Preliminary data in children with acute lung injury subjected to prone positioning showed improved oxygenation without serious adverse events . To date, only one RCT has been performed in children to investigate the efficacy of prone positioning on patient outcome . In this particular study, N = 102 patients with acute lung injury were randomised to prone position for 20 h each day or supine. Despite the significant improvement in oxygenation, the study was stopped at the planned interim analysis on the basis of futility. Prone positioning did not exert a beneficial effect on ventilator-free days, all-cause mortality, time to recovery from lung injury, the number of organ-failure-free days, cognitive function or overall health. However, the drawback of this trial was that it was not limited to paediatric patients with severe PARDS. A meta-analysis of adult ARDS patients showed that the effect of prone positioning was the greatest in patients with severe disease, i.e. a PaO2/FiO2 < 100 mmHg . This conclusion was supported by the adult PROSEVA trial, showing a significant improvement in mortality in patients with severe ARDS (i.e. PaO2/FiO2 < 150 mmHg .
Maintaining a patent airway is essential to the safe care of any mechanically ventilated patient, thereby making it one of the most performed interventions despite the lack of scientific evidence including in PARDS [28, 59, 106]. Also, the technique used to perform endotracheal suctioning also requires further study. So far, no RCT evaluating the effect of a closed versus open suctioning on patient outcome in PARDS is available. However, a drop in dynamic compliance and expired Vt indicative of a loss of lung volume may occur during open suctioning, thereby favouring closed suctioning systems [10, 105].
The use of chest physiotherapy for airway clearance and sputum evacuation in mechanically ventilated children cannot be considered standard of care . The efficacy of chest physiotherapy for PARDS also has not been tested in a single RCT to date.