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PubMed1992

Sleeping positions of infants in the Cape Peninsula.

The prone position is thought to be an important factor in the sudden infant death syndrome (SIDS). The sleep positions of unselected infants aged 6 months and younger attending clinics in the Cape Peninsula were studied; 62.4% slept prone with the face to the side. This position differs between the ethnic groups (whites 50.0%; blacks 58.7%; coloureds 69.8%) and the respondents' social class (higher classes 54.1%; lower classes 69.2%). The sex of the baby, the sleeping place and the educational level of the mother did not influence the position used. Ninety-four per cent of black infants slept with their mothers compared with 71% of coloured and 4% of white babies. The study confirmed that there are cultural differences in sleeping positions adopted by infants. The role this plays in SIDS among different ethnic groupings still needs to be clarified.

Educational Status↗

PubMed1999

Respiratory failure: current status of experimental therapies.

A number of advances in the treatment of infants and children with respiratory failure have been investigated in the laboratory with translation to clinical practice. Investigators have recognized that application of high ventilating pressures and failure to apply adequate levels of positive end-expiratory pressure (PEEP) can inflict injury to the already failing lung. Other interventions such as prone positioning and application of new ventilating strategies such as proportional assist ventilation (PAV), inverse ratio ventilation (IRV), high frequency ventilation, liquid ventilation, and intratracheal pulmonary ventilation (ITPV), continue to be developed and explored. Administration of inhaled nitric oxide (iNO) may improve pulmonary physiology and gas exchange in patients with respiratory insufficiency. Finally, the technique of extracorporeal life support (ECLS) is being simplified and refined. This report summarizes the status of these advances and describes the basic science and clinical research that brought them to clinical application.

Algorithms↗

PubMed2000

[The relationship between sleep position and therapeutic effect of the Esmarch-Scheine appliance in sleep apnea syndromes].

Recently an oral appliance is being used increasingly for the treatment of sleep apnea syndrome. But the success rate of oral appliance therapy shows large interindividual difference, and which factors influence its efficiency remain uncertain. To elucidate the influence of the sleep posture on the therapeutic effect of the Esmarch device, 58 patients with sleep apnea syndrome were investigated polysomnographically before and after insertion of the device. The sleep position during each apnea was classified into three types; supine, lateral and prone. The mean apnea index (25.6 +/- 18.7) decreased significantly (p < 0.0001) after insertion of the device (11.5 +/- 12.6). The number of apneas (in the supine and prone) positions was significantly reduced from 18.0 +/- 16.7 and 2.0 +/- 3.6 to 5.0 +/- 11.2, p < 0.001, and 0.3 +/- 0.4, p < 0.005, respectively, but that in the lateral position was slightly increased from 5.6 +/- 9.4 and 6.2 +/- 8.9. The percent of apneas was 70.3% for supine, 21.9% for lateral, and 7.8% for prone before therapy and 43.5%, 53.9% and 2.6%, respectively after therapy. The results indicated that the effectiveness of oral appliance therapy can differ greatly with the sleep posture. The sleep posture recorded polysomnography may be important for choice of oral appliance therapy and its prognosis.

Female↗

PubMed2005

Bench-to-bedside review: adjuncts to mechanical ventilation in patients with acute lung injury.

Mechanical ventilation is indispensable for the survival of patients with acute lung injury and acute respiratory distress syndrome. However, excessive tidal volumes and inadequate lung recruitment may contribute to mortality by causing ventilator-induced lung injury. This bench-to-bedside review presents the scientific rationale for using adjuncts to mechanical ventilation aimed at optimizing lung recruitment and preventing the deleterious consequences of reduced tidal volume. To enhance CO2 elimination when tidal volume is reduced, the following are possible: first, ventilator respiratory frequency can be increased without necessarily generating intrinsic positive end-expiratory pressure; second, instrumental dead space can be reduced by replacing the heat and moisture exchanger with a conventional humidifier; and third, expiratory washout can be used for replacing the CO2-laden gas present at end expiration in the instrumental dead space by a fresh gas (this method is still experimental). For optimizing lung recruitment and preventing lung derecruitment there are the following possibilities: first, recruitment manoeuvres may be performed in the most hypoxaemic patients before implementing the preset positive end-expiratory pressure or after episodes of accidental lung derecruitment; second, the patient can be turned to the prone position; third, closed-circuit endotracheal suctioning is to be preferred to open endotracheal suctioning.

Bronchi↗

PubMed1998

Sleeping position, breastfeeding, bedsharing and passive smoking in 3-month-old Swedish infants.

