Cot death and prone sleeping position.
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Humans↗
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[Crib death and infant mortality in the Nordic countries 1988-93].
During the years 1970-89 there was a marked increase in cot deaths in the Nordic countries Denmark, Finland, Norway and Sweden. Since 1990 cot death has decreased dramatically, especially in Norway and Denmark. Mortality rates have decreased by 74% between 1989 and 1993 in Norway and by 69% between 1991 and 1993 in Denmark. Investigations in Norway during the same period have shown a change in the sleeping positions of infants, from prone positions to supine/side positions. Infant mortality rates have decreased in all the Nordic countries and in 1993 varied from 5.45 per thousand live births in Denmark to 4.40 in Finland.
Humans↗
[Crib death and infant mortality in Scandinavia 1988-1993].
During the years 1970-1989 there was a marked increase in cot death in the Nordic countries Denmark, Finland, Norway and Sweden. Since 1990 cot death has decreased dramatically, especially in Norway and Denmark. Mortality rates have decreased by 74 per cent between 1989 and 1993 in Norway and by 69 per cent between 1991 and 1993 in Denmark. Investigations in Norway during the same period have shown a change in the sleeping positions of infants, from prone positions to supine/side positions. Infant mortality rates have decreased in all the Nordic countries and in 1993 varied from 5.45 per thousand live births in Denmark to 4.40 in Finland.
Humans↗
[A case of refractory bronchial asthma improving with treatments of sleep apnea syndrome].
A 29-year-old woman of the bronchial asthma was admitted to our hospital. Her asthmatic symptoms were refractory in spite of the administration of 30 mg of daily-oral prednisolone. During the asthma-attack, marked arterial oxygen desaturation was noted. So we doubted that she had obstructive sleep apnea complicated with obesity. Sleep Apnea Monitor revealed her nocturnal desaturation and frequent sleep apnea. To avoid the desaturation, we recommended her to keep prone position during the sleep. And both desaturation and asthmatic symptoms were dramatically improved. Nasal-CPAP also had been effective for them. These findings suggest that sleep apnea mediated oxygen desaturation may be one of the promotor of asthmatic symptoms.
Adult↗
Effect of prone sleeping on circulatory control in infants.
BACKGROUND: The mechanism of death in sudden infant death syndrome (SIDS) remains unclear. Progressive bradycardia is the pre-eminent terminal event, suggesting that circulatory failure might be a crucial factor. Vasomotor tone regulates the circulatory system by controlling blood volume distribution while maintaining venous return and blood pressure. AIM: To examine whether prone sleeping, the most consistently identified risk factor for SIDS, has a measurable influence on vasomotor/circulatory control. METHODS: 44 full term infants (mean age, 7.9 weeks) were studied during an overnight sleep. Recordings were made while the infants were horizontal and asleep in the supine and prone positions, and repeated after a head up tilt to 60 degrees, maintained for 30 minutes, while in both sleep positions. Blood pressure, heart rate, anterior shin, and anterior abdominal wall skin temperatures were measured. RESULTS: Systolic blood pressure was lower, but peripheral skin temperature and heart rate were higher during sleep, while horizontal, in the prone rather than the supine position. After tilting, there was a greater reduction in blood pressure and a greater increase in peripheral skin temperature and heart rate when in the prone position. Anterior abdominal wall skin temperature did not vary in either sleeping positions while horizontal or tilted. CONCLUSION: Prone sleeping has a measurable effect on circulatory control, with a reduction in vasomotor tone resulting in peripheral vasodilatation, a higher peripheral skin temperature, a lower blood pressure, and a higher resting heart rate. Because vasomotor tone is crucially important in circulatory control this could be a factor in increasing the risk of SIDS.
Autonomic Nervous System↗
Does prone or supine position influence pain responses in preterm infants at 32 weeks gestational age?
