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Cambios de posición para la dificultad respiratoria aguda en lactantes y niños hospitalizados

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Antecedentes

El síndrome de dificultad respiratoria aguda (SDRA) es una causa importante de hospitalización y muerte en niños pequeños. Los cambios de posición y la ventilación mecánica se han utilizado de forma habitual para reducir la dificultad respiratoria y mejorar la oxigenación en los pacientes hospitalizados. Debido a la asociación de la posición de decúbito prono (acostado sobre el abdomen) con el síndrome de muerte súbita del lactante (SMSL) dentro de los primeros seis meses, se recomienda colocar a los lactantes pequeños boca arriba (en posición supina). Sin embargo, la posición de decúbito prono podría ser una forma no invasiva de aumentar la oxigenación en individuos con dificultad respiratoria aguda, y ofrece una ventaja de supervivencia más significativa en aquellos que están ventilados mecánicamente. Existen diferencias importantes en la mecánica respiratoria entre los adultos y los lactantes. Aunque el sistema respiratorio experimenta un desarrollo importante durante los dos primeros años de vida, las diferencias en la fisiología de las vías respiratorias entre los adultos y los niños se hacen menos prominentes entre los seis y los ocho años de edad. Sin embargo, existe un menor riesgo de SMSL durante la ventilación artificial en los lactantes hospitalizados. Por lo tanto, se justifica una revisión actualizada centrada en los cambios de posición de los lactantes y los niños pequeños con SDRA. Esta es una actualización de una revisión publicada en 2005, 2009 y 2012.

Objetivos

Comparar los efectos de diferentes posiciones corporales en lactantes y niños hospitalizados con síndrome de dificultad respiratoria aguda de entre cuatro semanas y 16 años.

Métodos de búsqueda

Se realizaron búsquedas en CENTRAL, que contiene el Registro especializado del Grupo de Infecciones respiratorias agudas (Acute Respiratory Infections Group), MEDLINE, Embase y CINAHL desde enero de 2004 hasta julio de 2021.

Criterios de selección

Ensayos controlados aleatorizados (ECA) o cuasialeatorizados que compararan dos o más posiciones para el tratamiento de lactantes y niños hospitalizados con SDRA.

Obtención y análisis de los datos

Dos autores de la revisión extrajeron de forma independiente los datos de cada estudio. Las diferencias se resolvieron mediante consenso o se remitieron a un tercer colaborador que sirvió de árbitro. Los desenlaces bivariados se analizaron mediante el odds ratio (OR) y el intervalo de confianza (IC) del 95%. Los desenlaces continuos se analizaron mediante la diferencia de medias (DM) y el IC del 95%. Se utilizó un modelo de efectos fijos a menos que la heterogeneidad fuera significativa (estadística I2 > 50%), en cuyo caso, se utilizó un modelo de efectos aleatorios.

Resultados principales

Se incluyeron seis ensayos: cuatro ensayos cruzados (cross‐over) y dos ensayos aleatorizados paralelos, con 198 participantes de entre cuatro semanas y 16 años de edad, de los cuales todos, excepto 15, recibían ventilación mecánica. Cuatro ensayos compararon las posiciones de decúbito prono y supina. En un ensayo se comparó la posición de decúbito prono con la dependiente del pulmón sano (en la que la persona se acuesta del lado del pulmón sano, p. ej., si el pulmón derecho estaba sano, se le acostó sobre el lado derecho), y la independiente (o no independiente del pulmón sano, en la que la persona se acuesta del lado opuesto al pulmón sano, p. ej., si el pulmón derecho estaba sano, se le acostó sobre el lado izquierdo). Un ensayo comparó las posiciones independiente del pulmón sano con dependiente del pulmón sano.

Cuando se compararon las posiciones de decúbito prono (con ventiladores) y supina, no hubo información sobre los episodios de apnea ni la mortalidad debido a eventos respiratorios. No hubo resultados concluyentes en el caso de la saturación de oxígeno (SaO2; DM 0,40 mmHg; IC del 95%: ‐1,22 a 2,66; un ensayo, 30 participantes; evidencia de certeza muy baja); los gases sanguíneos, pCO2 (DM 3,0 mmHg; IC del 95%: ‐1,93 a 7,93; un ensayo, 99 participantes; evidencia de certeza baja), o la PO2 (DM 2 mmHg; IC del 95%: ‐5,29 a 9,29; un ensayo, 99 participantes; evidencia de certeza baja); o la función pulmonar (cociente PaO2/FiO2; DM 28,16 mmHg; IC del 95%: ‐9,92 a 66,24; dos ensayos, 121 participantes; evidencia de certeza muy baja). Sin embargo, hubo una mejoría en el índice de oxigenación (FiO2% X MPAW/ PaO2) con la posición de decúbito prono en los ensayos paralelos (DM ‐2,42; IC del 95%: ‐3,60 a ‐1,25; dos ensayos, 121 participantes; evidencia de certeza muy baja), y en el estudio cruzado (DM ‐8,13; IC del 95%: ‐15,01 a ‐1,25; un estudio, 20 participantes).

Se informaron los índices derivados de la mecánica respiratoria, como el volumen tidal, la frecuencia respiratoria y la presión positiva al final de la espiración (PEEP). Hubo una aparente disminución del volumen tidal entre los grupos de posición de decúbito prono y supina en un estudio paralelo (DM ‐0,60; IC del 95%: ‐1,05 a ‐0,15; un estudio, 84 participantes; evidencia de certeza muy baja). Cuando se compararon las posiciones de decúbito prono y supina en un estudio cruzado, no hubo resultados concluyentes en cuanto a la distensibilidad respiratoria (DM 0,07; IC del 95%: ‐0,10 a 0,24; un estudio, diez participantes); los cambios en la PEEP (DM ‐0,70 cm H2O; IC del 95%: ‐2,72 a 1,32; un estudio, diez participantes); ni la resistencia (DM ‐0,00; IC del 95%: ‐0,05 a 0,04; un estudio, diez participantes).

Un estudio informó eventos adversos. No hubo resultados concluyentes sobre el daño potencial entre los grupos en la extubación (OR 0,57; IC del 95%: 0,13 a 2,54; un ensayo, 102 participantes; evidencia de certeza muy baja); las obstrucciones del tubo endotraqueal (OR 5,20; IC del 95%: 0,24 a 111.09; un ensayo, 102 participantes; evidencia de certeza muy baja); las úlceras por presión (OR 1,00; IC del 95%: 0,41 a 2,44; un ensayo, 102 participantes; evidencia de certeza muy baja); ni la hipercapnia (niveles elevados de dióxido de carbono arterial; OR 3,06; IC del 95%: 0,12 a 76,88; un ensayo, 102 participantes; evidencia de certeza muy baja).

Un estudio (50 participantes) comparó las posiciones supinas con las posiciones dependientes e independientes de los pulmones. No hubo evidencia concluyente de que la PaO2 fuera diferente entre la posición supina y la dependiente del pulmón sano (DM 3,44 mm Hg; IC del 95%: ‐23,12 a 30,00; un ensayo, 25 participantes; evidencia de certeza muy baja). Tampoco hubo evidencia concluyente acerca de la posición supina y la posición independiente del pulmón sano (DM ‐2,78 mmHg; IC del 95%: ‐28,84; 23,28; 25 participantes; evidencia de certeza muy baja); o entre la posición dependiente y la independiente del pulmón sano (DM 6,22; IC del 95%: ‐21,25 a 33,69; un ensayo, 25 participantes; evidencia de certeza muy baja).

Como la mayoría de los ensayos no describieron cómo se abordaron los posibles sesgos, no está claro el potencial de sesgo en estos resultados.

Conclusiones de los autores

Aunque los estudios incluidos indican que la posición de decúbito prono podría ofrecer alguna ventaja, hubo poca evidencia para hacer recomendaciones definitivas. Parece haber evidencia de certeza baja de que los cambios de posición mejoran la oxigenación en los niños con SDRA con ventilación mecánica. Debido al mayor riesgo de SMSL con la posición de decúbito prono y de lesión pulmonar con la ventilación artificial, se recomienda que los lactantes y niños hospitalizados solamente se coloquen en esta posición mientras estén sometidos a una monitorización cardiorrespiratoria continua.

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Resumen en términos sencillos

Cambios de posición para la dificultad respiratoria aguda en lactantes y niños hospitalizados

Pregunta de la revisión

Se investigó si existía una diferencia en los desenlaces de los lactantes y los niños pequeños con síndrome de dificultad respiratoria aguda (SDRA) con ventilación artificial que se colocaban tumbados sobre el abdomen (la posición de decúbito prono), en comparación con los tumbados sobre la espalda (la posición supina), o de lado.

Antecedentes

El SDRA es una de las causas más frecuentes de hospitalización y muerte en los lactantes y los niños pequeños en todo el mundo. Cuando los niños con dificultad respiratoria grave son hospitalizados, el tratamiento puede incluir oxígeno adicional, con o sin ventilación asistida. Estos intentos de aumentar la oxigenación pueden dañar los pulmones. Los lactantes y los niños con dificultad respiratoria colocados en determinadas posiciones podrían estar más cómodos, respirar más fácilmente y tener mejores desenlaces. Sin embargo, las diferentes posiciones también podrían aumentar el riesgo de desenlaces adversos, como la obstrucción del tubo endotraqueal (el tubo que conecta a la persona con el ventilador) y la extubación (salida del tubo) accidental. Para averiguar si este era el caso, se buscó en la literatura para identificar ensayos controlados aleatorizados (ECA) y cuasialeatorizados que compararan dos o más posiciones corporales para el tratamiento de lactantes y niños hospitalizados con SDRA.

Fecha de la búsqueda

La evidencia está actualizada hasta el 26 de julio de 2021.

Características de los estudios

Se incluyeron seis ensayos, con un total de 198 participantes de entre cuatro semanas y 16 años. La mayoría estaban conectados a respiradores mecánicos. El tiempo de las intervenciones varió desde 15 minutos después de que el niño se instalara en una cama de hospital, hasta un máximo de siete días en el transcurso de la intervención. Solo un pequeño número (n = 15) de niños no tenía respiración asistida por un ventilador.

