Effect of prone positioning on clinical outcomes in children with acute lung injury: a randomized controlled trial.
BACKGROUND
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.


OBJECTIVE
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.


METHODS
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.


METHODS
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.


METHODS
Ventilator-free days to day 28.


RESULTS
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.


CONCLUSIONS
Prone positioning does not significantly reduce ventilator-free days or improve other clinical outcomes in pediatric patients with acute lung injury.
Curley
Martha A Q
MA
Children's Hospital Boston, Medical-Surgical Intensive Care Unit, 300 Longwood Ave, Boston, MA 02115, USA. martha.curley@childrens.harvard.edu
Hibberd
Patricia L
PL
Fineman
Lori D
LD
Wypij
David
D
Shih
Mei-Chiung
MC
Thompson
John E
JE
Grant
Mary Jo C
MJ
Barr
Frederick E
FE
Cvijanovich
Natalie Z
NZ
Sorce
Lauren
L
Luckett
Peter M
PM
Matthay
Michael A
MA
Arnold
John H
JH
D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015278:Intensive Care Units, Pediatric; D008297:Male; D016684:Prone Position; D012121:Respiration, Artificial; D012128:Respiratory Distress Syndrome / Q000628:therapy*; D012127:Respiratory Distress Syndrome, Newborn / Q000628:therapy*; D016683:Supine Position