Positioning Effects on Lung Function and Breathing Pattern

in Premature Newborns
Georgette Gouna, MD1, Thameur Rakza, MD1,2, Elaine Kuissi, MD1, Thomas Pennaforte, MD1, Sebastien Mur, MD1,2,
and Laurent Storme, MD1,2

Objective To compare breathing patterns and lung function in the supine, lateral, and prone positions in oxygen-
dependent preterm infants.
Study design Respiratory function in preterm infants receiving nasal continous positive airway pressure therapy
for mild respiratory failure was evaluated by respiratory inductive plethysmography. Infants were randomized to
supine, left lateral, and prone positions for 3 hours. A nest provided a semiflexed posture for the infants placed
in the left lateral position, similar to the in utero position. Tidal volume (Vt), phase angle between abdominal and tho-
racic movements, rib cage contribution to Vt, and dynamic elevation of end-expiratory lung volume were measured.
Results Fraction of inspired O2 was similar in the 3 positions for 19 infants (mean gestational age, 27  2 weeks;
mean birth weight, 950  150 g; mean postnatal age, 17  5 days). However, arterial O2 saturation and Vt were
higher in the left lateral and prone positions than in the supine position (P < .05). The phase angle between abdom-
inal and thoracic movements was lower and rib cage contribution to Vt was higher in the left lateral and prone
positions than in the supine position (P < .05). Dynamic elevation of end-expiratory lung volume was greater in
the supine position than in the left lateral and prone positions (P < .05).
Conclusion In oxygen-dependent preterm infants, both the left lateral and prone positions improve lung function
by optimizing breathing strategy. In the neonatal intensive care unit, the left lateral position can be used as an
alternative to the prone position for mild respiratory failure. (J Pediatr 2013;162:1133-7).

P
ositioning plays a critical role in pulmonary, digestive, and autonomic functions in preterm infants. Compared with the
supine position, the prone position elevates PaO2,1-3 enhances the contribution of the rib cage to tidal volume (Vt),4
improves thoracoabdominal synchrony,4 reduces obstructive apneas,5,6 promotes sucking,7 reduces stress behaviors,8,9
and increases sleep duration.5 However, prolonged prone positioning may alter postural control (dominance of the dorsal
extensor muscles) and sensorimotor organization.10,11 The tucked positions, involving gentle positioning of the infant’s
arms and legs in a flexed, midline position close to the body, is currently recommended for preterm infants to promote motor
and autonomic self-regulation, reduce stress behaviors, and enhance spontaneous movements.9,12-14 Gastroesophageal reflux is
reduced by left lateral positioning and increased by right lateral positioning.15,16 The lateral flexed position, similar to the in
utero position, facilitates tucking.9 The effects of lateral body position on pulmonary function and on breathing strategy in
preterm newborns are not known, however.
We hypothesized that in oxygen-dependent preterm infants, the left side-lying position, like the prone position, improves
lung function. To test this hypothesis, we compared breathing patterns and respiratory variables measured in the supine,
left lateral, and prone positions in preterm infants.

Methods
Our study was conducted over a 6-month period in the neonatal intensive care unit at the Regional University Hospital of Lille,
France. Inclusion criteria were preterm birth (gestational age 26-30 weeks), spontaneous breathing with nasal continuous pos-
itive airway pressure (NCPAP) therapy, and mild respiratory failure, defined as an oxygen requirement of 22%-35% to main-
tain arterial oxygen saturation (SpO2) between 88% and 95%, pH > 7.24, and PaCO2 <65 mm Hg. Exclusion criteria were
circulatory failure, receipt of vasoactive drugs, and periventricular leukomalacia or intraventricular hemorrhage. The study
was approved by the institutional Research
%RC Rib cage contribution to Vt
DEELV Dynamic elevation of end-expiratory lung volume
q Phase angle between abdominal and thoracic movements From the 1Department of Perinatology, Jeanne de
NCPAP Nasal continuous positive airway pressure Flandre Hospital, University Hospital of Lille; and
2
RIP Respiratory inductive plethysmography EA4489, Perinatal Environment and Growth, School of
Medicine, Universite
Lille 2, Lille, France
SpO2 Arterial oxygen saturation
The authors declare no conflicts of interest.
Ve Expiratory flow volume
Vt Tidal volume 0022-3476/$ - see front matter. Copyright ª 2013 Mosby Inc.
All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2012.11.036

