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AbstractObjectivesTo evaluate the effect of lateral versus supine positioning on incidence of hypoxaemia in sedated patients and to provide evidence based recommendations for respiratory strategies.DesignProspective, multicentre, randomised controlled trial.Setting14 tertiary hospitals in China, July to November 2024.Participants2159 adults (≥18 years) who underwent sedation.InterventionsSedated patients were randomly assigned (1:1) to receive either lateral positioning or conventional supine positioning, stratified by study centres.Main outcome measuresThe primary outcome was incidence of hypoxaemia (peripheral oxygen saturation (SpO2) ≤90%) within the first 10 minutes after positioning. Secondary outcomes included airway rescue interventions, incidence of severe hypoxaemia (SpO2 ≤85%), lowest oxygen saturation recorded, length of stay in the post-anaesthesia care unit, and safety measures (eg, bradycardia, tachycardia, hypotension, new onset arrhythmia). Analyses were performed on an intention-to-treat basis.ResultsOf 2159 patients randomised, 2143 were included in the primary analysis. The mean age of the patients was 53.1 years, mean body mass index was 23.9, and 53.7% (1150/2143) were women. The incidence of hypoxaemia was significantly lower in the lateral group compared with supine group (5.4% (58/1073) v 15.0% (161/1070); adjusted risk ratio 0.36, 95% confidence interval (CI) 0.27 to 0.49; P<0.001). Compared with patients in the supine group, patients in the lateral group required fewer airway rescue interventions (6.3% (68/1073) v 13.8% (148/1070); adjusted risk ratio 0.46, 0.34 to 0.61; P<0.001), had a lower incidence of severe hypoxaemia (0.7% (8/1073) v 4.8% (51/1070); adjusted risk ratio 0.16, 0.07 to 0.33; P<0.001), and had a higher mean lowest SpO2 level (96.9% v 95.7%, absolute adjusted mean difference 1.20%, 95% CI 0.87% to 1.54%; P<0.001). Additionally, length of stay in the post-anaesthesia care unit was shorter in the lateral group (38.2 v 40.5 minutes; absolute adjusted mean difference −2.22 minutes; 95% CI −3.63 to −0.80; P=0.002). Safety outcomes were comparable between the groups, but tachycardia was less frequent in the lateral group.ConclusionsPlacing sedated adults in the lateral position significantly reduces the incidence and severity of hypoxaemia and decreases the need for airway rescue interventions without compromising safety. Given its simplicity and low cost, lateral positioning could offer advantages in remote or resource constrained clinical settings. Further replication studies targeting patients with advanced age and high body mass index are needed to improve the generalisability of the findings.Trial registrationClinicalTrials.gov NCT06459167.

PurposeAwake prone positioning has been reported to reduce endotracheal intubation in patients with coronavirus disease 2019 (COVID-19)-related acute hypoxemic respiratory failure (AHRF). However, it is still unclear whether using the awake prone positioning for longer periods can further improve outcomes.MethodsIn this randomized, open-label clinical trial conducted at 12 hospitals in China, non-intubated patients with COVID-19-related AHRF were randomly assigned to prolonged awake prone positioning (target > 12 h daily for 7 days) or standard care with a shorter period of awake prone positioning. The primary outcome was endotracheal intubation within 28 days after randomization. The key secondary outcomes included mortality and adverse events.ResultsIn total, 409 patients were enrolled and randomly assigned to prolonged awake prone positioning (n = 205) or standard care (n = 204). In the first 7 days after randomization, the median duration of prone positioning was 12 h/d (interquartile range [IQR] 12–14 h/d) in the prolonged awake prone positioning group vs. 5 h/d (IQR 2–8 h/d) in the standard care group. In the intention-to-treat analysis, intubation occurred in 35 (17%) patients assigned to prolonged awake prone positioning and in 56 (27%) patients assigned to standard care (relative risk 0.62 [95% confidence interval (CI) 0.42–0.9]). The hazard ratio (HR) for intubation was 0.56 (0.37–0.86), and for mortality was 0.63 (0.42–0.96) for prolonged awake prone positioning versus standard care, within 28 days. The incidence of pre-specified adverse events was low and similar in both groups.ConclusionProlonged awake prone positioning of patients with COVID-19-related AHRF reduces the intubation rate without significant harm. These results support prolonged awake prone positioning of patients with COVID-19-related AHRF.