Fuente de financiación de los estudios

Los ensayos incluidos en esta revisión recibieron el apoyo de organismos públicos.

Resultados clave

La posición de acostado sobre el abdomen pareció mejorar el uso de oxígeno (el índice de oxigenación es la necesidad de oxígeno adicional en relación con el nivel de oxígeno del niño) en comparación con la posición de acostado sobre la espalda. Este hallazgo se basó en los datos de tres ensayos con 141 niños. Solo un ensayo con 102 niños informó efectos adversos, que no difirieron entre las dos posiciones. En un ensayo con 50 niños se comparó la posición acostado boca arriba con otras posiciones, y no fue posible mostrar diferencias consistentes en la oxigenación de la sangre. No hay suficiente información para establecer conclusiones sobre los efectos beneficiosos y perjudiciales de cualquier posición en lactantes y niños con dificultad respiratoria aguda.

Es importante recordar que estos niños estaban hospitalizados y con respiración asistida. Debido a la asociación entre la posición de acostado sobre el abdomen y el SMSL, los niños no se deben colocar sobre el abdomen a menos que estén en el hospital y su respiración esté constantemente monitorizada.

Certeza de la evidencia

Los resultados de esta revisión están limitados por el escaso número de ensayos identificados, cinco de los cuales tenían menos de 40 participantes; la corta duración de las intervenciones; y la falta de descripción de cómo los autores de los estudios abordaron el riesgo de sesgo en los ensayos. En general, no se sabe cómo las diferentes posiciones afectan los desenlaces principales de la revisión, como los niveles de oxigenación. Esto significa que se necesitan estudios de investigación futuros para mejorar la certeza de los resultados de esta revisión.

Authors' conclusions

Implications for practice

Prone positioning may offer some advantage over other positions in improved oxygenation and lung protection for ventilated infants or children hospitalised with acute respiratory distress. However, the benefits of prone positioning cannot be extrapolated to non‐hospitalised infants and children with respiratory distress, due to the increased risk of sudden infant death syndrome (SIDS) with prone positioning. Due to the increased risk of lung injury associated with artificial ventilation, it is further recommended that hospitalised infants placed in the prone position be closely monitored, due to the increased risk of hypoxia associated with acute respiratory distress.

At present, there is insufficient evidence to make solid recommendations regarding the preferred position to support hospitalised infants and children with acute respiratory distress. 

Implications for research

Large, international, multicentre, randomised controlled trials are required to better assess the effect of positioning respiratory‐distressed infants and children in the prone position. Future studies should also collect clinically meaningful data, such as mortality, morbidity, recovery variables, and adverse effects. Trials also need to determine the optimal frequency and timing of the prone position to gain maximal sustained benefits over a longer duration. As most identified studies reported data from children, future studies are needed to determine whether the prone position is also effective for infants, as well as the effect on their quality of life. In addition, to investigate whether findings are consistent across a range of participants, future trials should report separate data for subgroups of infants and children based on the age group, the causes of acute respiratory distress, and whether they are mechanically ventilated. Further research on the effectiveness of other positions for infants and children with acute respiratory distress is also needed.

Summary of findings

Open in table viewer
Summary of findings 1. Summary of findings table ‐ Prone compared to supine for acute respiratory distress in hospitalised infants and children (ARDs)

Prone compared to supine for acute respiratory distress in hospitalised infants and children (ARDs)

Patient or population: acute respiratory distress in hospitalised infants and children (ARDs)
Setting: hospital (paediatric critical care unit)
Intervention: prone
Comparison: supine

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Risk with supine

Risk with prone

Mortality (respiratory events) ‐ not reported

No studies reported this outcome

Oxygen saturation (SaO2)

The mean oxygen saturation (SaO2) ranged from 90.5 to 93.1 mmHg

mean 0.4 mmHg higher
(1.22 lower to 2.66 higher)

30
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

Blood gases (PO2)
follow‐up: range 1 hours to 7 days

The mean blood gases (PO2) ranged from 78 to 97.5 mmHg

mean 2 mmHg higher
(5.29 lower to 9.29 higher)

99
(1 RCT)

⊕⊕⊝⊝
Lowd,e

PaCO2
follow‐up: range 20 hours to 7 days

The mean paCO2 ranged from 6.5 to 53 mmHg

mean 3 mmHg higher
(1.93 lower to 7.93 higher)

99
(1 RCT)

⊕⊕⊝⊝
Lowd,e

Lung function (PaO2/FiO2 ratio)
follow‐up: range 1 hour to 7 days

The mean lung function (PaO2/FiO2 ratio) ranged from 153 to 176 mmHg

mean 28.16 mmHg higher
(9.92 lower to 66.24 higher)

121
(2 RCTs)

⊕⊝⊝⊝
Very lowa,b,d

Oxygenation index (FiO2% X MPAW/PaO2)
follow‐up: range 1 hour to 7 days

The mean oxygenation index (FiO2% X MPAW/PaO2) ranged from 9.5 to 11 mmHg

MD 2.42 mmHg lower
(3.6 lower to 1.25 lower)

121
(2 RCTs)

⊕⊝⊝⊝
Very lowa,f

Potential adverse outcomes (extubation)
assessed with: %
follow‐up: range 1 hours to 7 days

98 per 1000

58 per 1000
(14 to 216)

OR 0.57
(0.13 to 2.54)

102
(1 RCT)

⊕⊝⊝⊝
Very lowa,f

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; MD: mean difference; OR: odds ratio

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

See interactive version of this table: https://gdt.gradepro.org/presentations/#/isof/isof_question_revman_web_423281134243830314.

a We identified significant issues with the randomisation process and concealment of allocation
b The study was downgraded due to very wide confidence intervals indicating possible benefit or harm
c Downgraded due to very small single study assessment
d The study was downgraded due to very wide confidence intervals indicating possible benefit or harm
e This outcome was downgraded due to imprecision; very small single study
f Downgraded due to very small studies

Open in table viewer
Summary of findings 2. Summary of findings table ‐ Supine compared to good‐lung dependent for acute respiratory distress in hospitalised infants and children (ARDs)

Supine compared to good‐lung dependent for acute respiratory distress in hospitalised infants and children (ARDs)

Patient or population: acute respiratory distress in hospitalised infants and children (ARDs)
Setting: hospital (paediatric critical care unit)
Intervention: supine
Comparison: good‐lung dependent

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Risk with good‐lung dependent

Risk with supine

Mortality (respiratory events) ‐ not reported

No studies reported this outcome

Oxygen saturation (SaO2) ‐ not reported

No studies reported this outcome

PaO2
follow‐up: range 15 minutes to 45 minutes

The mean paO2 was 111.92 mmHg

mean 3.44 mmHg higher
(23.12 lower to 30 higher)

50
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

Blood gases (PaCO2) ‐ not reported

No studies reported this outcome

Lung function (PaO2/FiO2 ratio) ‐ not reported

No studies reported this outcome

Oxygenation index (FiO2% X MPAW/PaO2) ‐ not reported

No studies reported this outcome

Potential adverse outcomes (episodes of apnoea) ‐ not reported

No studies reported this outcome

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

See interactive version of this table: https://gdt.gradepro.org/presentations/#/isof/isof_question_revman_web_423282959442933151.

a We identified significant issues with the randomisation process as well as concealment of allocation
b A very wide and imprecise confidence intervals (CI), suggesting possible benefit or harm
c A very small single study

Open in table viewer
Summary of findings 3. Summary of findings table ‐ Supine compared to good‐lung independent for acute respiratory distress in hospitalised infants and children

Supine compared to good‐lung independent for acute respiratory distress in hospitalised infants and children

Patient or population: acute respiratory distress in hospitalised infants and children
Setting: hospital (paediatric critical care unit)
Intervention: supine
Comparison: good‐lung independent

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Risk with good‐lung independent

Risk with supine

Mortality (respiratory events) ‐ not reported

No studies reported this outcome

Oxygen saturation (SaO2) ‐ not reported

No studies reported this outcome

PaO 2
follow‐up: range 15 minutes to 45 minutes

The mean paO 2 was 118.14 mmHg

mean 2.78 mmHg lower
(28.84 lower to 23.28 higher)

50
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

Blood gases (PCO2) ‐ not reported

No studies reported this outcome

Lung function (PaO2/FiO2 ratio) ‐ not reported

No studies reported this outcome

Oxygenation index (FiO2% X MPAW/PaO2) ‐ not reported

No studies reported this outcome

Potential adverse outcomes (episodes of apnoea) ‐ not reported

No studies reported this outcome

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

See interactive version of this table: https://gdt.gradepro.org/presentations/#/isof/isof_question_revman_web_423283527611744015.

a We identified significant issues with the randomisation process as well as concealment of allocation
b Very wide confidence intervals indicating possible benefit or harm
c Downgraded due to very small single study

Open in table viewer
Summary of findings 4. Summary of findings table ‐ Good‐lung independent compared to good‐lung dependent positioning for acute respiratory distress in hospitalised infants and children

Good‐lung independent compared to good‐lung dependent positioning for acute respiratory distress in hospitalised infants and children

Patient or population: acute respiratory distress in hospitalised infants and children
Setting: hospital (paediatric critical care unit)
Intervention: good‐lung independent
Comparison: good‐lung dependent positioning

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Risk with good‐lung dependent positioning

Risk with good‐lung independent

Mortality (respiratory events) ‐ not reported

No studies reported this outcome

Oxygen saturation (SaO2) ‐ not reported

No studies reported this outcome

PaO 2 (cross‐over trial)
follow‐up: range 15 minutes to 45 minutes

The mean paO 2 (cross‐over trial) was 111.92 mmHg

MD 6.22 mmHg higher
(21.25 lower to 33.69 higher)

50
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

Blood gases (PaCO2) ‐ not reported

No studies reported this outcome

Lung function (PaO2/FiO2 ratio) ‐ not reported

No studies reported this outcome

Oxygenation index (FiO2% X MPAW/PaO2) ‐ not reported

No studies reported this outcome

Potential adverse outcomes (episodes of apnoea) ‐ not reported

No studies reported this outcome

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; MD: mean difference

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

See interactive version of this table: https://gdt.gradepro.org/presentations/#/isof/isof_question_revman_web_429747819004596191.

