# Early Prone Positioning in Three Pediatric Cases of Post-drowning Acute Respiratory Failure: A Case Series of Short-Term Changes in Oxygenation and Respiratory System Compliance

## TL;DR

This case series explores the short-term benefits of early prone positioning in three children with post-drowning respiratory failure, showing improved oxygenation and lung compliance.

## Contribution

The study provides early evidence on the use of prone positioning in pediatric drowning-induced respiratory failure, an area with limited prior research.

## Key findings

- Oxygenation improved significantly within four hours of prone positioning, with P/F ratios increasing from 158-250 to 316-506.
- Dynamic respiratory system compliance normalized to body weight increased from 0.45-0.80 to 0.88-1.00 mL/cmH2O/kg after prone positioning.
- All three patients survived without complications, with short ICU stays and brief mechanical ventilation durations.

## Abstract

Drowning is a process of respiratory impairment resulting from submersion or immersion in a liquid, and severe cases may develop acute respiratory failure due to drowning-associated lung injury. Prone positioning is a recognized adjunctive therapy for acute respiratory distress syndrome (ARDS), yet evidence in pediatric drowning remains limited. We conducted a retrospective, descriptive case series of three pediatric seawater drowning patients (age 2-6 years) without cardiac arrest who required endotracheal intubation and invasive mechanical ventilation and received early prone positioning for 2-4 hours. The primary descriptive outcomes were short-term changes (within four hours) in oxygenation (arterial oxygen partial pressure (PaO2)/fraction of inspired oxygen (FiO2) ratio, or P/F ratio) and dynamic respiratory system compliance normalized to body weight (Cdyn/kg). The pre-prone P/F ratio ranged from 158 to 250 and increased to 316-506 within four hours after prone positioning was initiated. Cdyn/kg (defined as tidal volume divided by the difference between peak inspiratory pressure and positive end-expiratory pressure (PEEP), normalized to body weight) increased from 0.45-0.80 to 0.88-1.00 mL/cmH2O/kg. The duration of mechanical ventilation was 20-23.5 hours, and the intensive care unit (ICU) length of stay was 2-3 days. All patients survived to discharge without sequelae. These observations are hypothesis-generating, and larger studies are needed to clarify efficacy, indications, and optimal conditions of early, short-duration prone positioning in pediatric drowning-associated acute respiratory failure.