OBJECTIVE: The purpose of this study was to examine the influence of prone and supine position in preterm infants during acute pain of blood collection. SETTING: Level III Neonatal Intensive Care Unit (NICU). STUDY DESIGN: Thirty-eight preterm infants (birthweight 1339 [590-2525] g, GA 29 [25- 32] wks) were in 2 groups depending on their position in the isolette prior to and during heel lance at 32 weeks post-conceptional age. The study design was a comparison between groups (Prone, Supine) during 2 events (Baseline, Heel lance). OUTCOME MEASURE: Pain measures were multidimensional, including behavioral (sleep-wake state and facial activity) and physiological (heart rate) responses measured continuously prior to (Baseline) and during blood collection (Lance). RESULTS: Both groups of infants displayed statistically significant shifts in sleep-wake state to greater arousal, and increased facial activity and heart rate, from Baseline to Lance. Prone position was associated with significantly more deep sleep during Baseline, compared with Supine position, but there were no differences in sleep-wake state during Lance. Minor increased facial activity was shown in some time segments of Baseline for infants in Supine compared with Prone, but did not differ overall between positions. Prone and Supine position did not affect heart rate significantly during Baseline or Lance events. CONCLUSIONS: Prone position promotes deep sleep in preterm neonates at 32 weeks post-conceptional age when they are undisturbed. However, placement in prone position is not a sufficient environmental comfort intervention for painful invasive procedures such as heel lance for blood sampling in the NICU. Neonates require other environmental supports to promote coping with this stressful event.
Facial Expression↗
[Is spinal anesthesia for operations in the prone or jackknife position suitable?].
There is still controversy on the usefulness of spinal anesthesia for operations performed in the prone or jackknife position. There is about the risk of inadvertent increase of the sensomotory blockade with the patient in the prone position and the difficulty of managing consecutive cardiorespiratory complications or inducing general anesthesia in case of failures. This article reviews the current literature in terms of safety and effectiveness of spinal anesthesia for such operations. For lower-limb or perianal operations with limited extension and blood loss, performed in the prone position, spinal anesthesia seems to be a safe, effective and economic technique in patients without severe a cardiac history. Substantial knowledge about the onset time, fixation time, duration of sensomotory block and baricity of the applied local anesthetic is crucial in this setting. Obese patients are at risk for sudden extension of the block when turned into the prone position. Additional narcotics and sedatives should be avoided and continuous monitoring of hemodynamic and respiratory parameters, of the level of the blockade and vigilance of the patient is mandatory.
Anesthesia, Spinal↗
Advances in the management of acute respiratory distress syndrome: protective ventilation.
The approach to mechanical ventilation has been revolutionized by new insights into the pathogenesis of respiratory failure in acute respiratory distress syndrome (ARDS). Concepts such as low-volume ventilation, permissive hypercapnia, inverse ratio ventilation, best and intrinsic positive end-expiratory pressure, airway shear, pressure volume curves, inflection points, and prone positioning have radically transformed thinking about ventilator management. Since 1966, more than 8000 ARDS-related publications have appeared. Studies highlighting the experimental basis for innovations in mechanical ventilation are presented. Selected clinical series that exemplify the use of these new strategies are reviewed, to demonstrate how key experimental and clinical research has altered our understanding about what works, and why. Mismanagement of mechanical ventilation causes lung injury and increases mortality. The strategy of protective ventilation has provided the first substantial reduction of mortality in the history of ARDS.
Humans↗
Static pressure volume curves and body posture in acute respiratory failure.
OBJECTIVE: In acute respiratory distress syndrome the body posture effects on pressure-volume (PV) curves are still unclear. We examined the effects of prone position on inflation PV curves and their potential relationships with postural alterations in gas exchange. DESIGN AND SETTING: Prospective study with patients serving as their own controls in a university-affiliated 30-bed intensive care unit. PATIENTS AND PARTICIPANTS: Thirteen anesthetized, paralyzed, semirecumbent, mechanically ventilated patients with early/severe/diffuse ARDS. INTERVENTIONS: Sequential body posture changes: preprone semirecumbent, prone, and postprone semirecumbent. MEASUREMENTS AND RESULTS: In each posture hemodynamics, gas exchange, and lung volumes were determined before/during removal and after restoration of positive end-expiratory pressure (PEEP=10.2+/-0.6 cmH2O). At zero PEEP PV curves of respiratory system, lung, and chest wall were constructed. Prone position vs. preprone semirecumbent resulted in significantly reduced pressure at lower inflection point of lung PV curve (2.2+/-0.2 vs. 3.7+/-0.5 cmH2O) and increased volume at upper inflection point (0.87+/-0.03 vs. 0.69+/-0.05 l). Postural reduction in lower inflection point pressure of lung PV curve was the sole independent predictor of pronation-induced increases in PaO2/FIO2 (R2=0.76). PaO2/FIO2 increases were also significantly related with increases in functional residual capacity (R2=0.60). CONCLUSIONS: In early/severe/diffuse ARDS prone position reduces lower inflection point pressure and increases upper inflection point UIP volume of the lung PV curve. Lower inflection point pressure reductions explain oxygenation improvements, which are also associated with a postural increase in functional residual capacity.