1133
THE JOURNAL OF PEDIATRICS  www.jpeds.com
Ethics Committee. Written informed consent was obtained
from the parent(s) of each infant.
Each infant was successively placed, in random order, in
the supine, left lateral, and prone positions. The body posi-
tions were stabilized in a nest, with the infant’s head posi-
tioned toward the midline in the supine and left lateral
positions. The nest provided a semiflexed posture in the in-
fants placed on the left side (tucked position) (Figure 1;
available at www.jpeds.com). Respiratory variables were
recorded for 3 hours in each body position. Special care was
taken to avoid motion artifacts by minimizing external
stimulation. Measurements were performed after feeding to
ensure quiet sleep. Given that sleep state may influence
breathing behavior,5 the infants’ sleep patterns were
recorded. An observer remained with the infant during the
study to record sleep states and wake periods. Sleep states
were described as active or quiet according to behavioral
criteria.17 Active sleep was defined by rapid eye movements,
frequent body and facial movements, and irregular
breathing with paradoxical movements of the rib cage and
abdomen. Quiet sleep was defined by lack of eye
movements, rare body or facial movements with occasional
startles, and regular breathing pattern. Sedation was not
used. Each infant served as his or her own control.
SpO2, transcutaneous PaCO2, heart and respiratory rates,
and arterial blood pressure were monitored continuously
(IntelliVue MP70 monitor; Philips Healthcare, Suresnes,
France), sampled at 1 Hz, and then averaged for each period
(IntelliVue Information Center; Philips Healthcare). Frac-
tion of inspired oxygen was set to maintain SpO2 between
88% and 95%. An apneic episode was defined as a ventilatory
pause of more than 10 seconds and/or episode of SpO2
<80%. Breathing pattern was recorded by respiratory
inductive plethysmography (RIP) (Respitrace Plus set in
AC-coupled mode; SensorMedics, Miami, Florida). RIP
was performed using 2 transducer bands, one around the
thorax at the nipple line and the other around the abdomen,
0.5 cm above the umbilicus. Special care was taken to prevent
RIP band displacement during nursing care or changes in po-
sitioning. Band positions and settings were secured and fixed
with adhesive tape. The impedance of the bands changed
with respiratory movements and was processed to measure
respiratory variables. Autocalibration of the device occurred
during periods of quiet breathing. The signals were recorded
continuously and processed by specific software (NIMS,
Respi-Events software; SensorMedics, Homestead, Florida).
Before recording, baseline airflow was measured by face
mask pneumotachography (Florian hot-wire pneumotacho-
graph, 0.7-mL dead space; Acutronic Medical Systems, Zug,
Switzerland). Vt, calculated from the integration of a series of
10 leak-free respiratory cycles, was used to calibrate the cor-
responding RIP breaths. Calibration was performed before
the start of recording and repeated during the study period
as required in the event of accidental displacement of the
RIP bands.
We recorded Vt, rib cage contribution to Vt (%RC),
phase angle between abdominal and thoracic movements
1134
Vol. 162, No. 6
(q), respiratory rate, and inspiratory time. The q value was
calculated using the analysis of the Lissajous figures of the
rib cage signal (y-axis) versus the abdominal signal (x-axis).
The width of the loop is related to the degree of thoracoabdo-
minal asynchrony. Asynchrony was assessed by calculating
q as follows: q = [sin 1(m/s)] for q < 90 or q = [180 -
sin 1(m/s)] for q > 90 , where m is the width of the Lissajous
figure at mid rib cage excursion and s is the width of the Lis-
sajous figure at its greatest abdominal excursion. The value of
q can range from 0 (synchronous breathing) to 180 (para-
doxical breathing). Ventilatory flow was computed as the de-
rivative of Vt. The flow-volume loops were analyzed to
estimate the dynamic elevation of end-expiratory lung vol-
ume (DEELV), representing the difference between the
end-expiratory lung volume level and the static relaxation
volume. The static relaxation volume was estimated from ex-
trapolation of the linear segment of the flow-volume curve to
zero flow, as described previously.18-20 The regression line of
the linear part of the flow-volume loop was calculated using
the least squares method (Respi-Events; SensorMedics)
(Figure 2).
Preliminary tests showed that the respiratory variables sta-
bilized within 30 minutes after the change in body position.
We analyzed the variables recorded 60-180 minutes after po-
sitioning and during quiet sleep periods only, to ensure com-
plete patient stabilization and few motion artifacts. Indeed,
active sleep-related body movements cause motion artifacts
on the RIP, precluding reliable RIP measurements.
Based on our previous work indicating a mean q = 95 