Parents of 1028 infants who attended community-based infant health clinics were interviewed concerning infant sleeping position, feeding habits, bedsharing and passive smoking at 3 months of postnatal age. In addition, they were asked to state which source of information had mainly influenced them in the choice of the sleeping position. Fifteen per cent of the infants were regularly laid to sleep in the prone position, compared with 72% (1991) before official guidelines concerning infant sleeping position were issued. The overall prevalence of exclusive breastfeeding was 70.4%. Prevalence of maternal smoking was 17.9% and 22.8% of the infants were regularly bedsharing with the parents. Those mothers who did not comply with official recommendations regarding infant sleeping position were also less likely to follow other recommendations concerning infant care practices. Prone sleeping infants were more likely to be formula fed and exposed to passive smoking, and hence associated with additional risk factors for sudden infant death syndrome.

Breast Feeding↗

PubMed1996

The relationship between surface and radiological deformity in adolescent idiopathic scoliosis: effect of change in body position.

Three-dimensional (3D) surface deformity of the trunk in adolescent idiopathic scoliosis (AIS) is affected by changes in patient position. Initial quantification of the curve and its associated deformity, as well as subsequent monitoring, relies on both radiological and surface measurements. However, there is often a discrepancy between radiological and apparent surface deformity. The present investigation studied the dynamics of the 3D deformity associated with changes in patient position on 27 patients with AIS. The trunk deformity was quantified in three positions by measuring the angle of thoracic inclination at each vertebral level using a scoliometer. The patients all had full spine radiography in the antero-posterior erect position. Vertebral rotation and lateral spinal curvature were measured from the radiographs. Body position altered the magnitude of the surface deformity over the whole trunk, with the prone position offering the optimum relationship between 3D trunk shape and radiological deformity. This could be attributed to the ease and standardisation of positioning for prone measurements, together with increased patient comfort. It is suggested that adoption of standardised positioning and measurement of surface and radiological deformity will permit consistency of clinical judgement based on these parameters.

Adolescent↗

PubMed2002

Back shape assessment in each of three positions in preoperative patients with adolescent idiopathic scoliosis: evaluation of a 10-level Scoliometer method interpolated to 18-levels.

A Scoliometer was used by one observer (RKP) to assess the reproducibility of angle of trunk inclinations (ATIs) in 13 preoperative patients with AIS (thoracic 7, thoracolumbar 6, mean Cobb angle 50 degrees, right 9, age 15.4 years, girls 10). Three positions were used namely standing forward-bending, (FB) sitting FB and prone. Readings of ATI on the back were obtained at each of 10 levels (T1-S1). The subject was repositioned after walking around the room and a second set of readings obtained (repeats). All readings were converted by a computer program to 18 levels and plotted. The readings from 18 levels were analysed by level, as well as summated and averaged both without and with correction for the side of the curve. Conclusions. Back surface asymmetry measured with a Scoliometer in these preoperative patients with AIS is less in the prone position than in each of the forward bending positions. The standing FB position has the best reproducibility which supports the practice of using this position to measure Scoliometer ATIs in preoperative patients with AIS.

Adolescent↗

PubMed2001

Comparison of CT myelography performed in the prone and supine positions in the detection of cervical spinal stenosis.

AIM: To quantify the change in the cross-sectional area of the cervical spinal cord and subarachnoid space (SAS) in the supine neutral vs prone extension positions in patients with myelopathy undergoing cervical CT myelography. MATERIAL AND METHODS: Axial CT myelgrams of 21 myelopathic patients were performed in both the supine neutral and prone extension positions. The SAS and cord cross-sectional areas were then measured at the disk spaces and mid-pedicle levels from C2 to T1 in both the supine and prone positions using a public domain NIH Image program, version 156b18. Mean area measurements in both positions were then compared for each level examined. RESULTS: Mean SAS cross-sectional area in the prone position was notably reduced compared with the supine position at C4-C5 [128.8 mm2 vs 168.1 mm2 (P<.05)], and C5-C6 [98.8 mm2 vs 143.2 mm2 (P<.05)] disk levels. The mean cord cross-sectional area failed to change significantly with positioning. CONCLUSIONS: Prone myelography may demonstrate a greater degree of cervical spine stenosis compared with CT myelography performed in the supine position in myelopathic patients. Imaging with the patient prone with neck extended in both myelography and CTM may improve precision in the results of measurements of the stenotic spinal canal when comparing these two methods. Blease Graham III, C. (2001). Clinical Radiology56, 35-39.

