Jurnal Keperawatan Padjadjaran

ISSN 2338-5324 (print)

ISSN 2442-7276 (online)
Online di http://jkp.fkep.unpad.ac.id
DOI : 10.24198/jkp

Prone Position Improve Physiological Parameters of Preterm Infants

Weaning from CPAP: A Randomized Control Trial

Ayu Simorangkir¹, Yeni Rustina², Defi Efendi3

1,2
Faculty of Nursing, Universitas Indonesia, Depok, Indonesia,
3
Neonatal Intensive Care Unit, RSUI, Depok, Indonesia
Corresponding Email: [email protected]

Received: 29-01-2021 Revised: 23-04-2021 Accepted: 28-04-2021

Abstract

The need for continuous positive airway pressure (CPAP) was vital for preterm infant with respiratory distress,
but the impact of long-term use was very harmful. The effort to do weaning must be done and facilitate the infant
to adapt wean off CPAP. The effect of positioning on stabilized physiological parameters may help preterm infant
to adapt under gradual weaning from CPAP. Aim in this study to determine the effect of prone positioning on
physiological parameters in preterm infants under gradual weaning CPAP. From Mei to September 2020 total
sample 60 preterm infants on non-invasive ventilation or CPAP were randomized into prone position (intervention
group, n = 30) and supine position (control group, n = 30). Oxygen saturation, respiratory and heart rate between
groups were compared. In the prone position was significant higher than supine position at 30th minute. The
mean oxygen saturation in the prone position (99.87±0.35) was higher than in the supine position (97.63±1.45;
p=0.001), the mean respiratory rate in the prone position (42.10±8.59 breaths/min) was lower than in the supine
position (53.20±6.24 breaths/min; p=0.001), and the mean heart rate in the prone position (144.63±13.07/
beats/min) was lower than in the supine position (153.53±10.02/beats/min; p=0.001), so that the prone position
can be applied to increase oxygen saturation and to maintain the stability of respiratory rate in preterm infants
during gradual weaning. The failure to wean off CPAP (re-CPAP) in the prone group was less frequent which
is 3 respondents (5% versus 10%). However, there is no relation between positioning and re-CPAP (p=0.472).

Keywords: Preterm infant, prone position, weaning CPAP.

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Introduction
hospitalization, decreased parental ties, and
Generally, premature infants have respiratory developmental therapy (Lam et al., 2019).
distress syndrome (RDS). This occurs in The CPAP weaning process must be done
newborns less than 28 weeks’ gestation and when the respiratory stability criteria are met
is very rare in full-term babies (Torabian, (Abdel-Hady, Shouman, & Nasef, 2015). The
Alinejad, Bayati, Rafiei, & Khosravi, 2019). criteria for readiness for weaning from nasal
RDS was more common in premature CPAP for 24–48 hour before weaning were
babies because the lungs of premature the pressure at FiO2 of 0.21, normal work of
babies were not able to produce sufficient breathing with no persistent tachypnea (60
surfactant, making it difficult for the lungs breaths for >2h), Oxygen saturation >93%,
to expand, and requiring more energy to no apnea associated with bradycardia (heart
breathe (Montgomery, Choy, Steele, & rate <100 beats/minute) (Amatya et al., 2014;
Hough, 2014). Clinical manifestations that Chawla et al., 2017).
arise from respiratory distress syndrome, The success of wean off CPAP is based
namely increased respiratory rate, decreased on the individual’s ability to adapt to
saturation, cyanosis, and decreased spontaneous breathing and maintain adequate
pulmonary sound (Emaliyawati, Fatimah, & gas exchange (Lam et al., 2019). The proper
Lidya, 2018). Newborns with prematurity, weaning process in premature babies from
difficulty breathing or respiratory distress wean off CPAP in a stable condition was very
must admitted immediately in the neonatal useful for reducing complications (Maffei,
intensive care unit (NICU) (Hendrawati et Gorgoglione, & Vento, 2017). The weaning
al., 2017). process was too fast reported, it would
Respiratory distress syndrome in preterm increase the frequency of apnea, air leakage
infants can be treated with non-invasive syndrome, abdominal distension, increasing
ventilator such as continuous positive airway work of breathing, and oxygen demand which
pressure (CPAP) (Ho, Subramaniam, & results in babies returning to use mechanical
Davis, 2020). CPAP is widely used in NICU ventilation (Abdel-Hady et al., 2015).
in some major hospitals in Indonesia. Based The positioning in premature infants was
on the medical record data of the Perinatology the basic standard of neonatal nursing. A
Unit of the Department of Pediatrics, Cipto prior study (Malagoli et al., 2012) found that
Mangunkusumo Hospital (IKA RSCM), 180 prone position was associated with decreased
(24%) babies receive CPAP. In addition, the inspiratory pressure and increased oxygen
medical record data of Fatmawati Central saturation compared to the supine position in
General Hospital, from January to June 2020, preterm infants during the weaning process
found that 187 babies received intensive care from mechanical ventilation. Few studies
and 54 (28.9%) babies received CPAP therapy. about the impacts of positioning preterm
Meanwhile, the number of babies who infant on their adaptation to spontaneous
received intensive care at the Gatot Subroto respiration after weaning from mechanical
Army Hospital, from January to June 2020, ventilation (Güler & Çalışır, 2020).
66 (18.6%) babies received CPAP therapy. Moreover, various studies have pointed to the
Currently, the early initial use of effects of prone positioning while they under
continuous positive airway pressure give continuous positive airway pressure (CPAP)
potential benefits rather than mechanical were oxygen saturation more stable, lower
ventilation (Dunn et al., 2011). This has led respiration rate, heart rate more stable, also
practice guidelines and recommendation by improving ventilation and optimizing gas
the American Academy of Pediatrics (AAP) exchange (Babaei et al., 2019; Ghorbani,
to utilize CPAP as the primary mode of Asadollahi, & Valizadeh, 2013). However,
respiratory support even the most premature the author was not found the study about the
infants (Committee on Fetus and Newborn, effect of body positioning during weaned off
2014). There were several adverse side effect CPAP and lack of trial evaluating position to
in long-term useing CPAP, namely nose prevent CPAP failure. The critical conditions
damage, delay in oral feeding, prolonged that need to continue is observed when
premature babies under weaning of the CPAP.