25 in the supine position,18,19 to detect a clinically signifi-
cant difference in q, defined as 25%, with a power of 80%
and a 2-sided a of 0.05, at least 18 infants were required.
The variables are expressed as mean  SD or median
(IQR). The data were compared using the Friedman test
for nonparametric and repeated-measures analysis. Inter-
group differences were analyzed by post hoc analysis with
the Wilcoxon signed-rank test and Bonferroni correction us-
ing SPSS version 11.5.1 (IBM, Armonk, New York). A P value
<.05 was considered significant.
Results
All 19 preterm infants had received mechanical ventilation at
birth for respiratory distress syndrome and received surfac-
tant treatment within the first hour of life. Duration of the
mechanical ventilation was less than 24 hours. NCPAP
(Infant-Flow; Vyasis, CareFusion, Voisins le Bretonneux,
France) was used to wean the infants from mechanical venti-
lation. At the time of the study, the infants were managed
with NCPAP and received caffeine. Mean gestational age
was 27  2 weeks, and mean birth weight was 950  150 g.
The infants were studied at a mean postnatal age of 17  5
days (mean weight, 1300  275 g).
Heart and respiratory rates and arterial blood pressure
were similar in all positions. Although fraction of inspired
oxygen was similar in the 3 positions, SpO2 was higher in
the left lateral and prone positions than in the supine position
Gouna et al
June 2013
Figure 2. Flow-volume loops of a representative infant in
supine, left lateral, and prone positions. DEELV represents the
difference between the end-expiratory lung volume and the
static relaxation volume. The static relaxation volume can be
estimated from the extrapolation of the linear segment of the
flow-volume curve to zero flow. In the prone and left lateral
positions, the Ve curve fell linearly to near the zero-flow line,
consistent with an almost complete passive deflation; DEELV
was low. On the other hand, the expiratory time was too short
to achieve complete lung deflation in the supine position, in-
dicating a high DEELV. Vi, inspiratory flow; Ti, inspiratory time.
(P < .05) (Table). Transcutaneous PaCO2 was lower in the
left lateral and prone positions than in supine position
(P < .05). Vt was greater in the left lateral and prone
positions than in the supine position. Inspiratory time was
not altered by the body position. Apneic and hypoxic
episodes were more frequent in the supine position than in
the left lateral and prone positions (P < .05).
Better synchronization of thoracoabdominal movements,
indicated by a lower q value was seen in the prone and left lat-
eral positions compared with the supine position (P < .05)
(Figure 3). The %RC value was significantly lower in the
supine position than in the left lateral and prone positions
(P < .05) (Figure 3).
Positioning Effects on Lung Function and Breathing Pattern in Premature Newborns
ORIGINAL ARTICLES
Table. Comparison of respiratory variables in the
supine, left lateral, and prone positions
Supine Left lateral Prone
Respiratory rate, breaths/minute 62  8 56  7 58  6
Vt, mL/kg 4.8  1.1 5.5  0.9* 5.7  0.9*
Ti, seconds 0.36  0.11 0.42  0.09 0.43  0.10
FiO2, % 28  5 24  3 23  2
SpO2, % 91  3 95  2* 96  1*
TcPCO2, mm Hg 57  7 52  5* 51  4*
Number of apnea episodes/3 hours 83 4  2* 5  2*
FiO2, fraction of inspired oxygen; TcPCO2, transcutaneous partial pressure of CO2.
*P < .05, compared with the value measured in the supine position.
The correlation coefficient (R2) of the regression lines cal-
culated from the linear segment of each flow-volume loop
was constantly >0.97. Flow-volume loops of a representative
infant placed in the supine, left lateral, and prone positions
are shown in Figure 2. The DEELV volume was twice as
large in the supine position than in the left lateral and
prone positions (P < .05) (Figure 3).
Discussion
We hypothesized that the left lateral position and prone po-
sition would improve lung function and breathing strategy in
our preterm infants. We found that transcutaneous SpO2 was
higher and PaCO2 was lower in the left lateral and prone
positions than in the supine position. Furthermore, the left
lateral and prone positions were associated with fewer apneic
and hypoxic episodes compared with the supine position.
Compared with the supine position, the left lateral and prone
positions increased the q and %RC values and decreased the
DEELV value. Taken together, these results demonstrate that
the left lateral position, as well as the prone position, improve
pulmonary function by optimizing ventilatory strategy and
lung volume.
Thoracoabdominal synchrony plays a key role in the effi-
ciency of lung ventilation.21,22 The Vt generated by the ab-
dominal and thoracic movements is dependent on q, the
phase angle between the chest and abdominal movement.21,22
At a similar amplitude of chest wall and abdominal displace-
ment, the resulting Vt decreases as thoracoabdominal asyn-
chrony increases. Thus, the increased Vt observed in the
left lateral and prone positions may result from better syn-
chrony of the chest wall and abdominal movements. Taken
together, these results indicate that the lower PaCO2 in the
left lateral and prone positions compared with the supine po-
sition may be related to a more efficient breathing pattern
through stabilization of the chest wall and increased thora-
coabdominal synchrony.
The mechanisms by which left lateral and prone positions
improve lung function in the preterm infant remain specula-
tive. Studies in adult patients and preterm infants have sug-
gested that the prone position may increase lung volume
through lung expansion in the dorsal region,23-25 caused by
decreased transmission of the weight of abdominal contents
to the dorsal regions and decreased lung compression by the
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Figure 3. A, Phase angles, q, expressed as degree between abdominal and thoracic motions, in the supine, left lateral, and
prone positions. q was lower in the left lateral and prone positions than in the supine position, indicating better thoracoabdominal
synchrony in the left lateral and prone positions. B, Contribution of rib cage displacement to Vt (%RC to Vt), expressed in %, in
the supine, left lateral, and prone positions. The %RC to Vt was greater in the left lateral and prone positions than in the supine
position. C, Mean DEELV, expressed as % of Vt, measured in the supine, left lateral, and prone positions. Values are median
(IQR). *P < .05, compared with values measured in the supine position.