Adult↗

PubMed2004

Characterization of lesions missed on interpretation of CT colonography using a 2D search method.

OBJECTIVE: We examined potential factors that may cause false-negative results on CT colonography examinations. MATERIALS AND METHODS: In this prospective and retrospective study, 500 asymptomatic patients at high risk for colorectal cancer underwent CT colonography and colonoscopy. Each CT data set was interpreted by two independent observers, who were unaware of endoscopic findings, using a method of searching through enlarged axial images to detect intraluminal lesions. Another observer identified and characterized lesions missed at prospective interpretation. Polyps were assessed for size, method of visualization, intrinsic and extrinsic features, and examination quality. RESULTS: We found 116 polyps at least 5 mm in diameter, 54 (47%) of which were missed by at least one of the prospective observers. Polyps seen in only one position were missed more often than polyps seen in both supine and prone positions (84% vs 50%, p < 0.01). Polyps located in suboptimally prepared colonic segments or along a thickened colonic wall were more frequently missed (p = 0.02 and p = 0.05, respectively). Endoscopic morphology and irregular surface contour were associated with missed lesions of all sizes (p = 0.03 and p = 0.04, respectively). Rounded intraluminal lesions were detected more often than other morphologies on CT (p = 0.04). CONCLUSION: Factors that influence the likelihood that a polyp may be missed at interpretation of CT colonography include being seen only in one position, having flat endoscopic or CT morphology, having surface irregularity, and being located in a poorly prepared segment or along a thickened colonic wall. Understanding these features should lead to improved polyp detection on CT colonography.

Aged↗

PubMed1998

Effect of customized small bowel displacement system in pelvic irradiation.

PURPOSE: Authors designed a customized small bowel displacement system (SBDS) to displace the small bowel out of the pelvic radiation fields and to minimize treatment related bowel morbidity. METHODS AND MATERIALS: From August 1995 to May 1996, 55 consecutive patients who received pelvic radiation therapy with the SBDS were included in this study. The SBDS consists of a customized Styrofoam compression device that can displace the small bowel out of the radiation fields and an individualized immobilization abdominal board for easy daily setup of the patient in prone position. After opacifying the small bowel with barium, the patients were laid prone and posterior-anterior (PA) and lateral (LAT) simulation films were taken with and without the SBDS. The volume of the small bowel included in the radiation fields with and without the SBDS were compared. RESULTS: Using the SBDS, the mean small bowel volume was reduced by 59% on PA and 51% on LAT films (p = 0.0001). In six patients (6 of 55, 11%), it was possible that no small bowel was included within the treatment fields. The mean upward displacement of the most caudal small bowel was 4.8 cm using the SBDS. Patients treated with the SBDS manifested a significantly lower incidence of diarrhea requiring medication (8 of 55, 15%) vs. those without the SBDS (24 of 39, 62%) (p < 0.05). CONCLUSION: The SBDS is a novel method that can be used to displace the small bowel away from the treatment portal effectively and to reduce the radiation therapy morbidity. Compliance with setup is excellent.

Adult↗

PubMed1999

Internal organ motion in prostate cancer patients treated in prone and supine treatment position.

BACKGROUND AND PURPOSE: To compare supine and prone treatment positions for prostate cancer patients with respect to internal prostate motion and the required treatment planning margins. MATERIALS AND METHODS: Fifteen patients were treated in supine and fifteen in prone position. For each patient, a planning computed tomography (CT) scan was used for treatment planning. Three repeat CT scans were made in weeks 2, 4, and 6 of the radiotherapy treatment. Only for the planning CT scan, laxation was used to minimise the rectal content. For all patients, the clinical target volume (CTV) consisted of prostate and seminal vesicles. Variations in the position of the CTV relative to the bony anatomy in the four CT scans of each patient were assessed using 3D chamfer matching. The overall variations were separated into variations in the mean CTV position per patient (i.e. the systematic component) and the average 'day-to-day' variation (i.e. the random component). Required planning margins to account for the systematic and random variations in internal organ position and patient set-up were estimated retrospectively using coverage probability matrices. RESULTS: The observed overall variation in the internal CTV position was larger for the patients treated in supine position. For the supine and prone treatment positions, the random components of the variation along the anterior-posterior axis (i.e. towards the rectum) were 2.4 and 1.5 mm (I standard deviation (1 SD)), respectively; the random rotations around the left-right axis were 3.0 and 2.9 degrees (1 SD). The systematic components of these motions (1 SD) were larger: 2.6 and 3.3 mm, and 3.7 and 5.6 degrees, respectively. The set-up variations were similar for both treatment positions. Despite the smaller overall variations in CTV position for the patients in prone position, the required planning margin is equal for both groups (about 1 cm except for 0.5 cm in lateral direction) due to the larger impact of the systematic variations. However, significant time trends cause a systematic ventral-superior shift of the CTV in supine position only. CONCLUSIONS: For internal prostate movement, it is important to distinguish systematic from random variations. Compared to patients in supine position, patients in prone position had smaller random but somewhat larger systematic variations in the most important coordinates of the internal CTV position. The estimated planning margins to account for the geometrical uncertainties were therefore similar for the two treatment positions.