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The evaluation was related to the impact preterm infants with respiratory distress who
of body positioning on oxygenation status underwent gradual weaning with a decrease
namely oxygen saturation, heart rate, and in oxygen fraction <25% (Dargaville et al.,
respiratory rate. The purpose of this study 2013). The study was conducted from May
was to identify the impact of the prone and to September 2020 in the Neonatal Intensive
supine position on oxygen saturation, heart Care Unit (NICU), Fatmawati Hospital and
rate, and respiratory rate in preterm infants Gatot Subroto Army Hospital, Jakarta. Block
undergoing the CPAP weaning process. randomization technique using computerized
was used. After obtaining consent from
infants’ parents, the author provide initial
Method randomization results on in envelopes. Then
the nurse took the envelope according to the
This study used a parallel-group study order of the baby, the mother of the premature
design with a randomized controlled trial infant had no knowledge of which treatment
(RCT). This study follows the guidelines was given in the room.
of the Consolidated Standards of Reporting
Trials (CONSORT). The intervention group Premature infants receiving care in the
was the prone position setting intervention NICU were recruited if they met the following
group and the control group was the supine criteria: 1) aged <37 weeks based on the
position. The sample in this study were all Ballard score; 2) diagnosed with RDS and

Figure 1 CONSORT flow diagram of participant recruitment process

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currently on CPAP; 3) currently undergoing obtained the proportion of failure incidence in

CPAP weaning with gradual decreased P1 (failure wean in prone position) of 4% and
oxygen fraction automatically (FiO2 <25%); 33% of success in P2 (success wean in supine
4) had no contraindication for prone and position), so the number of respondents per
supine position (e.g., post-abdominal surgery, group was 30 respondents. The sample size
congenital heart disease). The exclusion calculation was based on the hypothesis test
criteria included infants who had severe formula with different proportions of the
congenital diseases Tetralogy of Fallot independent group (Dahlan, 2016).
(ToF) and diaphragmatic hernia), worsening
oxygenation status or hemodynamically Zα=1.96; α= 0.05, B= 0.20; P1= 0.04;
unstable, had a history of air leak syndrome P2=0.33; P1-P2= 0.29 (effect size); P
and lung collapse, and infants with mottle. =(1/2(P1+P2))
Based on the study by Antunes et al. (2003)

