Prone positioning in children with respiratory failure because of coronavirus disease 2019

Abstract

Purpose of review: Acute respiratory distress syndrome (ARDS) is a common manifestation of severe COVID-19. Prone positioning has been used successfully in adult patients with ARDS and has been shown to decrease mortality. The efficacy of prone positioning in pediatric ARDS is less clear. In this review, we discuss the physiologic principles and literature on prone positioning in adults and children relative to COVID-19.

Recent findings: There are limited published data on prone positioning in respiratory failure because of COVID-19. The use of proning in nonintubated patients with COVID-19 may improve oxygenation and dyspnea but has not been associated with improved outcomes. Initial adult cohort studies of intubated patients undergoing prone positioning in severe ARDS related to COVID-19 have shown an improvement in mortality. Although the use of proning in children with severe COVID-19 is recommended, data supporting its use is scarce.

Summary: Additional studies to evaluate the efficacy of prone positioning in pediatric ARDS are needed to provide evidence for or against this treatment strategy in children. Given the unknown evolution of this pandemic, collaborative research efforts across pediatric centers provides the greatest opportunity to develop a data driven-approach to make use of this potential therapy.

Figure 1:

In the supine position, competitive forces from the chest wall, heart, and abdominal compartment lead to preferential ventilation of more anterior lung units (L) with collapse of more posterior lung units. Simultaneously, the posterior aspect of the lung receives a greater proportion of pulmonary blood flow, resulting in ventilation/perfusion mismatch. When prone, these competitive forces are reduced with more uniform aeration of lung units. A more uniform distribution of pulmonary blood flow in the prone position results in greater ventilation/perfusion matching. Black arrows indicate the force of gravity from heart and abdominal compartment; thicker arrows indicate greater force. Circles represent lung units with size of the circle indicative of degree of collapse.