Algorithms↗

PubMed1992

Gas exchange in dogs in the prone and supine positions.

To determine the cause of the difference in gas exchange between the prone and supine postures in dogs, gas exchange was assessed by the multiple inert gas elimination technique (MIGET) and distribution of pulmonary blood flow was determined using radioactively labeled microspheres in seven anesthetized paralyzed dogs. Each animal was studied in the prone and supine positions in random order while tidal volume and respiratory frequency were kept constant with mechanical ventilation. Mean arterial PO2 was significantly lower (P less than 0.01) in the supine [96 +/- 10 (SD) Torr] than in the prone (107 +/- 6 Torr) position, whereas arterial PCO2 was constant (38 Torr). The distribution of blood flow (Q) vs. ventilation-to-perfusion ratio obtained from MIGET was significantly wider (P less than 0.01) in the supine [ln SD(Q) = 0.75 +/- 0.26] than in the prone position [ln SD (Q) = 0.34 +/- 0.05]. Right-to-left pulmonary shunting was not significantly altered. The distribution of microspheres was more heterogeneous in the supine than in the prone position. The larger heterogeneity was due in part to dorsal-to-ventral gradients in Q in the supine position that were not present in the prone position (P less than 0.01). The decreased efficiency of oxygenation in the supine posture is caused by an increased ventilation-to-perfusion mismatch that accompanies an increase in the heterogeneity of Q distribution.

Animals↗

PubMedDate not supplied

Proning patients in intensive care.

Patients with acute lung injury pose significant problems for the intensive care team. The use of the prone position with these patients is attracting increasing interest. Information on the practicalities of proning was obtained from other intensive care units by using a simple questionnaire. The necessity for nursing guidelines for proning is discussed, and the consequent development of these is described.

Blood Gas Analysis↗

PubMed2005

Influence of supine sleep positioning on early motor milestone acquisition.

This study aimed to determine whether supine sleep-positioned infants have delayed motor skills at age 4 and 6 months, and if delays are associated with decreased exposure to prone position. One 4 and one 6-month-old sample of healthy infants born at term were recruited. Motor assessments included the Peabody Developmental Motor Scale (PDMS) and Alberta Infant Motor Scale (AIMS). Parents completed an infant behavior diary for 3 consecutive days. Seventy-one 4-month-old infants were assessed (38 males; mean age 4.4 mo, standard deviation [SD] 0.2). Mean motor scores were close to normative standards (AIMS 47.7, SD 19.6; PDMS gross motor quotient [GMQ] 96.3, SD 6.5; PDMS fine motor quotient [FMQ] 99.2, SD 4.8). No infant scored below cut-off values used to identify motor delay. Milestones less likely to be achieved included extended arm support in prone, hands to feet in supine, and sitting with arm support. Exposure to 'tummy time' while awake was correlated with AIMS scores (r = 0.38, p < 0.01). F i fty 6-month-old infants were assessed (21 males; mean age 6.4 mo, SD 0.4). Mean scores were shifted down for all scales, and as much as 1 SD for PDMS (AIMS 44.5, SD 21.6; PDMS GMQ 85.7, SD 7.6; PDMS FMQ 88.9, SD 9.0). Only 22% of 6-month-olds could sit without arm support versus 50% expected in a normative sample. Remarkably, 22% of our sample exhibited gross motor delays (quotient <78). Tummy time (awake) was significantly associated with the AIMS (r = 0.64) and PDMS GMQ (r = 0.55) and FMQ (r = 0.33) quotients, even after adjusting for confounders. Typically developing infants who were sleep-positioned in supine had delayed motor development by age 6 months, and this was significantly associated with limited exposure to awake prone positioning. This has important implications for interpreting motor assessments of infants at risk and for preventing inappropriate referrals.

Age Factors↗

PubMed1995

Structured observation of motor performance (SOMP-I) applied to neonatally healthy fullterm infants at the ages of 0-10 months.