Background The aim of our study is to compare the effect of the 30° reverse Trendelenburg position combined with the beach chair position on respiratory parameters in laparoscopic sleeve gastrectomy (LSG) with the 30° reverse Trendelenburg position alone. Material and method Fifty patients with body mass index > 30 were included in the study. The patients were divided into two groups; in the control group, the standard 30° reverse Trendelenburg. In the beach chair group, the feet were positioned at 30° flexion from the hips after a 30° RTP. For both positions, blood pressures, pulses, saturations, EtCO2, respiratory rate, inspiratory pressure (Pins), positive end-expiratory pressure (PEEP), minute volume, tidal volume, peak airway pressure (Ppeak), and dynamic compliance were recorded. In addition, the general surgeon was asked about his satisfaction with the intra-abdominal operation site view and whether he was uncomfortable with the position. Results Regardless of the group, the average age of the cases was 36.7 ± 12.1 years. There was no difference between the groups in terms of age, gender, BMI, operation time, blood pressures, heart rates, EtCO2, respiratory rate, PEEP, minute volume, tidal volume, and postoperative oxygen saturation ( p  > 0.05). Inspiratory and peak pressure were lower and dynamic compliance was higher in the beach chair position ( p  < 0.05). It was observed that the beach chair position decreased inspiratory and peak pressures and increased dynamic compliances in patients with a BMI between 35.1 and 40 ( p  < 0.05). Surgical satisfaction was high for both positions and there was no discomfort with the position. Conclusion It was determined that the beach chair position in LSGs reduced inspiratory and peak pressures and increased dynamic compliance. These parameters were related to BMI, and the beach chair position was more positive in terms of intraoperative lung pressures and dynamic compliance, especially in patients with a BMI between 35.1 and 40. ClinicalTrials.gov ID: NCT06402474 .

The head-elevated position during videolaryngoscopic intubation enables better visualization of the glottis than the head-flat position. We hypothesized that the head-elevated position would result in less cervical spine motion during videolaryngoscopic intubation under manual in-line stabilization. We conducted a randomized controlled trial in which we assigned patients undergoing coil embolization for unruptured cerebral aneurysms into the head-elevated (N = 55) or head-flat (N = 54) groups. Manual in-line stabilization was applied to simulate cervical spine immobilization during Macintosh-type videolaryngoscopic intubation. To measure the cervical spine angle, two lateral cervical spine radiographs using the capture method were taken, one before and one during intubation, respectively. The primary outcome was cervical spine motion during intubation (cervical spine angle during intubation - cervical spine angle before intubation) at the occiput-C1 segment. We investigated cervical spine motion at the C1-C2 and C2-C5 segments; intubation performance, such as the success rate at the first attempt, intubation time, and frequency of external laryngeal maneuver; and intubation-associated airway complications (airway bleeding, injury, sore throat, and hoarseness). There was significantly less cervical spine motion at the occiput-C1 segment in the head-elevated group than the head-flat group (mean [standard deviation], 8.6° [5.6°] vs 11.4° [5.7°]; mean difference [95% confidence interval], -2.9° [-5.0 to -0.7]; P = 0.009). Cervical spine motion at the C1-C2 and C2-C5 segments, intubation performance, and intubation-associated airway complications did not significantly differ between the groups. The head-elevated position during Macintosh-type videolaryngoscopic intubation with manual in-line stabilization resulted in less upper cervical spine motion than the head-flat position. CRIS.nih.go.kr ( KCT0008669 ); date of registration (approved), 1 August 2023.