a We identified significant issues due to randomisation and poor allocation concealment
b Very large confidence intervals suggesting possible benefit or harm
c Downgraded due to findings from very small single study

Background

Description of the condition

Acute respiratory distress is one of the most frequent causes of hospitalisation and death in young children (Buckmaster 2007Meurer 2000Mintegi Raso 2004Shay 1999), and infants across the world (Ahmed 2004Caitlin 2008Chang 2000Lal 2019Ritz 2020Simiyu 2004Sritipsukho 2007). While there is no official definition of acute respiratory distress (or breathing difficulty), it is clinically recognised as a presentation of one or more of the following signs or symptoms: shortness of breath, wheeze, increased breathing rate, increased heartbeat, increased chest wall retractions, thoracoabdominal asynchrony, pallor, cyanosis, nasal flare, expiratory grunt, and fatigue. Respiratory distress can lead to hypoxemia or hypercapnic respiratory failure, which may require positive pressure ventilation when prone positioning is relevant. Respiratory distress can lead to hypoxaemia with decreased PaO2 (arterial oxygen pressure), increased PaCO2 (arterial carbon dioxide pressure), altered neurological status (confusion), and ultimately to respiratory or multiple organ failure (or both), and eventually death (Amigoni 2017Hazinski 1992aHazinski 1992bKillien 2019). Most infants and young children who develop mild to moderate respiratory distress can be managed at home. However, children with more severe respiratory distress require hospitalisation for treatment, which may include supplemental oxygen, intravenous fluids, intravenous antibiotics, and possibly assisted ventilation.

Description of the intervention

Positioning for therapeutic effect has long been proposed as a means of improving respiratory mechanics and increasing oxygenation (oxygen requirement) in individuals with acute respiratory distress. We define respiratory mechanics as a measure of resistance and elastance, or compliance of the lungs with values of derived indices, such as tidal volume (VT), respiratory rate, and positive end‐expiratory pressure (PEEP (Bou Jawde 2020Hess 2014Silva 2018)). Each index exerts a direct effect on respiratory mechanics when plotted as a function of time or another respiratory index (Hess 2014). Body positioning is a non‐invasive intervention that may augment oxygenation, while avoiding further complications (Bloomfield 2015Hewitt 2016Wang 2016). There is no convincing evidence of either benefit or harm from the universal application of prone positioning among adults with hypoxaemia, mechanically ventilated in intensive care units (ICUs (Bloomfield 2015)). However, in children, particularly infants, the risk of injury from oxygen toxicity from mechanical ventilation is greater than in adults, as the lungs are going through a period of high growth and development (Bateman 2000Hazinski 1992a). Positioning may reduce the need for such interventions, or reduce the required length of time, thereby reducing the associated risk of longer‐term lung damage.

How the intervention might work

Numerous studies on adult and paediatric patients with acute respiratory distress in acute and complex care settings have found that the prone position improves arterial oxygenation compared to the supine position (Bloomfield 2015Abrams 2020Cumpstey 2020). Other positions, including lateral (side‐lying) positioning, have also been proposed to assist in maintaining optimal ventilation and oxygenation during episodes of respiratory distress (Hewitt 2016).

Structural differences in the respiratory system are evident in infants and young children when compared with adults (Hazinski 1992a). While supportive airway cartilage, small airway muscles, and the intercostal muscles are not fully developed until school age (Adams 1994), the chest wall of the infant and young child is also much more compliant than the chest wall of an adult (Hazinski 1992a). These differences may lead to a relative increase in the infant's or child's respiratory effort during an episode of respiratory distress, further compromising their ability to maintain adequate ventilation (Adams 1994Hazinski 1992a).

Why it is important to do this review

specific review of positioning for infants and young children with respiratory distress is warranted, as the structure and respiratory mechanics of the infant and young child differ from those of an adult. Infants and young babies are also at higher risk of deterioration or mortality from acute respiratory distress syndrome (ARDS). It is important to update this review to determine whether prone positioning improves the respiratory management of children with severe, acute respiratory distress. Furthermore, the use of prone positioning for infants is controversial, as it is linked to sudden infant death syndrome (SIDS (Horne 2019)).

Therefore, it is necessary to clarify the benefits and potential risks of body positioning in hospitalised infants and children with acute respiratory distress, to inform evidence‐based clinical practice. There have been four reviews, without meta‐analyses, of positioning in participants with respiratory distress (Ball 1999Ballout 2017Curley 1999Wong 1999). All reviews, except Ballout 2017, which included self‐ventilating infants with apnoea, found that the prone position improved oxygenation in ventilated neonates. However, so far, most of the participants in the reviewed studies are adults. Several of the studies in these reviews included small numbers of children, but excluded neonates.

This review is an update of a systematic review of the effects of positioning on respiratory distress in infants and children (Black 2005Gillies 2009Gillies 2012). Each of these reviews found that prone positioning increased oxygenation outcomes, but the majority of data came from trials of neonates. There have now been several Cochrane Reviews that specifically investigated the effects of positioning in neonates (Ballout 2017Riva‐Fernandez 2016). Although Ballout 2017 did not find evidence that body positioning had any benefits for spontaneously breathing in preterm infants with apnoea, Cochrane Reviews in neonates receiving mechanical ventilation found that the prone position improved oxygenation (Riva‐Fernandez 2016). Because of these reviews in spontaneously breathing and ventilated neonates, we removed neonates from this 2022 update, and focused on infants and children aged between four weeks and 16 years.

Objectives

To compare the effects of different body positions in hospitalised infants and children with acute respiratory distress syndrome aged, between the ages of four weeks and 16 years.

Methods

Criteria for considering studies for this review

Types of studies

We included randomised controlled trials (RCTs) or quasi‐RCTs, comparing two or more positions in the management of infants and children hospitalised with acute respiratory distress.

Types of participants

 

Hospitalised infants older than four weeks, and children up to 16 years of age, with a primary or secondary diagnosis of acute respiratory distress, or with an acute exacerbation of a chronic respiratory illness. The studies included the following conditions in infants and children.

  1. Acute respiratory failure

  2. Acute respiratory distress syndrome (ARDS)

  3. Acute lung injury

  4. Acute respiratory distress due to lower respiratory tract infections: bronchiolitis, pneumonia (bacterial, viral, and atypical)

  5. Bronchitis, legionella, whooping cough; chronic neonatal lung disease (bronchopulmonary dysplasia, respiratory distress syndrome, hyaline membrane disease)

  6. Upper respiratory tract infections, including croup, epiglottitis (laryngotracheobronchitis)

  7. Laryngeal infections; acute episodes of chronic suppurative lung diseases, including bronchiectasis and cystic fibrosis; inflammatory respiratory conditions, such as asthma

  8. Congenital malformations of the bronchi, lungs, diaphragm, and rib cage

  9. Disorders of the pleura (for example pneumothorax, pleural effusion)

Types of interventions

Body positions used for the management of infants and children with acute respiratory distress included the following.

  1. Sitting − erect sitting, forward‐leaning sitting, and non‐erect sitting

  2. Prone − prone abdomen free, prone abdomen restricted, semi‐prone, quarter‐prone, horizontal (flat), and head elevated

  3. Lateral recumbent or side‐lying position − horizontal (flat) and head elevated (this position can be good‐lung dependent, where the person lies on the side of the healthy lung; or good‐lung independent, where the person lies on the side opposite to the healthy lung).

  4. Supine − horizontal (flat) and head elevated

  5. Kinetic positioning − continuous postural therapy (usually with an automated bed)

  6. Body tilting

Types of outcome measures

A range of outcomes on positioning for infants and young children with ARDS was assessed in the included studies. The outcomes measured and reported also varied across the trials. Oxygenation outcomes included: arterial oxygen saturation, partial pressure of oxygen and carbon dioxide in arterial blood, lung function, and oxygenation index. Ventilatory outcomes included: tidal volume, minute volume, dynamic lung compliance, inspiratory resistance, expiratory resistance, total pulmonary resistance, respiratory rate, work of breathing, and laboured breathing index. Other outcomes were heart rate, oesophageal pressure, and adverse events. These are listed below, with their definition and significance.

Primary outcomes

  1. Mortality: respiratory events

  2. Oxygen saturation: arterial oxygen saturation (SaO2)

  3. Blood gases: partial pressure of carbon dioxide in arterial blood (PaCO2) and partial pressure of oxygen in arterial blood (PaO2), all in mmHg

  4. Lung function or P/F ratio (PaO2/FiO2 ratio): ratio of arterial oxygen partial pressure (PaO2 in mmHg) to the fraction of inspired oxygen (FiO2 expressed as a fraction, not a percentage). It is a clinical indicator of hypoxemia that suggests the possibility of ARDS from a sudden state of lung insufficiency. The severity of ARDS is measured by the PaO2/FiO2 ratio, which ranges from 200 to 300 for mild, 100 to 200 for moderate, and 0 to 100 for severe hypoxemia (ARDS Definition Task Force 2012).

  5. Oxygenation index (FiO2% X MPAW/PaO2): used in paediatrics to determine the breathing capacity, and to predict the future outcome or assessment for potential extracorporeal membrane oxygenation (ECMO (Trachsel 2005)). An oxygenation index < 25% predicts a good outcome, 25% to 40% indicates signs of mortality, and children with values > 40% should be considered for ECMO (Kathirgamanathan 2009).