Adult↗
Arterial oxygen saturation in infants at risk of sudden death: influence of sleeping position.
To study the possible influence of sleeping position on arterial oxygen saturation, measured by pulse oximetry (SpO2), 7-h overnight recordings of breathing movements and ECG were performed in 43 infants (median age 2.4 months, range 0.2-11 months) at increased risk of sudden infant death syndrome (SIDS). Infants were randomly allocated to start sleeping either in their usual sleeping position or in the opposite position. After 3.5 h, all infants were gently turned over. Thus, each infant served as their own control. Recordings were analysed for sleep time, baseline SpO2 (only during regular breathing), and the number and duration of desaturations (a decrease in SpO2 to < or = 80%). In the prone position, a significantly higher proportion of time was spent asleep (median 79% versus 70%; p < 0.05). Median baseline SpO2 was 98.8% (91.7-100%) in the prone and 99.0% (92.0-100%) in the supine position (ns). A total of 191 desaturations were found in 29 recordings; 96 in the prone and 95 in the supine position (ns). One infant subsequently died of SIDS while sleeping in the prone position. He had a relatively high number of desaturations (n = 12) which all occurred in the prone position. These results confirm earlier studies which could not find a significant influence of sleeping position on baseline oxygenation. The occurrence of desaturations in the prone position only in the infant who subsequently died requires further investigation.
Electrocardiography↗
Effect of infant sleeping position on sleep spindles.
Sleep spindles play an active role in inducing and maintaining sleep and may affect arousal by blocking the transmission of external stimuli through the thalamus to the cortex. Previously we have demonstrated that sleeping in the prone position impairs arousal in infants at 2-3 months of age, but not at 5-6 months. We aimed to examine if sleeping position and postnatal age affected duration and/or density of sleep spindles. Twenty-one healthy term infants were studied using daytime polysomnography at 2-3 months and 16 were again studied at 5-6 months. Infants slept both prone and supine at each study. The mean duration of non-rapid eye movement (NREM) sleep was not different between the two studies in either position. At 2-3 months both spindle density (P < 0.001) and proportion of NREM sleep (P < 0.025) with spindles were significantly greater in the supine than in the prone position. At 5-6 months spindle duration was longer in the supine than in the prone position (P < 0.03). Spindle density in the supine position was not different between the two studies, however, when infants slept prone, it was significantly increased at 5-6 months compared with 2-3 months (P < 0.001). Arousal threshold was not correlated with either spindle density or percentage of NREM sleep with spindles in either position at either study. In this study spindle density and the percentage time spent with spindles were not well correlated with infant arousability, and hence may not be able to be used as markers of depressed arousal responses in infants.
Arousal↗
The influence of sleeping position on functional residual capacity and effective pulmonary blood flow in healthy neonates.
Variation in body position has been shown to affect respiratory function in adults and neonates with and without respiratory illness. At present it remains unclear why respiratory function should be affected by different body positions. We hypothesized that the effect of body weight on the relatively compliant chest wall of the newborn infant in the prone position would cause a reduction in functional residual capacity (FRC) and a compensatory improvement in ventilation/perfusion matching as measured by effective pulmonary blood flow. To evaluate this, a paired crossover study was performed on 12 normal newborn infants. The inert gas (argon) rebreathing method adapted for neonates was used to measure FRC. Simultaneously effective pulmonary blood flow (Qpeff) was determined using Freon 22 and a mass spectrometer with computerized analysis. The babies were studied in three different positions in random order: prone, supine and right lateral decubitus. The means (95% confidence intervals) of the three groups of FRC were 23.8 (19.2 to 28.4), 23.8 (20.2 to 27.5), and 24.3 (19.5 to 29.2) ml/kg, respectively (P = 0.59) and for Qpeff were 104 (91 to 116), 108 (95 to 122), 109 (97 to 122) ml/ kg-min, respectively (P = 0.11). Thus no significant differences were demonstrated. In nine of the babies, a repeat supine measurement was taken at the end of the study to assess repeatability of the method. In these nine babies alone the results were 22.7 (19.1 to 26.3) and 22.1 (18.6 to 25.6) ml/kg for FRC, and 102 (89 to 116) and 98 (90 to 107) ml/kg-min for Qpeff. The coefficients of repeatability were 4.7 ml/kg for FRC (21%) and 30 ml/kg-min for Qpeff (30%).