In Japan, the lateral position method is known as a postural therapy for breech presentation wherein the mother lies down in lateral position according to the orientation of the fetal back. Few studies have formally tested lateral position management for breech presentation, and no method exists to prevent breech recurrence after cephalic version. We hypothesized that postural management comprising a combination of opposite-side lateral position for breech presentation and same-side lateral position after cephalic version demonstrates a clinically relevant effect size on breech presentation. We conducted a stratified, open-label randomized controlled trial at an academic hospital in Kawasaki, Japan. A total of 200 women diagnosed with breech presentation between 28 +  0 and 30 +  0 gestational weeks were randomized to postural management (n =  100) or control (no intervention, n =  100) group. The intervention was instruction every 2 weeks on lying in the lateral position on the opposite-side of fetal back for breech presentation and on the same-side of fetal back for head-first presentation. The primary outcome was the rate of fetuses in breech presentation at 37 weeks of gestation, and the secondary outcomes were cesarean delivery, cesarean delivery for breech presentation, head presentation 2, 4, and 6 weeks later, breech presentation recurrence, and adverse events. Breech presentation rate at 37 gestational weeks was 11% in the intervention group, using the combination of the opposite-side and same-side lateral positions, compared with 19% in the control group. However, we found no statistical significance in the intention-to-treat analysis (11% [11/100] versus 19% [19/100]; relative risk, 0.58 [95% CI, 0.29 to 1.15]; p =  0.11). In the control group, 23 participants (23%) unknowingly took the same posture as the intervention group, and the prespecified per-protocol analysis excluding crossover found the same direction of effect but with statistical significance. In the intention-to-treat analysis, the intervention group had a higher cephalic version rate 2 weeks after the instruction (69% [69/100] versus 54% [54/100]; relative risk, 0.67 [95% CI, 0.47 to 0.96]; p =  0.029), and lower breech presentation recurrence rates (2% [2/91] versus 10% [9/88]; relative risk, 0.22 [95% CI, 0.048 to 0.97]; p =  0.031) than the control group. Regarding adverse events in the intervention group, three participants experienced discomfort and one participant complained of pain in the lateral abdomen; these symptoms resolved spontaneously. For breech presentation at the beginning of the third trimester, providing postural therapy instruction on opposite-side lateral positioning and same-side lateral positioning was associated with 8% reduction of breech fetuses at 37 gestational weeks compared with the control group, but this primary endpoint did not reach statistical significance. Regarding the secondary endpoints, the intervention group showed a significantly higher rate of cephalic version after 2 weeks and lower rate of breech recurrence. The direction of the effect of postural therapy based on fetal back position on breech presentation was promising, and further research to validate this approach, with consideration for unplanned participant crossover, may be warranted. UMIN Clinical Trials Registry (UMIN000043613, https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000049800).

Purpose Residual fragments not removed with urinary stone surgery may become symptomatic. In this context, this study was carried out to investigate the effect of performing retrograde intrarenal surgery, which is conventionally performed in the lithotomy position, in the modified lithotomy position (Trend-side) on stone-free rates following the surgery. Methods This prospective study consisted of 100 patients with a single kidney stone smaller than 2 cm between 2021 and 2023. These patients were randomized into two groups of 50 patients each to be operated on in the conventional lithotomy and Trend-side positions. Variables were compared using independent t test for continuous variables and chi-square test for categorical variables. Results There was no significant difference between the lithotomy and Trend-side position groups in terms of preoperative size, density, location of the stone, and hydronephrosis degree. Stone-free rate was 72% (n = 36) in the lithotomy group and 92% (n = 46) in the Trend-side group. Hence, there was a significant difference between the groups in the stone-free rate in favor of the Trend-side group (p = 0.009). Fragmentation time was statistically significantly shorter in the Trend-side group than in the lithotomy group (34 ± 17 min vs. 43 ± 14 min; p = 0.006). There was no significant difference between the groups in postoperative complication rates. Conclusion Performing retrograde intrarenal surgery in the Trend-side position shortened the duration of fragmentation compared to the lithotomy position and was associated with higher stone-free rates. In conclusion, the Trend-side position can be safely preferred in patients undergoing retrograde intrarenal surgery due to kidney stones.

Study objective Accurate bronchial blocker placement is essential for effective lung isolation during thoracic surgery. Approximately one-third of patients experience bronchial blocker malposition during the transition from the supine to lateral decubitus position. It has been unclear whether bronchial blocker placement directly in the lateral position can reduce the incidence of malposition. This study investigated the incidence of bronchial blocker malposition in the lateral versus supine position and evaluated the effectiveness of lateral placement. Adults aged ≥18 years scheduled for thoracic surgery were enrolled. Seven tertiary hospitals in China. Bronchial blockers were placed either in the lateral or supine position. The primary outcome was the incidence of bronchial blocker malposition. Secondary outcomes included the times of bronchial blocker reposition, perioperative complications, intubation duration, and satisfaction scores. Among 324 patients who underwent randomization, 306 completed the study (152 in the lateral group and 154 in the supine group). The incidence of bronchial blocker malposition was significantly lower in the lateral group (1/152 (0.7 %)) than in the supine group 39/154 (25.3 %), P < 0.001). The times of bronchial blocker reposition was also lower in the lateral group (median [interquartile range]: 0 [0,0]) than in the supine group (1.0 [1.0, 2.0], P < 0.001). Lateral bronchial blocker placement was associated with lower incidences of postural injury (P < 0.001). The median intubation duration (single-lumen tube intubation plus bronchial blocker placement) was similar between the two groups (P = 0.089). Patients and surgeons reported higher satisfaction scores in the lateral group (P < 0.001). Lateral bronchial blocker placement reduced the incidence of malposition in patients undergoing thoracic surgery; it was associated with fewer complications and higher satisfaction scores. These findings indicate that lateral placement is an effective approach with substantial advantages over conventional supine placement. Clinial trial registration:NCT05482230. •Lateral placement reduced the incidence of bronchial blocker malposition.•Lateral bronchial blocker placement reduced postural injuries.•Lateral placement showed higher surgeons and patients satisfactory scores.•Bronchial blocker placed laterally showed similar intubation time to supine position.

