In children with acute respiratory distress syndrome (PARDS), the lungs suddenly become severely inflamed. As a result, oxygen transfer to the bloodstream is impaired. The condition is associated with high morbidity and mortality: children are admitted to the paediatric intensive care unit, where invasive ventilation supports their breathing while physicians treat the underlying cause.
But how can physicians best ventilate these children? For more than 30 years, paediatric critical care clinicians have debated the risk-benefit ratio of prone versus supine positioning and high-frequency oscillatory ventilation (HFOV) versus conventional mechanical ventilation. Prone positioning has shown favourable survival outcomes in adults with ARDS, but are the methods used in adults equally beneficial for children? Until now, there were insufficient data to support either prone positioning or HFOV in PARDS.
To answer these questions, Kneyber, who is affiliated with the Beatrix Children’s Hospital of the UMCG, led the international PROSpect study, together with two American colleagues. Around sixty paediatric intensive care units worldwide took part. The researchers compared prone positioning with supine positioning and conventional ventilation with HFOV in a study that assigned paediatric patients (0-20 years) with moderate-to-severe PARDS to one of four combinations of position and ventilation strategy.
The research found that neither intervention improved ventilator-free days up to day 28. The trial also did not show significant interaction effects between position and ventilation strategy, or between either strategy and the type of lung injury or age group. This result is particularly striking for prone positioning, since this treatment is common in adults with ARDS. The results did show that adverse events such as artificial airway obstruction and pressure-related skin injuries occurred more frequently during prone positioning. Additionally, haemodynamic instability was observed more frequently in HFOV.
Absence of a benefit, together with more potential harm, causes the researchers to recommend against the routine use of prone positioning or HFOV as first-line therapy in patients with moderate-to-severe PARDS. They do however highlight that these findings do not include the use of prone positioning or HFOV as a rescue treatment in select patients.
The findings give physicians more guidance in the treatment of critically ill paediatric patients. They also underscore why research in the paediatric intensive care unit is essential: results in adults cannot directly be translated to children.
The American National Institutes of Health (NIH) / National Heart, Lung and Blood Institute (NHLBI) supported the study with more than 15 million dollars.
Read the full publication in The Lancet.