Argon↗
Cardiac axis change between prone and supine positioning may contribute to differences in 99Tc(m)-MIBI myocardial SPET imaging.
The aims of this study were to assess the effect of prone and supine positioning on 99Tc(m)-MIBI myocardial SPET images and the contribution of cardiac axis change. We compared 227 tomograms of patients imaged in the prone position with 227 tomograms of the same patients imaged in the supine position. For each tomographic session, the axis angle of the heart was recorded using an in-house program. The results showed a significant change in the cardiac axis angle of 9 degrees in the transaxial plane (P < 0.001). This change in the cardiac axis correlated with differences in cardiac wall activity (wall activity when the patient was imaged in the prone position minus wall activity when the patient was imaged in the supine position). Our results suggest that factors other than diaphragmatic movement and attenuation could account for the differences in wall activity observed when patients are imaged prone versus supine. Differences in the intensity of photon attenuation in the heart itself, depending on the cardiac axis, could be a contributing factor. Quantitation of the variation in wall activity leads us to suggest that 99Tc(m)-MIBI SPET should be performed in the prone position to allow better visualization of the inferior and the septal walls. The anterior and lateral walls are better studied in the supine position. Images acquired in both the prone and supine positions would allow the best assessment of all walls.
Coronary Disease↗
Prognostic implications of combined prone and supine acquisitions in patients with equivocal or abnormal supine myocardial perfusion SPECT.
UNLABELLED: Although acquisition of (99m)Tc-sestamibi myocardial perfusion SPECT (MPS) with the patient in the prone position is commonly used to minimize attenuation artifacts, the impact of combined prone and supine imaging on the prognostic evaluation of coronary artery disease (CAD) has not been determined. The prognostic implications of MPS obtained in both prone and supine positions in patients with perfusion defects on supine MPS were evaluated. METHODS: We studied 3,834 patients who were monitored for 24.2 +/- 6.0 mo after rest (201)Tl/stress (99m)Tc-sestamibi MPS acquired during 1994-1995, when prone acquisition was performed only in patients with inferior wall perfusion defects that might represent attenuation or motion artifact. RESULTS: During follow-up, there were 132 hard events (cardiac death or myocardial infarction) and 375 total events (hard events or late myocardial revascularization). Overall, patients who underwent prone and supine acquisitions had similar characteristics to those who underwent supine-only imaging, with the exception of being more commonly male. In multivariable analysis, there were similar independent predictors for hard events and total events; the type of acquisition (prone and supine or supine-only) was not a significant predictor of either of these outcome events. After risk adjustment, the predicted event rates were nearly identical for patients undergoing prone and supine compared with supine-only studies. Both observed and predicted hard event rates of patients with normal prone and supine versus supine-only imaging were very low (observed, 0.7%/y and 0.5%/y, respectively; predicted, 1.5% over 24 mo for both). There was no reduction in the higher rates of events associated with abnormal scan results with the combination of prone and supine imaging. CONCLUSION: Patients with inferior wall defects on supine MPS that are not present on prone MPS have a low risk of subsequent cardiac events, similar to that of patients with normal supine-only studies.
Adenosine↗
[Effect of kinetic therapy on the treatment outcome in patients with post-traumatic lung failure].