  6. Episodes of apnoea in non‐ventilated children

Secondary outcomes

  1. Respiratory mechanics: measure of resistance and elastance, or compliance of the lungs with values of derived indices, such as tidal volume (VT), respiratory rate, and positive end‐expiratory pressure (PEEP)

  2. Heart rate

  3. Per cent inspired oxygen received: FiO2; standardised protocol

  4. Duration of supplemental oxygenation: standardised protocol

  5. Intensive care unit (ICU) admission: standardised protocol

  6. Length of hospital stay

  7. Mortality: all causes

  8. Haemodynamic parameters

  9. Ventilatory parameters

Potential adverse outcomes

  1. Accidental removal and compression of intravenous lines, endotracheal tube (or both)

  2. Hypercapnia

  3. Facial oedema

  4. Pressure ulcer

  5. Cutaneous damage to the chest wall

  6. Contractures of the hip and shoulder

  7. Raised intra‐ocular pressure, deterioration in visual acuity

  8. Gastrointestinal event

  9. Any other adverse events reported by study authors

Search methods for identification of studies

Electronic searches

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 7) in the Cochrane Library, which contains the Acute Respiratory Infections Group's Specialised Register, MEDLINE (January 2004 to July week 4, 2021), Embase (January 2004 to July 2021), and CINAHL (January 2004 to July 2021).

We searched CENTRAL and MEDLINE using the search strategy described in Appendix 1. We combined the MEDLINE search terms with the Cochrane Highly Sensitive Search Strategy for identifying randomised trials in MEDLINE, sensitivity‐ and precision‐maximising version (2008 revision); Ovid format (Lefebvre 2021). We adapted the search strategy to search Embase (Appendix 2), and CINAHL (Appendix 3). We used no language or publication restrictions. Previous searches are detailed in Appendix 4.

Searching other resources

We searched the trials registries, World Health Organization International Clinical Trials Registry Platform (apps.who.int/trialsearch) and US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (www.clinicaltrials.gov) for completed and ongoing trials up to July 2021. We made all reasonable efforts to contact recognised experts in the fields of respiratory and intensive care medicine to obtain any additional trials, where applicable. We sent emails to primary or corresponding authors of potentially eligible studies and used the information provided if we got a reply. We manually searched the reference lists of included and excluded trials to identify any other published or unpublished works relevant to the review topic.

Data collection and analysis

Selection of studies

Initially, two review authors (JYT, APB) independently examined all potentially relevant citations using Covidence and retrieved the full text of articles that met the selection criteria in Review Manager 2020. Two review authors (JYT, APB) independently compared each article against the selection criteria to determine which articles to select for data extraction. During a subsequent update, due to expired search dates, two review authors (DAN, LV) independently examined all potentially relevant citations using Covidence, and retrieved the full text of articles that met the inclusion criteria in Review Manager 2020. We resolved any differences either by referral to a topic expert, consensus with a co‐author, or both. To reduce the risk of publication bias, there were no language restrictions.

Data extraction and management

We used a standardised data extraction form. Two review authors (JYT, APB) independently extracted data from each study, without blinding to authorship or journal publication. We resolved differences either by consensus or by referral to a contributor with topic expertise. When there were missing data, or further information was required, we contacted trial authors to obtain the required information. We extracted data from graphs where necessary. When duplicate publication occurred, the publication with the most data was the primary reference for the review. We kept and managed records of all articles identified from the search strategies, included and excluded, using a reference management system (Covidence).

Data extraction included the following categories.

  1. Method of allocation

  2. Concealment of allocation

  3. Country and setting where the study was performed

  4. Participant details

  5. Inclusion and exclusion criteria

  6. Details of intervention

  7. Outcomes measured

  8. Confounders

  9. Duration of study and frequency of measurements

  10. Numbers enrolled and completed in each group

  11. Baseline characteristics

  12. Results for each group

Assessment of risk of bias in included studies

Three review authors (JYT, APB, MK) independently assessed the quality of the trials to be included, without blinding to authorship or journal of publication. We assessed primary outcomes (where available) or secondary outcomes of parallel trials and cross‐over trials using the Cochrane RoB 2 tool (Sterne 2019). We also evaluated the risk of bias in the trials based on blinding to intervention, outcome measurement and completeness of follow‐up. We resolved differences in the allocation of trials into quality categories either by consensus or by referral to a third person with content expertise.

Measures of treatment effect

For binary outcomes, we calculated the odds ratio (OR) and 95% confidence interval (CI). We calculated the mean difference (MD) and 95% confidence interval (CI), using a fixed‐effect model for continuous outcomes. If we found significant heterogeneity (I2 statistic > 50%), we used a random‐effects model (Assessment of heterogeneity). For the other comparisons, we extracted data as median and interquartile range in Table 1, or mean and standard deviation in Table 2 and Table 3.

Open in table viewer
Table 1. Prone versus supine positioning (median and range data)

Study

Outcome

Supine (N)

Supine

(median)

Supine

(IQ range*)

Prone (N)

Prone

(median)

Prone

(IQ range*)

Baudin 2019

TcPCO2 (kPA)

14

6.5

* 6.1 to 6.8

14

6.9

* 6.1 to 7.7

Baudin 2019

FiO2 (%)

14

30

* 25 to 35

14

27

* 25 to 30

Baudin 2019

SpO2 (%)

14

97.5

* 95 to 99

14

96.5

* 94 to 98

Baudin 2019

Heart rate (beats/min)

14

159

* 146 to 164

14

156

* 144 to 163

Curley 2005

Minute

ventilation (minutes)

42

1.6

* 1.0 to 3.2

42

1.6

0.6 to 2.8

* Interquartile range

Open in table viewer
Table 2. Supine compared to good‐lung dependent (mean and SD data)

Study

Outcome

Participants (N)

Supine (mean)

Supine (SD)

Good‐lung dependent lung (mean)

Good‐lung dependent lung (SD)

Polacek 1992

PO2

25

115.36

45.28

111.92

50.42

Cross‐over trial with 13 participants in the intervention arm and 12 in the control arm

SD = standard deviation

Open in table viewer
Table 3. Supine compared to good‐lung independent (mean and SD data)

Study

Outcome

Participants (N)

Supine (mean)

Supine (SD)

Good‐lung independent lung (mean)

Good‐lung independent lung (SD)

Polacek 1992

PO2

25

115.36

45.28

118.14

48.67

Cross‐over trial with 12 participants in the intervention arm and 13 in the control arm

SD = standard deviation

Unit of analysis issues

Ideally, we would have used the results from paired analyses from the cross‐over trials. However, we included data from the first period only, as the cross‐over studies only reported data from the first period. Therefore, to maintain the quality of the current study, we followed the recommendations of Elbourne 2002 that state, "the results of two or more cross‐over trials might be combined, but with this pooled result kept separate from the data from  parallel‐group trials". We could not correct data for paired analysis in the meta‐analysis of cross‐over trials because of incomplete information, which may mean that we over‐estimated the pooled variance. Therefore, significant effects across groups may be less apparent in the meta‐analyses of cross‐over trials compared to the meta‐analyses of parallel‐group studies.

Dealing with missing data

We analysed data, as planned, on an intention‐to‐treat (ITT) basis. However, we did not perform a sensitivity analysis for parallel randomised trials or cross‐over trials, as data for this analysis were not reported.

Assessment of heterogeneity

We interpreted a Mantel‐Haenszel Chi2 value of less than 0.10, or an I2 statistic greater than 50%, or both, as significant heterogeneity. If heterogeneity was significant, we used a random‐effects model.

Assessment of reporting biases

Had there been 10 or more parallel trials reporting the same primary outcome, we would have generated a funnel plot (trial effect against trial size) to investigate the possibility of publication bias, but there were not enough data to do this.

Data synthesis

We undertook meta‐analyses where similar and meaningful combinations of participants with the same treatments and comparison groups were reported under similar clinical timings. We calculated the pooled OR and corresponding 95% CI for binary outcomes using a fixed‐effect model. We calculated the mean difference (MD) and 95% CI interval for meta‐analysis of continuous outcomes using a fixed‐effect model. If we found significant heterogeneity, we used a random‐effects model (Assessment of heterogeneity).

Subgroup analysis and investigation of heterogeneity

We considered a subgroup analysis to compare findings in different age groups, but there were not enough study data.

The pathophysiology of acute respiratory distress varies substantially. Therefore, we proposed to undertake a subgroup analysis based on the reported cause (and related pathophysiology) of respiratory distress.

We also proposed to include a subgroup analysis of the following age categories.

  1. Infants (28 days to 12 months)

  2. Toddlers and young children (12 months to 5 years)

  3. School‐age children (5 to 16 years)

As there may be greater scope for non‐ventilated participants to benefit from therapeutic body positioning, we also planned subgroup analysis of ventilated versus non‐ventilated children. We planned a subgroup analysis based on the temporal parameters of the positioning, if appropriate.

Sensitivity analysis

We had planned to undertake a sensitivity analysis based on the level of potential allocation bias. However, there were not enough data to do this.

Summary of findings and assessment of the certainty of the evidence

We created four summary of findings tables for the following outcomes: mortality (respiratory events), oxygen saturation (SaO2), blood gases (PaCO2 and PaO2), PaO2/FiO2 ratio, oxygenation index (FiO2% X MPAW/ PaO2), episodes of apnoea, and adverse outcomes (extubation or apnoea). See summary of findings Table 1summary of findings Table 2summary of findings Table 3summary of findings Table 4.

We used the five GRADE considerations (study limitations, consistency of effect, imprecision, indirectness, and publication bias) to assess the quality of evidence as it related to the studies that contributed data to the meta‐analyses for the prespecified outcomes (Atkins 2004). We used methods and recommendations described in Section 8.5 and Chapter 12 of the Cochrane Handbook for Systematic Reviews of Interventions, and GRADEproGDT software (GRADEpro GDTHiggins 2021). We justified all decisions to down‐ or upgrade the quality of evidence in footnotes, and made comments to aid readers’ understanding of the review where necessary.

Results

Description of studies

See Characteristics of included studies and Characteristics of excluded studies tables.

Results of the search

Following the original search, the first, second, and final updates that searched electronic databases up to July 2021, we identified 4798 unique records with 425 duplicates. We obtained 123 citations reporting 119 studies, commentaries, and reviews in full text based on the title and abstract. We excluded 116 studies (115 citations) following data extraction and included 6 studies (7 records). Citation screening identified one additional study after the final update for inclusion (Baudin 2019).