The Health Research Ethics Committee at

the National Hospital Cipto Mangunkusumo a. Prone position
approved this study with a requirement to The infant in study group were turned
obtain written consent from the participants to a prone position for 120 minute, and
at Rumah Sakit Umum Pusat Fatmawati level of heart rate, respiratory rate, oxygen
and Rumah Sakit Pusat Angkatan Darat saturation were recorded every 15 minute.
Gatot Subroto (Reff: 279/UN2.F1/ETIK/ The intervention procedure followed a
PPM.00.02/2020). protocol developed based on Efendi, Sari,
Riyantini, Anggur, and Lestari (2019) which
Intervention was follows: a) The author prepared a tool, a
Each infant have different time for swaddling cloth to support the baby’s body
readiness weaning from CPAP. The study when giving position, b) Preparing assessment
process takes place from 08.00 a.m.- 04.00 and observation sheets, and ensuring the
p.m. For each study group, the intervention readiness of the monitor to function properly,
was conducted twice a day one infant in c) Ensuring that the positioning was done
control group and one infant in study group after 60 minutes feeding competed d)
which lasted for 150 minute. The authors have Nurses washed their hands according to
previously shared the aim and explained the WHO guidelines, e) Nurses provide prone
procedures of the study to the NICU nurses positions with several stages, namely: 1)
who cared for the infants recruited for the Maintaining the baby’s head in the midline
study. The procedures of the study were based or midline position and not turning to one
on a previous study by Babaei, Mohammadi, side, and providing soft pads on the baby’s
and Soleimani (2019), the authors made neck to support the head, 2 ) Give the head a
observations every 15 minute for 120 minute. slightly flexed position with the chin close to
Due to the possibility of the instability of the chest, 3) Give the baby a soft cloth until
the physiological conditions, in the first 15 the shoulders are slightly flexed towards the
minutes of placing the infant in any of the two chest, 4) The position of the baby’s hands is
positions, no data was recorded; then, after abducted so that the ends of the hands are near
the infant was in constant conditions, every the baby’s mouth, 5) Then give the position
15 minutes, heart rate, SpO2, and respiratory of the hips and knees flexion, 6) The baby’s
rate were recorded. knees are in the midline of body growth and
the position of the knees is not wide open, 7)
Provide a nest position to be able to support

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the legs in a flexed and crossed position, 8) mouth, 5) Then give the position of the hips
tighten the nest on the outermost part of the and knees flexed, 6) The baby’s knees are
baby’s body so that it looks like the baby is in the middle line of growth body and knee
confined in a cage and attaches the fixation to positions are not wide open, 7) Provide a nest
the nesting see Fig 2. position to support the legs to form a flexed
and crossed position, 8) Tighten the nest on
b. Supine position the outer part of the baby’s body so that it
The infant in control group were placed to looks like the baby is confined in a cage and
a supine position for 120 minute, and level of attaches the fixation to nesting see Fig. 2.
heart rate, respiratory rate, oxygen saturation The measurements in this study were
were recorded every 15 minute. Whereas parameters of oxygenation status were
the supine position is given through several namely oxygen saturation, respiratory rate,
stages, namely: 1) Maintaining the baby’s and heart rate. As references, normal values
head in the midline or midline position and of vital signs for preterm infants are follows:
not turning to one side, and providing soft heart rate of 121 – 179 beats per minute;
pads on the baby’s neck to support the head, respiratory rate of 21 – 59 breaths per minute;
2) Providing a slightly flexed head position and oxygen saturation (SpO2) of ≥93%
with the chin close to the chest, 3) Give a (Baker, 2015). The data collection tools
soft cloth to the baby until the shoulders used were the observation sheet to obtain
are slightly flexed towards the chest, 4) The primary data directly from the respondent’s
position of the baby’s hands is abducted so parents and medical records. Measurement of
that the ends of the hands are near the baby’s oxygenation status using a cardiorespiratory

Supine position A and B Prone position A and B

Figure 2 The illustration of giving body position for preterrm infants (Source:
Boxwel (2010): Neonatal Intensive Care Nursing. 2nd Edition)