Intermittent prone positioning (PP) is a promising therapy of patients with severe respiratory failure. Evaluations of patient outcomes can not, to dare, be found in the literature. This study was conducted to investigate the effects of intermittent PP on patients with posttraumatic respiratory failure (PaO2/FiO2 < 280 mmHg) in comparison with conventional therapy in suspine position. The collected data is part of our prospective polytrauma study. 136 polytraumized patients (mean ISS 23.4) were included and evaluated. 77 patients had a severe chest trauma with an AIS > or = 3. Of these, 47 patients developed a respiratory failure. 19 of these patients were treated conventionally in suspine position, 28 patients were intermittently turned prone. Having similar AIS (3.6 vs. 33), the PP-patients had a significantly severer trauma (ISS 35.8 vs. 24.5). Though the injury severity of the PP-patients was much higher, the time of ventilation (32 vs. 31 d) and the ICU stay (39 vs. 36 d) was similar to the patients treated in suspine position. The mortility of PP-patients was 0%, of suspine positioned patients 26%. After the first PP the PaO2/FiO2 ratio increased with an average of 82 mmHg (26-151 mmHg). The FiO2 was reduced from 0.45 (0.35-1.0) to 0.26 (0.21-0.35). Beside the beneficial effect of PP on the oxygenation we have, for the first time evidence that PP improves the outcome of patients with posttraumatic respiratory failure.
Adolescent↗
The supine view in double-contrast knee arthrography.
Knee arthrography is a widely used diagnostic procedure, but there is disagreement regarding the relative efficacy of single vs. double-contrast examinations in the evaluation for meniscal tears. In 353 double-contrast knee arthrograms, combining supine positioning with the routinely accepted prone views, there were 222 meniscal tears diagnosed using prone positioning alone, and seven additional tears were found with the added supine maneuver. Even though the knee joint was distended with both contrast material and air, the prone views tended to outline the meniscus in a double-contrast fashion, whereas the supine views provided single positive contrast detail of the same area. Supine views are particularly helpful when an obvious meniscal tear is not fluoroscopically apparent during prone filming.
Adolescent↗
Infant sleep position: A telephone survey of inner-city parents of color.
OBJECTIVE: To assess what positions parents were placing their infants to sleep and their opinion about sleep positioning. DESIGN: A prospective telephone survey of parents of 2-month-old infants with repeated measures at 4 months that began during the second wave of the Back to Sleep campaign in 1994. PARTICIPANTS: African-American, Hispanic, Asian, and American Indian parents from inner cities in the north central United States. RESULTS: Preference for prone positioning existed at both 2 and 4 months (over 40%). Twenty-four percent of parents disagreed with the recommendations of the American Academy of Pediatrics regarding supine or lateral positioning. CONCLUSIONS: Although prone sleep positioning has decreased over the past 5 years, many inner-city parents of color prefer this over supine. The Back to Sleep campaign appears effective in changing attitudes and medical personnel appear influential in promoting risk reductions associated with sudden infant death syndrome. More efforts are clearly needed to convince parents who disagree with and resist recommendations.sleep, infants, SIDS, African-Americans, Back to Sleep (campaign).
Ethnicity↗
Body position does not influence the location of ventilator-induced lung injury.
OBJECTIVE: To ascertain whether the locations of ventilator-induced lung injury (VILI) are influenced by body position. DESIGN: Randomized prospective short-term study. SETTING: Animal laboratory at a university school of medicine. INTERVENTIONS: Twelve white rabbits were mechanically ventilated in IMV mode with an infant ventilator (V.I.P. Bird, Bird Products, Palm Springs, Calif., USA). Based on the results of a preliminary study to determine the ventilator settings at which the lungs of rabbits were injured within 5 h in the supine position, the ventilator was set at F(I)O2 0.21, at a rate of 30/min, T(I) 0.6 s, peak inspiratory pressure 30 cm H2O, inspiratory flow 10 l/min with no applied positive end-expiratory pressure (PEEP). Six of the animals were tested in the supine position and the other six in the prone position. Respiratory gases were measured and CT scanning was performed every 30 min. The animals were ventilated for 5 h or until pulmonary parenchymal opacification was detected. The lungs were divided into three areas from apex to base and three levels from ventral to dorsal, and the location of opacification was ascribed according to this scheme. After the experiment, the lungs were excised and examined histologically. MEASUREMENTS AND RESULTS: Parenchymal opacification occurred mainly in the dorsal lung areas. The time from the beginning of ventilation to the appearance of lung damage was 60-120 min in the supine (S) group, and 60-270 min in the prone (P) group, and it was significantly longer in the prone group (P < 0.01). We observed diffuse lung damage, including hyaline membrane formation, intra-alveolar edema, and infiltration of inflammatory cells. CONCLUSIONS: Body position affected the time course of the development of VILI, but it did not affect the location.
Analysis of Variance↗