A new protocol for structured observation of motor performance in infants, SOMP-I, was applied to 72 neonatally healthy fullterm infants at 0, 2, 4, 6 and 10 months of age. It contains 13 items, formed as ascending scales, consisting of detailed descriptions of motor performance in different body positions and body parts. The observed motor performance is assessed regarding level of development (progress), and degree and type of deviation from the described performance (quality). When observed according to the new protocol, the infants' motor performance corresponded to higher levels of motor development with increasing age and agreed with descriptions in other standardized developmental scales. With age, the motor performance observed was distributed over more levels in the different scales and the number of infants with deviations from the described performance increased in most positions, but decreased in the prone position. The item for the head, at 2 months, showed the largest number of infants with deviations. The total number of deviations in each infant was small. In conclusion, the SOMP-I protocol can describe motor performance in a group of infants who were healthy at birth and is detailed enough to identify differences regarding progress of motor development and quality of motor performance. The assessment is easily performed.

Aging↗

PubMed1978

Radiological features of vascular compression of the duodenum occurring as a complication of the treatment of scoliosis (the cast syndrome).

The application of a body cast or the surgical correction of scoliosis is occasionally associated with acute obstructive vascular compression of the duodenum. The clinical and radiological manifestations observed in 10 such patients are described. All cases manifested abdominal distension and vomiting, while epigastric pain was present in 50%. Plain radiographs of the abdomen demonstrated duodenal distension with little gas in the remainder of the bowel in three cases. Barium studies in nine patients demonstrated an intact mucosal pattern and a duodenum dilated proximal to the site where the superior mesenteric vessels crossed it. All cases recovered with non-operative treatment which included nasogastric suction, intravenous fluids, change in position, particularly nursing in the prone position, and, occasionally, cast removal. The obstruction may sometimes persist or recur and then duodenojejunal side-to-side anastomosis is the surgical procedure of choice. The term "cast syndrome" is a misnomer as vascular compression of the duodenum may also occur in patients who are undergoing treatment for scoliosis without the use of a body cast.

Adolescent↗

PubMed1996

Partial liquid ventilation provides effective gas exchange in a large animal model.

PURPOSE: The purpose of this study was to show the ability of partial liquid ventilation (PLV) to sustain gas exchange in normal large (50 to 70 kg) adult animals. METHODS: Ten adult sheep (53.7 +/- 2.8 kg) were anesthetized and mechanically ventilated. Sequential dosing of perflubron (LiquiVent, Alliance Pharmaceutical Corp, San Diego, CA) was performed to cumulative doses of 10 mL/kg, 20 mL/kg, 40 mL/kg, and 60 mL/kg. Physiological data were assessed at baseline and after each dose. Five animals were rotated through the left decubitus, right decubitus, supine, and prone positions while five animals remained prone throughout the experiment. RESULTS: PaO2 and PaCO2 did not change significantly from baseline during administration of perflubron except for the PaO2 in rotated animals when supine (rotated-supine PaO2: baseline = 519 +/- 64 mm Hg; 60 mL/kg = 380 +/- 109 mm Hg, P = .0131). In both groups, static lung compliance (CT) decreased steadily with each successive perflubron instillation (nonrotated CT: baseline = 1.55 +/- 0.22 mL/cm H2O/kg; 60 mL/kg = 0.52 +/- 0.10 ml/cmH2O/kg, P = .0003). CONCLUSIONS: These data show that during PLV in this normal animal model, effective gas exchange is sustained and CT decreases with increasing perflubron dose.

Animals↗

PubMed2000

Re-opened foramen ovale--a rare cause of postoperative dyspnea following pneumonectomy.

Dyspnea and hypoxemia are common postoperative problems following pneumonectomy. Platypnea, the increased dyspnea in the erect position relieved by assuming a prone position, has been reported as a result of right to left inter-atrial shunt. We report here on our experience with a patient who had severe platypnea with remarkable positional arterial desaturation following right pneumonectomy. After establishing the diagnosis with contrast-enhanced transesophageal echocardiography of the preoperatively undetected interatrial right-left shunt, cardiac surgery led to clinical improvement and resumption of platypnea. Given the rarity of the diagnosis, we think interatrial shunt, based on an open foramen ovale, should be taken into consideration when platypnea occurs in patients as a postoperative complication following lung surgery. Transesophageal echocardiography may be helpful in detecting patients with "anatomical closed but functional open" foramen ovale or genuine inter-atrial septal defect prior to lung surgery.

Dyspnea↗