Objective:Changes in cerebrovascular hemodynamics associated with head position may be important in the pathogenesis of periventricular-intraventricular hemorrhage (PIVH) in premature infants. This study evaluated the effect of elevated midline head positioning on cardiopulmonary function and the incidence of PIVH.Study design:ELBW infants were randomized to FLAT (flat, supine) or ELEV (supine, bed elevated 30 degrees) for 96 h. Cardiopulmonary function, complications of prematurity, and the occurrence of PIVH were documented.Results:Infants were randomized into FLAT (n = 90) and ELEV groups (n = 90). No significant differences were seen in the incidence of BPD or other respiratory complications. The ELEV group developed significantly fewer grade 4 hemorrhages (p = 0.036) and survival to discharge was significantly higher in the ELEV group (p = 0.037).Conclusions:Managing ELBW infants in an elevated midline head position for the first 4 days of life appears safe and may decrease the likelihood of severe PIVH and improve survival.

Adequate luminal distension is essential for improving adenoma detection during colonoscope withdrawal. A few crossover studies have reported that dynamic position changes maximize luminal distension and increase adenoma detection rates (ADR). We designed a multicenter, randomized, parallel-group trial to verify the effect of dynamic position changes on colonic adenoma detection. This study was conducted at the six hospitals of the Catholic University of Korea. Patients aged 45-80 years who underwent a colonoscopy for the first time were included. In the position change group, the position changes during colonoscope withdrawal were as follows: cecum, ascending colon, and hepatic flexure: left lateral position; transverse colon: supine position; splenic flexure, descending colon, sigmoid colon, and rectum: right lateral position. In the control group, the examinations were performed entirely in the left lateral position during colonoscope withdrawal. The primary outcome measure was the ADR, which was defined as the proportion of patients with ≥1 adenoma. A total of 1,072 patients were randomized into the position change group (536 patients) or the control group (536 patients). The ADR was higher in the position change group than in the control group (42.4 vs. 33.0%, P=0.002). More adenomas were detected per subject in the position change group (0.90 vs. 0.67, P=0.01). Increases in the number of adenomas were observed in examinations of the transverse colon (0.22 vs. 0.13, P=0.016) and the left colon (0.37 vs. 0.27, P=0.045). A significant increase in the ADR was observed for endoscopists with a relatively low detection rate. For endoscopists with a high detection rate, non-significant changes in the ADR were observed. Dynamic position changes during colonoscope withdrawal increased the ADR.

Purpose The lateral Trendelenburg position (LTP) may hinder the primary pathophysiologic mechanism of ventilator-associated pneumonia (VAP). We investigated whether placing patients in the LTP would reduce the incidence of VAP in comparison with the semirecumbent position (SRP). Methods This was a randomized, multicenter, controlled study in invasively ventilated critically ill patients. Two preplanned interim analyses were performed. Patients were randomized to be placed in the LTP or the SRP. The primary outcome, assessed by intention-to-treat analysis, was incidence of microbiologically confirmed VAP. Major secondary outcomes included mortality, duration of mechanical ventilation, and intensive care unit length of stay. Results At the second interim analysis, the trial was stopped because of low incidence of VAP, lack of benefit in secondary outcomes, and occurrence of adverse events. A total of 194 patients in the LTP group and 201 in the SRP group were included in the final intention-to-treat analysis. The incidence of microbiologically confirmed VAP was 0.5% (1/194) and 4.0% (8/201) in LTP and SRP patients, respectively (relative risk 0.13, 95% CI 0.02–1.03, p  = 0.04). The 28-day mortality was 30.9% (60/194) and 26.4% (53/201) in LTP and SRP patients, respectively (relative risk 1.17, 95% CI 0.86–1.60, p  = 0.32). Likewise, no differences were found in other secondary outcomes. Six serious adverse events were described in LTP patients ( p  = 0.01 vs. SRP). Conclusions The LTP slightly decreased the incidence of microbiologically confirmed VAP. Nevertheless, given the early termination of the trial, the low incidence of VAP, and the adverse events associated with the LTP, the study failed to prove any significant benefit. Further clinical investigation is strongly warranted; however, at this time, the LTP cannot be recommended as a VAP preventive measure. ClinicalTrials.gov identifier NCT01138540.