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monitor, pulse oximetry to assess oxygen Demographics and clinical history were
saturation that has been calibrated at the collected from the patient’s medical records,
hospital’s electromedical technician, and to including the use of surfactants, antenatal
support the positioning of the baby’s body steroids, intrauterine growth restriction
using a soft swaddle. (IUGR), patent ductus arteriosus (PDA),
bronchopulmonary dysplasia (BPD), and
Data collection gastroesophageal reflux. The duration of
The measurement is divided into 3 parts, use of CPAP has been recorded from the
namely; 1) baseline data for 10 seconds, time the infant received various forms of the
the author recorded the oxygenation status noninvasive ventilator (Bubble Continuous
before giving the position (T0); 2) the resting Positive Airway Pressure (BCPAP) or non
phase, namely the author and NICU nurses invasive ventilator (NIV).
provides a prone/supine body position for Data analysis
15 minutes to prevent the effects of previous Normality test on data oxygen
activities or positioning; 3) the intervention saturation, respiratory rate, and heart rate
phase of the baby in the prone/supine position at start intervention 30 minutes (T1) and
for 120 minutes (T1-T7), see Fig.1 (Babaei, end of intervention at 120 minutes (T7)
Mohammadi, & Soleimani, 2019). with the Shapiro Wilk test. While the
Infants who experienced an increase homogeneity test on demographic data used
in respiratory rate of >75 times/minute, the Independent T-test. Bivariate analysis
desaturation of <88%, and bradycardia between physiological parameter and body
(<100 beats/min)for less than 6 hours position was applied by used the Independent
were considered CPAP failure, and thus, t-test. In addition, the corellation between
needed to be back on CPAP (re-CPAP) re-CPAP and body position were used Chi-
(Wright, Sherlock, Sahni, & Polin, 2018). square (α=0.05).

Figure 3 The sequence of study procedure

Results preterm infants who failed weaning were 9

respondents (15%) (Table 1). However, the
Subjects’ Demography bivariate analysis were used chi-square results
The characteristics of the infants who between body position against reCPAP were
participated in this study were the mean not significant. See table 2. Based on table 3
gestational age of premature babies in the preterm infants who failed to wean off CPAP,
prone position with RDS 32.87 weeks, the mean age of gestation was 30 weeks, birth
while the mean age of correction was 33.90 weight was 1440 grams, and the duration of
weeks. The average length of time using using CPAP was 12.3 days. Based on table
CPAP in the prone position was faster than 4, the preterm infants who failed to wean off
the supine position, which was 6.3 days. CPAP (reCPAP) did not get antenatal steroids
Based on the results of the homogeneity test, 8 infants, not getting surfactant 7 infants, and
it can be seen that there is no difference in experiencing sepsis/NEC 7 infants.
the characteristics of the intervention group
and the control group (p value> 0.05) (Table Oxygen saturation
1). The proportion of males was 66.7%, and The intervention was conducted in 120

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minute, from the baseline (T0) until end p = 0.001). Similarly, the mean percentage
of intervention (T7) the mean of oxygen oxygen saturation was also higher in infants
saturation of prone position more higher than with prone position compared with that in
supine position (see table 5). Independent infants with supine position at 120 minutes
T-test showed that there was a difference in (100 ± 0.00 vs 97 ± 0.87; p = 0.001), see table
the percentage oxygen saturation between 5.
the prone and supine groups at 30 minutes
(T1) and 120 minutes (T7). At 30 minutes Respiration rates
(T1), the mean percentage oxygen saturation The mean of preterm infant’s respiration
was significantly higher in infants with prone rate in the prone group was lower than in the
position (99.87 ± 0.35) compared with that supine group, and more stable at T5 (see table
in infants with supine position (97.63 ± 1.45; 5). Further analysis with the Independent
Table 1 Demographic Characteristics of Preterm Infants May – September 2020 (n=60)
Prone Supine
Characteristic
Min- Min- P
(n,%) Mean SD (n,%) Mean SD
Max Max

Gestational age 32.87 2.57 28-36 32.07 3.34 26-36 0.303

(week)*

Correctional age 33.90 2.52 29-38 32.43 3.42 26-36 0.064

(week)*

Actual body 1873 439.05 1165- 1657.33 566.27 800- 0.309

weight (gram)* 2670 3200

Prolong of using 6.30 2.63 2-14 9.33 3.42 3-15 0.062

CPAP (day)*

Sex**

Male 21 (52.5) 19 (47.5) 0.784

Female 9 (45) 11(55)

Antenatal 9(15) 11(18.3) 0.791

steroids**

Surfactant** 2(3.3) 3(5) 0.647

Sepsis/NEC** 9(15) 11(18.3) 0.584

PDA** 13(21.7) 16(26.5) 0.438

IUGR** 9(15) 15(25) 0.114

Re-CPAP**

Yes 3 (5) 6 (10)

No 27 (45) 24 (40)
*Independent t-test,
**Chi-square; Abbreviations: NEC: enterocolitis necroticans,
**PDA: patent ductus arteriosus, IUGR: intrauterine growth restriction.

