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Three Part Question

In [infants with lung disease needing respiratory support] does [prone position] improve [oxygenation]?

Clinical Scenario

A 25-week ex-preterm infant is continuous positive airway pressure dependent for chronic lung disease. His oxygen requirement increases with frequent desaturations in supine position and the nurse looking after the baby wants to turn the infant prone to improve oxygenation. I wonder if there is evidence for such a claim.

Search Strategy

Primary source: Medline 1966-2004, EMBASE 1974-2004, British nursing index 1994 to 2004 and CINHAL 1982-2004 using the Dialog Datastar.
The search term [{Prone OR supine} AND {oxygenation}] Filter: controlled clinical trial. Limit to human and English language. Hits: Medline (1), EMBASE (48), British nursing index (1) and CINAHL (28).

Search Outcome

4 relevant studies identified (see table).

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Wagaman MJ et al 1979	14 intubated infants recovering from neonatal respiratory disease.	Controlled clinical trial	Arterial oxygen tension (Pao2)	Supine= 70.4 +/- 2.5 to Prone=81.1 +/- 4.4mm Hg mean (+/- SEM) (Significant)	Small sample size
Kornecki A et al 2001 Canada	10 children (mean (SD) age, 5 ± 3.6 years) with ARF with a baseline oxygenation index (OI) of 22 ± 8.5 were randomized to supine /prone or prone/supine sequence.	Randomized, cross over, controlled trial.	Oxygenation Index	Prone=7.9 ± 5.3 U (34 ± 17%) improvement (p = 0.002	Small sample size
McEvoy et al 1997 USA	55 infants (birth weight less than or equal 1000 gm) with CLD in studied in the supine versus prone position, for 1-hour time intervals	Controlled clinical trial	Oxygen saturation (SpO2)	Supine=92.0% to Prone=94.1% (p <0.001)
			Episodes SpO2 < 90%, 85%, and 80%	Decreased in prone position(p <0.001).
Chang Y et al 2002 China	28 infants receiving mechanical ventilation (25 to 36 weeks' gestation) within 7 postnatal days of birth were randomly assigned to a supine/prone or prone/supine position sequence.	Randomized, cross over, controlled trial.	SpO(2), episodes of oxygen desaturation, and motor activity	Better in prone than supine position (data not available for scrutiny)
			Duration of SpO(2) less than 90%, 85%, and 80%.	No significant differences (data not available for scrutiny)

Comment(s)

The search yielded 4 relevant clinical trials, 3 neonatal and 1 paediatric age groups. All trials reported improvement in oxygenation measured either as arterial PaO2 or SpO2.

Clinical Bottom Line

Prone position improves oxygenation in infants requiring respiratory support for lung disease.

References

1. Wagaman M J, Shutack J G, Moomjian A S et al Improved oxygenation and lung compliance with prone positioning of neonates J Pediatr 1979, 94 (5):787-91
2. Kornecki A, Frndova H, Coates A L, Shernie S D 4A randomized trial of prolonged prone positioning in children with acute respiratory failure Chest 2001;119(1):211-8.
3. McEvoy C, Mendoza M E, Bowling S, Hewlett V, Sardesai S, Durand M Prone positioning decreases episodes of hypoxemia in extremely low birth weight infants (1000 grams or less) with chronic lung disease J Pediatr 1997; 130(2):305-9
4. Chang YJ, Anderson GC, Dowling D, Lin CH Decreased activity and oxygen desaturation in prone ventilated preterm infants during the first postnatal week Heart Lung 2002; 31(1):34-42