Included studies

Overall, we extracted data from six trials. Four were randomised controlled cross‐over trials (Baudin 2019Kornecki 2001Levene 1990Polacek 1992). The remaining two trials were parallel randomised trials (Curley 2005Ibrahim 2007).

Baudin 2019 was funded by a grant from the Fonds de recherche en santé du Québec. Curley 2005 was funded by the NIH/NINR. Levene 1990 was funded by the North East Thames Regional Health Authority. Ibrahim 2007 was supported by Al‐Noor specialist hospital‐KSA. Kornecki 2001 was supported by the Department of Critical Care Medicine, Division of Respiratory Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario. Polacek 1992 was supported by the Children's Mercy Hospital, Kansas City, Missouri.

There was a total of 198 participants. Thirteen (7.1%) of the participants were infants, aged between four weeks and 12 months (Levene 1990). The remaining 171 participants were aged one month to 16 years (Curley 2005Ibrahim 2007Kornecki 2001Polacek 1992), all but 15 of whom were mechanically ventilated (Polacek 1992).

The inclusion and exclusion criteria were not uniform across included trials. One study did not list any exclusion criteria, but excluded two children from the prone versus supine comparison because physical restrictions prevented them from being placed prone (Kornecki 2001). Curley 2005 and Ibrahim 2007 had extensive exclusion criteria, which included cardiac, respiratory, and neurological abnormalities.

The interventions included prone versus supine (Baudin 2019Curley 2005Ibrahim 2007Kornecki 2001Levene 1990); supine versus prone versus lateral; and right lateral versus left lateral (Polacek 1992).

The trial times also varied greatly, ranging from 15 minutes after a 15‐minute settling‐in period in Polacek 1992, to a median of 20 hours over a four‐day period in the studies by Curley 2005 and Ibrahim 2007. The outcomes reported across trials were arterial oxygen saturation (SaO2), transcutaneous oxygen pressure (PO2), transcutaneous carbon dioxide pressure (PCO2), lung function or P/F ratio, oxygenation index, tidal volume (VT), heart rate, respiratory rate, and adverse events.

Excluded studies

We excluded 27 of the 49 citations selected for full‐text review in the original review. These citations did not meet the selection criteria during a previous update (Gillies 2012) and remained excluded for this update. In this update, we excluded 36 studies as they did not meet the selection criteria. In 16 studies, the population was ineligible; eight used the wrong population (Akatsuka 2018Jang 2020Li Bassi 2017aLi Bassi 2017bLi Bassi 2017cLi Bassi 2017Najafi 2017Panigada 2017a), seven evaluated the intervention among an adult population (Anonymous 2005Ayzac 2016Hassankhani 2017Li 2018Pelosi 2001Thompson 2013Trikha 2013), and one evaluated a neonatal population (Pourazar 2018). Out of 10 studies, two used observational study designs (Curley 2000Murdoch 1994), and eight studies used inappropriate study designs (Baston 2019Brzęk 2019Casado‐Flores 2002Du 2018Kamo 2018Lee 2018Leger 2017Munshi 2017). Five studies were literature reviews (Bourenne 2018Dalmedico 2017Gattinoni 2018Guervilly 2019Johnson 2017), two were systematic reviews (Teng 2018Yue 2017), and one was a commentary (Kavanagh 2005). One study evaluated the wrong intervention (Li 2018), and one reported the wrong outcomes (Yonis 2017). One study was a conference presentation (Panigada 2017b), and one was a duplicate record for a study already considered for inclusion (Panigada 2017a).

Risk of bias in included studies

The overall risk of bias for primary or main outcomes as reported by study authors is summarised in Figure 1. See Characteristics of included studies.


Risk of bias summary: review authors' judgements about each risk of bias item for each included study

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

Allocation

Only two included trials provided an adequate description of the random sequence generation and concealment of allocation (Baudin 2019Curley 2005). We judged both trials at low risk of allocation bias. We considered all other trials at unclear risk of bias because sequence generation and allocation concealment were not described. This raised concerns about selection bias.

Blinding

We considered all trials at unclear risk or posing some concerns, because there was an inadequate description of the blinding process. However, we considered the risk of unblinded observers biasing the outcome unlikely, because objective outcomes were used.

Incomplete outcome data

We considered four trials as unclear risk of bias due to missing outcomes, as there was some loss to follow‐up (1/102)  in Curley 2005Ibrahim 2007, and Kornecki 2001, though minimal (2/16) in the study by Baudin 2019. However, we considered Levene 1990 at high risk of bias due to missing outcomes. Levene 1990 did not collect data from nine infants as the babies did not sleep or wake up during study time. There appeared to be complete follow‐up in Polacek 1992, which we considered at low risk of bias due to missing outcomes.

Selective reporting

We identified selective reporting of data for lung mechanics by Kornecki 2001. While the authors reported no differences between interventions, the data justifying this report were not shown.

Other potential sources of bias

A potential source of bias was the inclusion of four randomised controlled cross‐over trials (Baudin 2019; Kornecki 2001; Levene 1990; Polacek 1992). However, we did not identify bias arising from period or carry‐over effects in these studies. Furthermore, we analysed these studies using data from the first period only.

Effects of interventions

See: Summary of findings 1 Summary of findings table ‐ Prone compared to supine for acute respiratory distress in hospitalised infants and children (ARDs); Summary of findings 2 Summary of findings table ‐ Supine compared to good‐lung dependent for acute respiratory distress in hospitalised infants and children (ARDs); Summary of findings 3 Summary of findings table ‐ Supine compared to good‐lung independent for acute respiratory distress in hospitalised infants and children; Summary of findings 4 Summary of findings table ‐ Good‐lung independent compared to good‐lung dependent positioning for acute respiratory distress in hospitalised infants and children

Comparison 1: Prone versus supine positioning

Primary outcomes
1. Mortality: respiratory events

None of the studies included in this comparison reported data for this primary outcome.

2. Oxygen saturation (SaO2)

One trial reported oxygen saturation for prone versus supine positioning (Levene 1990). There was an inconclusive finding between the prone and supine groups in the SaO2 (mean difference (MD) 0.40 mmHg, 95% confidence interval (CI) ‐1.22 to 2.66; 30 participants; very low certainty evidence). The evidence is very uncertain about the change in oxygen saturation in the upper respiratory tract infection (MD ‐0.50 mmHg, 95% CI ‐2.58 to 1.58; 13 participants) and lower respiratory tract infection (MD 1.80, 95% CI ‐0.78 to 4.38; 17 participants; fixed‐effect; Analysis 1.1).

3. Blood gases (PaCO2, PaO2)

Curley 2005 reported PaCO2 and PaO2 for prone versus supine positioning in 99 participants. There was no conclusive finding between the prone and supine groups in the PaCO2 (MD 3.0 mmHg, 95% CI ‐1.93 to 7.93; 99 participants; low certainty evidence; fixed‐effect; Analysis 1.2). There were also inconclusive results between the prone and supine groups in the PaO2 (MD 2 mmHg, 95% CI ‐5.29 to 9.29; 99 participants; fixed‐effect; Analysis 1.3).

4. Lung function (PaO2/FiO2)

Two trials measured lung function (Curley 2005Ibrahim 2007).

There were no conclusive findings in lung function or PaO2/FiO2 (MD 28.16 mmHg, 95% CI ‐9.92 to 66.24; 2 trials, 121 participants; very low certainty evidence; random‐effects; Analysis 1.4).

5. Oxygenation index (FiO2% X MPAW/PaO2)

Two parallel trials (Curley 2005Ibrahim 2007) and one cross‐over trial (Kornecki 2001) reported oxygenation index for prone versus supine positioning. The oxygenation index was improved in the prone group (MD ‐2.42, 95% CI ‐3.60 to ‐1.25; 2 trials, 121 participants; very low certainty evidence; I2 = 0%; fixed‐effect; Analysis 1.5). This was largely due to the greater weighting given to the smaller study by Ibrahim 2007, which reported small standard deviations. Placing participants in the prone position also improved the oxygenation index in the study by Kornecki 2001 (MD ‐8.13, 95% CI ‐15.01 to ‐1.25; 10 participants; fixed‐effect; Analysis 1.6).

Oxygenation index by time

Kornecki 2001 also measured the oxygenation index as an outcome over time. Measurements were taken at 0.5 hours (MD ‐0.83, 95% CI ‐8.04 to 6.38), 2 hours (MD ‐2.08, 95% CI ‐8.61 to 4.45), 4 hours (MD ‐4.20, 95% CI ‐9.37 to 0.97), 6 hours (MD ‐5.13, 95% CI ‐10.13 to ‐0.13), 8 hours (MD ‐6.89, 95% CI ‐12.93 to ‐0.85), and 12 hours (MD ‐8.13, 95% CI ‐15.01 to ‐1.25). Measurements were inconclusive between prone and supine positioning until the six‐hour measurement. However, this improvement continued and was maintained for up to 12 hours; fixed‐effect; Analysis 1.6.

6. Episodes of apnoea

None of the studies included in this comparison reported data for this primary outcome.

Secondary outcomes
1. Respiratory mechanics (as defined by study authors)

Two trials assessed respiratory mechanics for prone versus supine positioning (Curley 2005Kornecki 2001). 

There was an apparent decrease in tidal volume between the prone and supine groups in the study by Curley 2005 (MD ‐0.60, 95% CI ‐1.05 to ‐0.15; 84 participants; fixed‐effects; Analysis 1.7). 

Kornecki 2001 did not report the collective data for respiratory mechanics but reported compliance, positive end‐expiratory pressure (PEEP), and resistance instead. There were inconclusive results between the prone and supine positions in respiratory compliance (MD 0.07, 95% CI ‐0.10 to 0.24; 10 participants; fixed‐effect; Analysis 1.8), a change in PEEP (MD ‐0.70 cm H2O, 95% CI ‐2.72 to 1.32; 20 participants; fixed‐effect; Analysis 1.9), and resistance (MD ‐0.00, 95% CI ‐0.05 to 0.04; 20 participants; fixed‐effect; Analysis 1.10).

2. Heart rate

Baudin 2019 assessed heart rate for prone versus supine positioning. The authors reported no significant difference in heart rate between the prone and the supine position (Table 1).