heart.26,27 In the left lateral position, expansion of the right
lung can be expected for the same reasons. Our finding of
decreased DEELV in the prone and left lateral positions
provides additional evidence supporting for this hypothesis.
Indeed, end-expiratory lung volume depends on both static
and dynamic phenomena, and is maintained above the
passive resting volume during active breathing in preterm
infants mainly by breaking the expiratory flow.28 We previ-
ously showed that expiratory flow volume (Ve) loops provide
information on the volume of trapped gas by DEELV. The
difference between end-expiratory lung volume and relaxa-
tion volume can be estimated by extrapolating the linear
segment of the flow-volume curve to zero flow.18-20 Our
data show that the Ve curve falls linearly to near the zero-
flow line in the prone and left lateral positions, consistent
with complete passive deflation toward the passive resting
lung volume (Figure 2). These results indicate that the
characteristic protective expiratory braking observed in the
premature infants is diminished in the prone and left
lateral positions compared with the supine position.
Previous studies have shown that passive relaxation vol-
ume and DEELV are inversely related. NCPAP-induced pas-
sive increases in end-expiratory lung volume are associated
with a decrease in the volume of gas actively trapped by expi-
ratory braking.18,29 We speculate that the volume-preserving
dynamic mechanisms required to elevate end-expiratory
lung volume above the relaxation volume are no longer nec-
essary in both the left lateral and prone positions, suggesting
that these positions cause a passive increase in end-expiratory
lung volume. Results of a study showing an increase in func-
tional residual capacity in the prone position in preterm
infants are in accordance with this hypothesis.30 This effect
of positioning on lung volume remains speculative, however,
1136
given that we did not directly measure absolute end-
expiratory lung volume in this study.
This study has several limitations. The effect of the right
lateral position was not studied. In preterm infants, gastro-
esophageal reflux is increased in the right lateral posi-
tion.15,16 In addition, with the anatomic asymmetry, we
cannot estimate the impact of right lateral positioning on
lung function. RIP has been used mainly to assess ventilation
strategies and lung volumes in preterm infants. A linear
relationship between pneumotachography and RIP volumes
has been reported, which was not altered by sleep state,
position, respiratory rate, or %RC value.31 The repro-
ducibility of RIP measurements in this population has not
been reported, however. In the present study, each infant
was his or her own control, and the order of positioning
was randomized, limiting the potential bias induced by
interindividual reproducibility of the RIP measurements.
Our study population was limited to preterm infants with
mild respiratory failure managed with NCPAP; whether or
not the effects of body position are similar in other popula-
tions of preterm infants remains an open question. Finally,
we did not investigate the role of body position on ventila-
tion distribution in this study.
Although the prone position is largely used in neonatal
intensive care units, warnings regarding the potential ad-
verse impacts of prolonged prone positioning on later pos-
tural control and sensorimotor organization have been
reported.10,11 On the other hand, “tucked” positions are
currently recommended in preterm infants to promote mo-
tor and autonomic self-regulation,9,12 reduce stress,9,32 and
improve spontaneous movements.13 The side-lying position,
similar to the in utero position, promotes facilitated tucking
of the preterm infant.14 Furthermore, the left lateral position
Gouna et al
June 2013
reduces gastroesophageal reflux.15 Because left lateral and
prone positions have similar respiratory effects, we propose
that the left lateral position can serve as an alternative to
prone position in the oxygen-dependent preterm infants
in the neonatal intensive care unit. n
Submitted for publication May 16, 2012; last revision received Oct 22, 2012;
accepted Nov 8, 2012.
Reprint requests: Laurent Storme, MD, Po^ le Femme Me re Nouveau-ne
,
^ pital Jeanne de Flandre, 1 Avenue Euge
Ho ne Avine
e, CHRU de Lille, Lille
Cedex 59035, France. E-mail: lstorme@chru-lille.fr
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Figure 1. Photograph of a preterm infant placed in the left

side-lying position. A “nest” provides a gentle semiflexed
posture, similar to the in utero position, which facilitates
tucking. The arms and legs are in a flexed, midline position
close to the body.

1137.e1 Gouna et al