chinese Clinical Trial Registry. The findings of the trial will be disseminated through peer-reviewed journals. Ethics approval number: 2021ZDSYLL203-P01 Trial registration: ChiCTR, ChiCTR2100049311. Registered on 29 July 2021, https://www.chictr.org.cn/listbycreater.aspx Trial status : Recruiting. Recruitment is expected to be completed in December 2024. 

/pdf/postoperative-awake-prone-position-in-geriatric-patients-2o2j6fj7.pdf

Postoperative awake prone position in geriatric patients with hip fracture: a protocol for a randomized controlled trial on the efficacy of postoperative prone position in reducing pulmonary complications and improving oxygenation

Objective
To systematically evaluate the clinical effect of prone position mechanical ventilation on the improvement of oxygenation in patients with severe pneumonia.


Methods
Pubmed, Embase, Cochrane Library, CNKI, Wanfang Data and VIP database were searched from the time of database built up until December 10th, 2017. All the published randomized controlled trials (RCTs) about the effects of prone position ventilation on the oxygenation of severe pneumonia patients were screened, and were confirmed by the literature reference citation retrieval. Inclusion and exclusion criteria had been used to review and rank the literature. After evaluating the quality of included studies, the data was extracted from RCTs and given a Meta-analysis using RevMen 5.1.


Results
Twelve RCTs with 650 cases were included. Eleven of them were Chinese literature while 1 was in English. Ten studies showed that the prone position ventilation had a significant influence on improving partial pressure of oxygen [weighted mean difference (WMD) = 9.93, 95% confidence interval (95%CI) = 2.92-16.95, P = 0.006], publication bias was found in these studies. Seven studies showed that the prone position ventilation had a significant influence on partial pressure of carbon dioxide (WMD = 9.99, 95%CI = 1.81-18.18, P = 0.02), publication bias was found in these studies. Seven studies showed that the prone position ventilation had a significant influence on oxygenation index (WMD = 31.22, 95%CI = 26.06-36.39, P < 0.000 01), publication bias was found in these studies. Two studies showed that the prone position ventilation had a significant influence on oxygen saturation of blood (WMD = 2.12, 95%CI = 1.24-3.00, P < 0.000 01), no publication bias was found in these studies.


Conclusion
Prone position ventilation can effectively improve the patients' oxygenation index, partial pressure of oxygen, and oxygen saturation of blood, and reduce the partial pressure of carbon dioxide.


Key words: 
Severe pneumonia; Prone position ventilation; Oxygenation; Meta-analysis

Meta analysis of observing prone position ventilation role in the oxygenation of severe pneumonia patients

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Meta analysis of observing prone position ventilation role in the oxygenation of severe pneumonia patients