3. Per cent inspired oxygen received (FiO2)

Baudin 2019 also assessed per cent inspired oxygen for prone versus supine positioning. The authors reported no significant difference in FiO2 between the prone and the supine position (Table 1).

None of the included trials evaluated any of the other secondary outcomes or measured the length of intensive care unit or hospital stay.

Potential adverse outcomes

Curley 2005 reported extubations due to adverse events, obstructions of the endotracheal tube, pressure ulcers, and hypercapnia (high levels of arterial carbon dioxide). There were no conclusive findings for groups for extubation (odds ratio (OR) 0.57, 95% CI 0.13 to 2.54; 1 trial; 102 participants; very low certainty evidence), and the obstruction of the endotracheal tubes (OR 5.20, 95% CI 0.24 to 111.09; 1 trial; 102 participants; fixed‐effect; Analysis 1.11). The authors also found no conclusive evidence of a difference between groups for pressure ulcers (OR 1.00, 95% CI 0.41 to 2.44; 1 trial; 102 participants) and hypercapnia (OR 3.06, 95% CI 0.12 to 76.88; 1 trial; 102 participants; fixed‐effect; Analysis 1.11).

None of the included trials reported data for cutaneous damage to the chest wall. 

Comparison 2: Supine versus good‐lung dependent positioning

Primary outcomes
1. Mortality: respiratory events

None of the included trials in this comparison reported data for this primary outcome.

2. Oxygenation saturation (SaO2)

None of the included trials in this comparison reported data for this primary outcome.

3. Blood gases (PaCO2, PO2)

Polacek 1992 compared the PaO2 in the supine position to the good‐lung independent position. There was an inconclusive result that PaO2 was different between supine position and good‐lung independent (MD 3.44 mmHg, 95% CI ‐23.12 to 30.00; 1 study, 25 participants; very low certainty evidence; Table 2; fixed‐effect; Analysis 2.1).

4. Lung function (PaO2/FiO2)

None of the included trials in this comparison reported data for this primary outcome.

5. Oxygenation index (FiO2% X MPAW/PaO2)

None of the included trials in this comparison reported data for this primary outcome.

6. Episodes of apnoea

None of the included trials in this comparison reported data for this primary outcome.

Secondary outcomes

None of the included trials evaluated any secondary outcomes or measured the intensive care unit, or hospital length stay.

Potential adverse outcomes

For this comparison, no data were reported for any of the potential adverse outcomes.

Subgroup analysis

We intended to conduct subgroup analyses on ventilated versus non‐ventilated subgroups based on age groups, but there were inadequate data.

Sensitivity analysis

We had planned to conduct a sensitivity analysis based on the risk of bias assessment. However, this was not possible due to inadequate data.

Comparison 3: Supine versus good‐lung independent positioning

Primary outcomes
1. Mortality: respiratory events

None of the included trials in this comparison reported data for this primary outcome.

2. Oxygenation saturation (SaO2)

None of the included trials in this comparison reported data for this primary outcome.

3. Blood gases (PaCO2, PO2)

Polacek 1992 compared the PaO2 in the supine position with the good‐lung independent positioning. There was no conclusive result between positions for the PaO2 (MD ‐2.78 mmHg, 95% CI ‐28.84 to 23.28; 1 study, 25 participants; very low certainty evidence; fixed effects; Analysis 3.1Table 3).

4. Lung function (PaO2/FiO2)

None of the included trials in this comparison reported data for this primary outcome.

5. Oxygenation index (FiO2% X MPAW/PaO2)

None of the studies included in this comparison reported data for this primary outcome.

6. Episodes of apnoea

None of the included trials in this comparison reported data for this primary outcome.

Secondary outcomes

None of the included trials evaluated any secondary outcomes or measured the length of intensive care unit or hospital stay.

Potential adverse outcomes

None of the included trials in this comparison reported data for any potential adverse outcomes.

Comparison 4: Good‐lung independent positioning versus good‐lung dependent positioning

Primary outcomes
1. Mortality: respiratory events

None of the included trials in this comparison reported data for this primary outcome.

2. Oxygenation saturation (SaO2)

None of the included trials in this comparison reported data for this primary outcome.

3. Blood gases (PaCO2, PO2)

Polacek 1992 compared the PaO2 in the good‐lung independent position with the good‐lung dependent positioning. There was no conclusive finding between positions for the PaO2 (MD 6.22, 95% CI ‐21.25 to 33.69; 1 study, 25 participants; very low certainty evidence; fixed‐effect; Analysis 4.1Table 4).

Open in table viewer
Table 4. Good‐lung independent compared to good‐lung dependent (mean and SD data)

Study

Outcome

Participants (N)

Good‐lung independent (mean)

Good‐lung independent lung (SD)

Good‐lung dependent (mean)

Good‐lung dependent lung (SD)

Polacek 1992

PO2

25

118.14

48.67

111.92

50.42

Cross‐over trial with 12 participants in the intervention arm and 13 in the control arm

SD = standard deviation

4. Lung function (PaO2/FiO2)

None of the included trials in this comparison reported data for this primary outcome.

5. Oxygenation index (FiO2% X MPAW/PaO2)

None of the included trials in this comparison reported data for this primary outcome.

6. Episodes of apnoea

None of the included trials in this comparison reported data for this primary outcome.

Secondary outcomes

None of the included trials evaluated any secondary outcomes or measured intensive care unit length of stay or hospital stay.

Potential adverse outcomes

None of the included trials in this comparison reported data for any potential adverse outcomes.

Discussion

Overall, there seems to be little, and low certainty evidence to suggest a positive impact of positioning and mechanical ventilation on pulmonary physiology in hospitalised infants and children. An understanding of how haemodynamic stability and respiratory mechanics vary with changes in oxygenation and ventilatory outcomes becomes vital for optimal gas exchange and alveolar perfusion. Although a clear relationship between deficiency in a single oxygenation parameter and hypoxemia exists, respiratory mechanics vary due to changes in one ventilatory parameter against another, or as a function of time. 

In the current review, ventilatory outcomes were analysed by Curley 2005 and Kornecki 2001. While data for lung mechanics were not shown by Kornecki 2001, we separately reported study results of the indices predicting respiratory mechanics. However, results should be interpreted with caution, as to whether parameters represent a causal relationship with the observed change.

Prolonged ventilation with higher tidal volumes and airway pressures may exacerbate ventilator‐associated lung injury for patients in prone positions (Henderson 2014). While Curley 2005 investigated the use of low tidal volumes during prolonged periods of prone ventilation, the observed decrease in tidal volume allows for an even distribution of oxygen in the alveoli. One of the major complications associated with prone positioning is reduced tidal volume, with a concomitant decrease in the amount of oxygen delivered in or out of the lungs. However, the clinical benefits lie in its ability to reduce or prevent mechanical lung injury from alveolar distension and trauma. Likewise, there is a concomitant increase in oxygenation index during prone positioning, with more homogenous lung ventilation and perfusion. Guérin 2013 also reported improved oxygenation and reduced ventilator days as a complementary benefit of prone positioning in adults with acute respiratory distress syndrome. However, the current evidence is insufficient to determine the relationship between low tidal volume and reduced ventilator days in infants and children on prone ventilation.

It is also important to bear in mind the possible bias introduced by the included cross‐over studies. As included cross‐over designs only reported data from first periods, there was a lack of information to ascertain how issues regarding carry‐over effects were resolved by the authors. As paired analysis was not possible, we reported data from cross‐over trials as if they were parallel trials, but did not combine them with the parallel randomised trials. Therefore, these results need to be interpreted with caution. The inclusion of the study by Baudin 2019 introduced bias to the review, as study results were reported as interquartile ranges, indicative of skewed data. However, it would be inappropriate to remove the Baudin 2019 trial, as this could also introduce selection bias. Therefore, we reported the results for heart rate and FiO2 narratively.

Summary of main results

There appears to be low certainty evidence that there may be a positive effect of positioning on improving oxygenation in children with ARDS, who are mechanically ventilated. However, these results were limited by insufficient data from the included trials. There were also limited data to make any conclusions about adverse effects.

While there were few studies that met the inclusion criteria of this updated review, the included cross‐over trials reported data from only the first periods, which may have introduced a selection bias of the corresponding analyses. Although a particular concern with cross‐over designs is the risk of a carryover effect, the trial authors did clarify why they analysed data from the first period only. Another potential source of bias acknowledged in the study by Kornecki 2001 was incomplete outcome data and attrition bias as the trial authors also did not account for one participant when analysing respiratory mechanics. Baudin 2019 reported data as means and interquartile ranges (IQR). While the use of IQR depicts a high probability of bias in the reported data, calculating SD from interquartile range was not feasible, and results were reported narratively. While we considered the risk of selection, attrition, and detection bias to be high in the majority of the included studies, the trials did not describe how these potential biases were addressed. Therefore, there may still be other risks of bias in these trials.

Overall completeness and applicability of evidence

Given the limited amount of data and the possibility of publication bias, we were unable to draw any conclusions about the relative benefits and harms of any position in infants and children who have acute respiratory distress. No data were reported for clinically meaningful outcomes, such as mortality, morbidity, and recovery variables.

Although, we proposed to undertake a subgroup analysis based on age, the reported cause, and related pathophysiology of respiratory distress, we could not evaluate inconsistency in the result due to variation in the pathophysiology of acute respiratory distress. The only data available for subgroups came from one small trial by Levene 1990, which reported data from infants with upper and lower respiratory tract infections in the prone and supine positions.

Studies conducted amongst young infants face technical difficulties during outcome measurements. Hence, they are usually done when the infants are asleep, and are of short duration. For example, 2/12 participants were not included in one trial because they could not be placed in a prone position due to physical restrictions (Kornecki 2001). In the trial by Levene 1990, 9/39 infants did not go to sleep or woke when moved; hence did not contribute data to the review.

