Florent Baudin1, Guillaume Emeriaud2, Sandrine Essouri3, Jennifer Beck4, Aurelie Portefaix5, Etienne Javouhey6, Claude Guerin7. 1. Lyon University Hospital, Hôpital Femme Mère Enfant, Pediatric Intensive Care Unit, Bron, France; University of Lyon, University Claude Bernard Lyon1, Ifsttar, UMRESTTE, UMR T_9405, Lyon, France. Electronic address: florent.baudin@chu-lyon.fr. 2. Pediatric Intensive Care Unit, CHU Sainte-Justine, University de Montréal, Montreal, Quebec, Canada; Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada. 3. Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada. 4. Keenan Research Center for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St-Michael's Hospital, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada. 5. Center of Clinical Investigation, Lyon University Hospital, Bron, France. 6. Lyon University Hospital, Hôpital Femme Mère Enfant, Pediatric Intensive Care Unit, Bron, France; University of Lyon, University Claude Bernard Lyon1, Ifsttar, UMRESTTE, UMR T_9405, Lyon, France. 7. Lyon University Hospital, Hôpital Femme Mère Enfant, Medical Intensive Care Unit, Bron, France; University of Lyon, Université Claude Bernard Lyon 1, Villeurbanne, France; INSERM 955-Eq13, Institut Mondor de Recherche Biomédicale, Créteil, France.
Abstract
OBJECTIVE: To assess the effect of the prone position on physiological measures, including inspiratory effort, metabolic cost of breathing, and neural drive to the diaphragm as compared with the supine position in infants with severe bronchiolitis requiring noninvasive ventilation. STUDY DESIGN:Fourteen infants, median age 33 days (IQR [first and third quartiles], 25-58) were randomized to receive 7 cmH2O continuous positive airway pressure for 1 hour in the prone position or in the supine position, which was followed by cross-over to the supine position and the prone position for 1 hour, respectively. Flow, esophageal, airway, gastric, and transdiaphragmatic pressures, as well as electrical activity of the diaphragm were simultaneously recorded. The modified Wood clinical asthma score was also assessed. RESULTS:Median esophageal pressure-time product per minute was significantly lower in the prone position than in the supine position (227 cmH2O*s/minute [IQR, 156-282] cmH2O*s/minute vs 353 cmH2O*s/minute [IQR, 249-386 cmH2O*s/minute]; P = .048), as were the modified Wood clinical asthma score (P = .033) and electrical activity of the diaphragm (P = .006). The neuromechanical efficiency of the diaphragm, as assessed by transdiaphramagtic pressure to electrical activity of the diaphragm swing ratio, was significantly higher in the prone position than in the supine position (1.1 cmH2O/µV [IQR, 0.9-1.3 cmH2O/µV] vs 0.7 cmH2O/µV [IQR, 0.6-1.2 cmH2O/µV], respectively; P = .022). CONCLUSIONS: This study suggests a benefit of the prone position for infants with severe bronchiolitis requiring noninvasive ventilation by significantly decreasing the inspiratory effort and the metabolic cost of breathing. Further studies are needed to evaluate the potential impact of these physiological findings in a larger population. TRIAL REGISTRATION: Clinicaltrials.gov: NCT02602678.
RCT Entities:
OBJECTIVE: To assess the effect of the prone position on physiological measures, including inspiratory effort, metabolic cost of breathing, and neural drive to the diaphragm as compared with the supine position in infants with severe bronchiolitis requiring noninvasive ventilation. STUDY DESIGN: Fourteen infants, median age 33 days (IQR [first and third quartiles], 25-58) were randomized to receive 7 cmH2O continuous positive airway pressure for 1 hour in the prone position or in the supine position, which was followed by cross-over to the supine position and the prone position for 1 hour, respectively. Flow, esophageal, airway, gastric, and transdiaphragmatic pressures, as well as electrical activity of the diaphragm were simultaneously recorded. The modified Wood clinical asthma score was also assessed. RESULTS: Median esophageal pressure-time product per minute was significantly lower in the prone position than in the supine position (227 cmH2O*s/minute [IQR, 156-282] cmH2O*s/minute vs 353 cmH2O*s/minute [IQR, 249-386 cmH2O*s/minute]; P = .048), as were the modified Wood clinical asthma score (P = .033) and electrical activity of the diaphragm (P = .006). The neuromechanical efficiency of the diaphragm, as assessed by transdiaphramagtic pressure to electrical activity of the diaphragm swing ratio, was significantly higher in the prone position than in the supine position (1.1 cmH2O/µV [IQR, 0.9-1.3 cmH2O/µV] vs 0.7 cmH2O/µV [IQR, 0.6-1.2 cmH2O/µV], respectively; P = .022). CONCLUSIONS: This study suggests a benefit of the prone position for infants with severe bronchiolitis requiring noninvasive ventilation by significantly decreasing the inspiratory effort and the metabolic cost of breathing. Further studies are needed to evaluate the potential impact of these physiological findings in a larger population. TRIAL REGISTRATION: Clinicaltrials.gov: NCT02602678.