الفهرس 
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Abstract
Mechanical ventilation in the prone position has been evaluated as a strategy to improve oxygenation and lung recruitment in acute respiratory failure.
The mechanisms by which prone positioning may benefit patients with acute respiratory distress syndrome (ARDS) undergoing mechanical ventilation include improving
• Ventilation–Perfusion matching.
• Increasing end-expiratory lung volume.
• Preventing VILI by more uniform distribution of tidal volume through lung recruitment and changes in chest wall mechanics.
Prone positioning transferred from a salvage therapy for refractory hypoxemia to a lung-protective strategy intended to improve survival in severe ARDS.
Prone positioning has never been proved to allow a survival advantage when used as a late rescue management for refractory hypoxemia.
Thus, following up patients’ hemodynamic parameters during prone position is important to detect early hemodynamic instability and termination of prone position procedure.
The aim of the study was to determine the hemodynamic effects of prone position in children with acute respiratory distress syndrome (ARDS).
In this prospective observational study, patients were diagnosed ARDS according to Pediatric Acute Lung Injury consensus conference (PALICC)2015.
Patients were classified to patients with mild, moderate and severe ARDS, then subdivided into success and failure group according who complete the study and whom the study was aborted with failure criteria.
Patients with increased ICP or spinal instability, increased IAP, patients with abdominal or chest wounds, extremely obese patients, hemodynamic instability, patients suffered from congenital heart diseases or arrhythmia were excluded from the study.
The following data were collected from the studied group, history taking, then monitoring vital data including( HR, RR, MAP,SPO2,measuring CVP and IVP) initially, and calculating pediatric SOFA score assessing the severity of illness and organ dysfunction and withdrawing labs including: CBC, CRP, blood and sputum cultures and doing CXR.
Then, adjusting ventilatory mechanics and calculating oxygenation indices(OI, OSI, P/F ratio and S/F ratio) initially according to each patient’s condition. Finally assessing patients’ hemodynamic stability using echo measuring: stroke volume, pulmonary pressure and lt ventricular EF and calculating cardiac output, cardiac index, systemic vascular resistance index and IVC distensibility index.
After patients’ stabilization within 2-4hrs, patients were prepared for prone position paying attention to precautions during placing patients in prone position.
50 patients were included in this study, 26 males (52%) and 24 females (48%) with average age 13.7±11.6 months and average weight 7.8±3.3 Kg.
10 (20%) patients presented with mild ARDS,17 (34%) patient were moderate ARDS and 23 (46%) severe ARDS with further subdivision into success group 43(86%) patients and failure group 7patients (14%), those that showed:
1) All required progressive increase in vasopressors and inotropes during prone position. 4 patients suffered from tachycardia, 6 pts developed hypotension and decreased CI.
2) 5 patients out of 7, developed DROP in SPO2 <10% of their baseline.Only 1 patient was desaturated <90%.
3) 6 patients were suffered from severe ARDS with initial OI ˃18.
4) All 7 patients, their P/F ratio was <100 after PP.
Out of 50 patients, 22 (44%) patients with pulmonary causes(pneumonia) of ARDS while 28 (56%) patients with extrapulmonary(septic shock).
Age, weight and sex were not a factor that predicted response to prone position in this study.
Regarding clinical data, patients were shifted from supine to prone position assessing vital data. There was significant decrease in HR from 139.5±28.1 beat/min in supine to 131.1±23.3b/min in PP after 16hrs.
There was significant improvement in SpO2 in PP 98.5±2% in PP after 16hrs than 96.9% in supine.
As regard hemodynamics: there was significant increase in pulmonary pressure and DIVC after 16hrs PP P+ was 23.3 mmHg than initial P+ was 21.2mmHg in supine.
As regard oxygenation indices: there was significant improvement in oxygenation with improvement of P/F ratio, S/F ratio, OI and OSI after 16hrs PP despite non-significant change in mechanical ventilation parameters.
Then, patients were classified into success and failure group. Success group who completed 16hrs prone position had significantly lower SOFA score at admission, yet no significant difference in RR, HR, mean blood pressure, and CVP between the two groups but there was significant higher IVP in failure group.
There was non-significant change in initial hemodynamics between both groups.
As regards respiratory mechanics, success group has significant lower initial MAP(17.4 mmHg) while 21.7 mmHg in failure group, delta P 44.1 in success group and 56.7 in failure group. Higher FIO2 (81.4%) needed in failure group and 62% in success group.
Regarding oxygenation indices, failure group showed significantly higher oxygenation index(25.9),significantly lower S/F ratio (119.8) and lower PH (7.2)in ABG.
In conclusion, PP used in treatment of pediatric ARDS for a period upto 16 hours improving oxygenation without hemodynamic instability.