Quality of the evidence

Small participant numbers and short study times are major limitations to the conclusions drawn from this review. There was very low certainty evidence on the effects on oxygen saturation, lung function (PaO2/FiO2 ratio), oxygenation index (FiO2% X MPAW/ PaO2), tidal volume, extubation, obstructions of the endotracheal tube, pressure ulcers, and hypercapnia with prone positioning in both the parallel trials and cross‐over studies.

There was very low certainty evidence when supine positioning was compared to good‐lung dependent and independent positioning. There was very low certainty evidence when good‐lung independent positions and good‐lung dependent positions were compared. 

The majority of studies reported data from fewer than 50 infants or children, with the number of participants ranging from 10 (Kornecki 2001) to 102 (Curley 2005). Only two trials used random sequence generation during the conduct of their trials (Baudin 2019Curley 2005). As most of the trials included in this review were of short duration, it was not possible to establish whether any beneficial or adverse effects of positioning became clinically meaningful over longer periods. Only three trials collected data for more than an hour. Three reported outcomes from 2 to 24 hours (Curley 2005Ibrahim 2007Kornecki 2001), and no trial reported data for more than 24 hours. The study by Kornecki 2001 highlights the importance of collecting data for longer periods. While there was no difference between the prone and supine positions until the sixth hour, oxygenation appears to have steadily increased up to 12 hours.

Potential biases in the review process

For the primary objective, we compared studies amongst hospitalised infants and children with acute respiratory distress syndrome aged between four weeks and 16 years, to minimise potential biases in interpreting the intervention effects, by following Cochrane recommendations (Higgins 2011).  We conducted comprehensive searches without limiting the searches to a specific language. Two review authors independently assessed study eligibility, extracted data, and assessed the risk of bias for each included study. A third reviewer (with clinical expertise) adjudicated when there were discrepancies. 

However, there is the possibility that some studies available through the grey literature or unpublished may have been missed. Also, we used the updated version of the RoB 2 tool to assess the limitations of some of the source's biases in included studies (Sterne 2019). Since this version of the review is an update, this post hoc decision may have introduced some bias, but improved the comparability of our findings with current research.

Agreements and disagreements with other studies or reviews

The findings from this review show that short‐ and medium‐term prone positioning may be beneficial in improving oxygenation and ventilation in acutely respiratory‐distressed ventilated infants or children. Riva‐Fernandez 2016 concluded that prone position in ventilated preterm neonates improved oxygenation in the short term.

Similarly, reviews of positioning for respiratory‐distressed, ventilated adult participants have also concluded that prone positioning helped improve oxygenation in the short term (Ball 1999Curley 1999Munshi 2017Wong 1999). However, the evidence is inconclusive for mortality and adverse events, which were higher among participants placed in prone positions in Bloomfield 2015 and Munshi 2017.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

Figuras y tablas -
Figure 1

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

Comparison 1: Prone versus supine positioning, Outcome 1: SaO2

Figuras y tablas -
Analysis 1.1

Comparison 1: Prone versus supine positioning, Outcome 1: SaO2

Comparison 1: Prone versus supine positioning, Outcome 2: PaCO2

Figuras y tablas -
Analysis 1.2

Comparison 1: Prone versus supine positioning, Outcome 2: PaCO2

Comparison 1: Prone versus supine positioning, Outcome 3: PaO2

Figuras y tablas -
Analysis 1.3

Comparison 1: Prone versus supine positioning, Outcome 3: PaO2

Comparison 1: Prone versus supine positioning, Outcome 4: PaO2/FiO2 ratio

Figuras y tablas -
Analysis 1.4

Comparison 1: Prone versus supine positioning, Outcome 4: PaO2/FiO2 ratio

Comparison 1: Prone versus supine positioning, Outcome 5: Oxygenation index (parallel trials)

Figuras y tablas -
Analysis 1.5

Comparison 1: Prone versus supine positioning, Outcome 5: Oxygenation index (parallel trials)

Comparison 1: Prone versus supine positioning, Outcome 6: Oxygenation index (cross‐over trial)

Figuras y tablas -
Analysis 1.6

Comparison 1: Prone versus supine positioning, Outcome 6: Oxygenation index (cross‐over trial)

Comparison 1: Prone versus supine positioning, Outcome 7: Tidal volume

Figuras y tablas -
Analysis 1.7

Comparison 1: Prone versus supine positioning, Outcome 7: Tidal volume

Comparison 1: Prone versus supine positioning, Outcome 8: Respiratory compliance

Figuras y tablas -
Analysis 1.8

Comparison 1: Prone versus supine positioning, Outcome 8: Respiratory compliance

Comparison 1: Prone versus supine positioning, Outcome 9: Positive end‐expiratory pressure (PEEP)

Figuras y tablas -
Analysis 1.9

Comparison 1: Prone versus supine positioning, Outcome 9: Positive end‐expiratory pressure (PEEP)

Comparison 1: Prone versus supine positioning, Outcome 10: Respiratory resistance

Figuras y tablas -
Analysis 1.10

Comparison 1: Prone versus supine positioning, Outcome 10: Respiratory resistance

Comparison 1: Prone versus supine positioning, Outcome 11: Potential adverse outcomes

Figuras y tablas -
Analysis 1.11

Comparison 1: Prone versus supine positioning, Outcome 11: Potential adverse outcomes

Comparison 2: Supine versus good‐lung dependent positioning, Outcome 1: PaO2 (cross‐over trial)

Figuras y tablas -
Analysis 2.1

Comparison 2: Supine versus good‐lung dependent positioning, Outcome 1: PaO2 (cross‐over trial)

Comparison 3: Supine versus good‐lung independent positioning, Outcome 1: PaO 2 (cross‐over trial)

Figuras y tablas -
Analysis 3.1

Comparison 3: Supine versus good‐lung independent positioning, Outcome 1: PaO 2 (cross‐over trial)

Comparison 4: Good‐lung independent versus good‐lung dependent positioning, Outcome 1: PaO2 (cross‐over trial)

Figuras y tablas -
Analysis 4.1

Comparison 4: Good‐lung independent versus good‐lung dependent positioning, Outcome 1: PaO2 (cross‐over trial)

Summary of findings 1. Summary of findings table ‐ Prone compared to supine for acute respiratory distress in hospitalised infants and children (ARDs)

Prone compared to supine for acute respiratory distress in hospitalised infants and children (ARDs)

Patient or population: acute respiratory distress in hospitalised infants and children (ARDs)
Setting: hospital (paediatric critical care unit)
Intervention: prone
Comparison: supine

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Risk with supine

Risk with prone

Mortality (respiratory events) ‐ not reported

No studies reported this outcome

Oxygen saturation (SaO2)

The mean oxygen saturation (SaO2) ranged from 90.5 to 93.1 mmHg

mean 0.4 mmHg higher
(1.22 lower to 2.66 higher)

30
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

Blood gases (PO2)
follow‐up: range 1 hours to 7 days

The mean blood gases (PO2) ranged from 78 to 97.5 mmHg

mean 2 mmHg higher
(5.29 lower to 9.29 higher)

99
(1 RCT)

⊕⊕⊝⊝
Lowd,e

PaCO2
follow‐up: range 20 hours to 7 days

The mean paCO2 ranged from 6.5 to 53 mmHg

mean 3 mmHg higher
(1.93 lower to 7.93 higher)

99
(1 RCT)

⊕⊕⊝⊝
Lowd,e

Lung function (PaO2/FiO2 ratio)
follow‐up: range 1 hour to 7 days

The mean lung function (PaO2/FiO2 ratio) ranged from 153 to 176 mmHg

mean 28.16 mmHg higher
(9.92 lower to 66.24 higher)

121
(2 RCTs)

⊕⊝⊝⊝
Very lowa,b,d

Oxygenation index (FiO2% X MPAW/PaO2)
follow‐up: range 1 hour to 7 days

The mean oxygenation index (FiO2% X MPAW/PaO2) ranged from 9.5 to 11 mmHg

MD 2.42 mmHg lower
(3.6 lower to 1.25 lower)

121
(2 RCTs)

⊕⊝⊝⊝
Very lowa,f

Potential adverse outcomes (extubation)
assessed with: %
follow‐up: range 1 hours to 7 days

98 per 1000

58 per 1000
(14 to 216)

OR 0.57
(0.13 to 2.54)

102
(1 RCT)

⊕⊝⊝⊝
Very lowa,f

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; MD: mean difference; OR: odds ratio

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

See interactive version of this table: https://gdt.gradepro.org/presentations/#/isof/isof_question_revman_web_423281134243830314.

a We identified significant issues with the randomisation process and concealment of allocation
b The study was downgraded due to very wide confidence intervals indicating possible benefit or harm
c Downgraded due to very small single study assessment
d The study was downgraded due to very wide confidence intervals indicating possible benefit or harm
e This outcome was downgraded due to imprecision; very small single study
f Downgraded due to very small studies

Figuras y tablas -
Summary of findings 1. Summary of findings table ‐ Prone compared to supine for acute respiratory distress in hospitalised infants and children (ARDs)
Summary of findings 2. Summary of findings table ‐ Supine compared to good‐lung dependent for acute respiratory distress in hospitalised infants and children (ARDs)

Supine compared to good‐lung dependent for acute respiratory distress in hospitalised infants and children (ARDs)

Patient or population: acute respiratory distress in hospitalised infants and children (ARDs)
Setting: hospital (paediatric critical care unit)
Intervention: supine
Comparison: good‐lung dependent

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Risk with good‐lung dependent

Risk with supine

Mortality (respiratory events) ‐ not reported

No studies reported this outcome

Oxygen saturation (SaO2) ‐ not reported

No studies reported this outcome

PaO2
follow‐up: range 15 minutes to 45 minutes

The mean paO2 was 111.92 mmHg

mean 3.44 mmHg higher
(23.12 lower to 30 higher)

50
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

Blood gases (PaCO2) ‐ not reported

No studies reported this outcome

Lung function (PaO2/FiO2 ratio) ‐ not reported

No studies reported this outcome

Oxygenation index (FiO2% X MPAW/PaO2) ‐ not reported

No studies reported this outcome

Potential adverse outcomes (episodes of apnoea) ‐ not reported

No studies reported this outcome

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

See interactive version of this table: https://gdt.gradepro.org/presentations/#/isof/isof_question_revman_web_423282959442933151.

a We identified significant issues with the randomisation process as well as concealment of allocation
b A very wide and imprecise confidence intervals (CI), suggesting possible benefit or harm
c A very small single study

Figuras y tablas -
Summary of findings 2. Summary of findings table ‐ Supine compared to good‐lung dependent for acute respiratory distress in hospitalised infants and children (ARDs)
Summary of findings 3. Summary of findings table ‐ Supine compared to good‐lung independent for acute respiratory distress in hospitalised infants and children

Supine compared to good‐lung independent for acute respiratory distress in hospitalised infants and children

Patient or population: acute respiratory distress in hospitalised infants and children
Setting: hospital (paediatric critical care unit)
Intervention: supine
Comparison: good‐lung independent

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Risk with good‐lung independent

Risk with supine

Mortality (respiratory events) ‐ not reported

No studies reported this outcome

Oxygen saturation (SaO2) ‐ not reported

No studies reported this outcome

PaO 2
follow‐up: range 15 minutes to 45 minutes

The mean paO 2 was 118.14 mmHg

mean 2.78 mmHg lower
(28.84 lower to 23.28 higher)

50
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

Blood gases (PCO2) ‐ not reported

No studies reported this outcome

Lung function (PaO2/FiO2 ratio) ‐ not reported

No studies reported this outcome

Oxygenation index (FiO2% X MPAW/PaO2) ‐ not reported

No studies reported this outcome

Potential adverse outcomes (episodes of apnoea) ‐ not reported

No studies reported this outcome

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

See interactive version of this table: https://gdt.gradepro.org/presentations/#/isof/isof_question_revman_web_423283527611744015.

a We identified significant issues with the randomisation process as well as concealment of allocation
b Very wide confidence intervals indicating possible benefit or harm
c Downgraded due to very small single study

Figuras y tablas -
Summary of findings 3. Summary of findings table ‐ Supine compared to good‐lung independent for acute respiratory distress in hospitalised infants and children
Summary of findings 4. Summary of findings table ‐ Good‐lung independent compared to good‐lung dependent positioning for acute respiratory distress in hospitalised infants and children

Good‐lung independent compared to good‐lung dependent positioning for acute respiratory distress in hospitalised infants and children

Patient or population: acute respiratory distress in hospitalised infants and children
Setting: hospital (paediatric critical care unit)
Intervention: good‐lung independent
Comparison: good‐lung dependent positioning

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Risk with good‐lung dependent positioning

Risk with good‐lung independent

Mortality (respiratory events) ‐ not reported

No studies reported this outcome

Oxygen saturation (SaO2) ‐ not reported

No studies reported this outcome

PaO 2 (cross‐over trial)
follow‐up: range 15 minutes to 45 minutes

The mean paO 2 (cross‐over trial) was 111.92 mmHg

MD 6.22 mmHg higher
(21.25 lower to 33.69 higher)

50
(1 RCT)

⊕⊝⊝⊝
Very lowa,b,c

Blood gases (PaCO2) ‐ not reported

No studies reported this outcome

Lung function (PaO2/FiO2 ratio) ‐ not reported

No studies reported this outcome

Oxygenation index (FiO2% X MPAW/PaO2) ‐ not reported

No studies reported this outcome

Potential adverse outcomes (episodes of apnoea) ‐ not reported

No studies reported this outcome

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; MD: mean difference

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

See interactive version of this table: https://gdt.gradepro.org/presentations/#/isof/isof_question_revman_web_429747819004596191.

a We identified significant issues due to randomisation and poor allocation concealment
b Very large confidence intervals suggesting possible benefit or harm
c Downgraded due to findings from very small single study

Figuras y tablas -
Summary of findings 4. Summary of findings table ‐ Good‐lung independent compared to good‐lung dependent positioning for acute respiratory distress in hospitalised infants and children
Table 1. Prone versus supine positioning (median and range data)

Study

Outcome

Supine (N)

Supine

(median)

Supine

(IQ range*)

Prone (N)

Prone

(median)

Prone

(IQ range*)

Baudin 2019

TcPCO2 (kPA)

14

6.5

* 6.1 to 6.8

14

6.9

* 6.1 to 7.7

Baudin 2019

FiO2 (%)

14

30

* 25 to 35

14

27

* 25 to 30

Baudin 2019

SpO2 (%)

14

97.5

* 95 to 99

14

96.5

* 94 to 98

Baudin 2019

Heart rate (beats/min)

14

159

* 146 to 164

14

156

* 144 to 163

Curley 2005

Minute

ventilation (minutes)

42

1.6

* 1.0 to 3.2

42

1.6

0.6 to 2.8

* Interquartile range

Figuras y tablas -
Table 1. Prone versus supine positioning (median and range data)
Table 2. Supine compared to good‐lung dependent (mean and SD data)

Study

Outcome

Participants (N)

Supine (mean)

Supine (SD)

Good‐lung dependent lung (mean)

Good‐lung dependent lung (SD)

Polacek 1992

PO2

25

115.36

45.28

111.92

50.42

Cross‐over trial with 13 participants in the intervention arm and 12 in the control arm

SD = standard deviation

Figuras y tablas -
Table 2. Supine compared to good‐lung dependent (mean and SD data)
Table 3. Supine compared to good‐lung independent (mean and SD data)

Study

Outcome

Participants (N)

Supine (mean)

Supine (SD)

Good‐lung independent lung (mean)

Good‐lung independent lung (SD)

Polacek 1992

PO2

25

115.36

45.28

118.14

48.67

Cross‐over trial with 12 participants in the intervention arm and 13 in the control arm

SD = standard deviation

Figuras y tablas -
Table 3. Supine compared to good‐lung independent (mean and SD data)
Table 4. Good‐lung independent compared to good‐lung dependent (mean and SD data)

Study

Outcome

Participants (N)

Good‐lung independent (mean)

Good‐lung independent lung (SD)

Good‐lung dependent (mean)

Good‐lung dependent lung (SD)

Polacek 1992

PO2

25

118.14

48.67

111.92

50.42

Cross‐over trial with 12 participants in the intervention arm and 13 in the control arm

SD = standard deviation

Figuras y tablas -
Table 4. Good‐lung independent compared to good‐lung dependent (mean and SD data)
Comparison 1. Prone versus supine positioning

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1.1 SaO2 Show forest plot

1

60

Mean Difference (IV, Fixed, 95% CI)

0.40 [‐1.22, 2.02]

1.1.1 Upper respiratory Indices

1

26

Mean Difference (IV, Fixed, 95% CI)

‐0.50 [‐2.58, 1.58]

1.1.2 Lower respiratory Indices

1

34

Mean Difference (IV, Fixed, 95% CI)

1.80 [‐0.78, 4.38]

1.2 PaCO2 Show forest plot

1

99

Mean Difference (IV, Fixed, 95% CI)

3.00 [‐1.93, 7.93]

1.3 PaO2 Show forest plot

1

99

Mean Difference (IV, Fixed, 95% CI)

2.00 [‐5.29, 9.29]

1.4 PaO2/FiO2 ratio Show forest plot

2

121

Mean Difference (IV, Random, 95% CI)

28.16 [‐9.92, 66.24]

1.5 Oxygenation index (parallel trials) Show forest plot

2

121

Mean Difference (IV, Fixed, 95% CI)

‐2.42 [‐3.60, ‐1.25]

1.6 Oxygenation index (cross‐over trial) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

1.6.1 30 minutes

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

1.6.2 2 hour

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

1.6.3 4 hours

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

1.6.4 6 hours

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

1.6.5 8 hours

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

1.6.6 12 hours

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

1.7 Tidal volume Show forest plot

1

84

Mean Difference (IV, Fixed, 95% CI)

‐0.60 [‐1.05, ‐0.15]

1.8 Respiratory compliance Show forest plot

1

20

Mean Difference (IV, Fixed, 95% CI)

0.07 [‐0.10, 0.24]

1.9 Positive end‐expiratory pressure (PEEP) Show forest plot

1

20

Mean Difference (IV, Fixed, 95% CI)

‐0.70 [‐2.72, 1.32]

1.10 Respiratory resistance Show forest plot

1

20

Mean Difference (IV, Fixed, 95% CI)

‐0.00 [‐0.05, 0.04]

1.11 Potential adverse outcomes Show forest plot

1

408

Odds Ratio (M‐H, Fixed, 95% CI)

1.07 [0.53, 2.14]

1.11.1 Extubation

1

102

Odds Ratio (M‐H, Fixed, 95% CI)

0.58 [0.13, 2.54]

1.11.2 Obstructed endotracheal tube

1

102

Odds Ratio (M‐H, Fixed, 95% CI)

5.20 [0.24, 111.09]

1.11.3 Pressure ulcers

1

102

Odds Ratio (M‐H, Fixed, 95% CI)

1.00 [0.41, 2.44]

1.11.4 Hypercapnia

1

102

Odds Ratio (M‐H, Fixed, 95% CI)

3.06 [0.12, 76.88]

Figuras y tablas -
Comparison 1. Prone versus supine positioning
Comparison 2. Supine versus good‐lung dependent positioning

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

2.1 PaO2 (cross‐over trial) Show forest plot

1

50

Mean Difference (IV, Fixed, 95% CI)

3.44 [‐23.12, 30.00]

Figuras y tablas -
Comparison 2. Supine versus good‐lung dependent positioning
Comparison 3. Supine versus good‐lung independent positioning

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

3.1 PaO 2 (cross‐over trial) Show forest plot

1

50

Mean Difference (IV, Fixed, 95% CI)

‐2.78 [‐28.84, 23.28]

Figuras y tablas -
Comparison 3. Supine versus good‐lung independent positioning
Comparison 4. Good‐lung independent versus good‐lung dependent positioning

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

4.1 PaO2 (cross‐over trial) Show forest plot

1

50

Mean Difference (IV, Fixed, 95% CI)

6.22 [‐21.25, 33.69]

Figuras y tablas -
Comparison 4. Good‐lung independent versus good‐lung dependent positioning