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Table 2 The Relation Between Recpap with Prone and Supine Position (N=60)
reCPAP
Intervention groups no yes Total Correlation p-value*
n % n % n %

Prone 27 90 3 10 30 100 0.140 0.472

Supine 24 80 6 20 30 100

Total 51 85 9 15 60 100
*Chi square

Table 3 Demographic Characteristics of The Preterm Infant with Recpap (Gestational Age,
Birth Weight, Duration of Using Cpap) (N= 9)
Characteristic Mean Min-Max

Gestational age (weeks) 30 27–32

Birth weight (grams) 1440.3 800–2100

Duration of using CPAP (days) 12.3 7–15

Table 4 Demographic Characteristics of The Preterm Infant with Recpap (Antenatal Steroids,
Surfactant, Sepsis/Nec, Pda, Iugr) (N= 9)
Characteristic Yes No

Antenatal steroids 1 8

Surfactant 2 7

Sepsis/NEC 7 2

PDA 3 6

IUGR 4 5

Table 5 The Mean of Oxygen Saturation, Respiration Rate and Heart Rate In Prone and Supine
Position During Intervention
Prone Supine
Category Time
mean SD mean SD

Oxygen T0 97.87 1.19 97.00 1.43

Saturation
T1 99.87 0.35 97.63 1.45

T2 99.23 1.00 97.50 1.50

T3 99.60 0.62 97.47 1.50

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Prone Supine
Category Time
mean SD mean SD

Oxygen T4 99.97 0.18 97.13 1.38

Saturation
T5 100 0 97.23 1.50

T6 100 0 97.13 1.22

T7 100 0 97.00 0.87

Respiration Rate T0 49.03 6.32 53.30 7.16

T1 42.10 8.59 53.20 6.24

T2 41.73 5.06 52.53 7.50

T3 38.57 6.17 54.17 7.00

T4 37.83 5.66 52.70 6.96

T5 36.27 5.77 53.63 6.87

T6 36.13 4.66 54.47 6.65

T7 34.37 4.66 56.47 4.49

Heart Rate T0 155.83 7.28 154.80 9.03

T1 144.63 13.07 153.53 10.02

T2 143.30 10.36 153.40 8.73

T3 141.57 8.06 153.77 8.46

T4 138.93 6.51 153.90 7.84

T5 138.57 6.71 153.00 8.69

T6 137.07 5.61 155.53 8.38

T7 135.73 4.14 158.30 8.50

Table 6 Differences In Oxygen Saturation, Respiratory Rate, and Heart Rate Between Two
Groups (N=6)
Physiological Parameters Intervention groups T Independent
Prone Supine T value P-value

Oxygen saturation

Baseline 0 minute (T0) 97.87 + 1.19 97.00 + 1.43 2.488 0.628

30 minutes (T1) 99.87 + 0.35 97.63 + 1.45 8.206 0.001

120 minutes (T7) 100 + 0.00 97 + 0.87 18.866 0.001

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Physiological Parameters Intervention groups T Independent

Prone Supine T value P-value

Respiratory rate

Baseline 0 menit (T0) 49.03 + 6.32 53.30 + 7.16 2.538 0.318

30 minutes (T1) 42.10 + 8.59 53.20 + 6.24 5.726 0.001

120 minutes (T7) 34.37 + 4.66 56.47 + 4.49 18.705 0.001

Heart rate

Baseline 0 menit (T0) 155.83 + 7.28 154,80 + 9.03 2.446 0.471

30 minutes (T1) 144.63 + 13.07 153,53 + 10.02 2.959 0.004

120 minutes (T7) 135.73 + 4.13 158,30 + 8.50 13.074 0.001

α=0.05
T-test showed that the respiratory rate of the infant with undergoing from mechanical
groups in the prone and supine positions at 30 ventilation the change in oxygen saturation
minutes (T1) and at 120 minutes (T7) obtained was significant after the first 15 minutes to
p-value = 0.001 <α (0.05), it can be explained 120 minutes after administration (p = 0.01).
that there was a difference. significantly the The main results of this study indicated that
respiratory rate at 30 minutes (T1) and 120 there was a significant difference between the
minutes (T7) between the prone and supine position of the prone and supine bodies on
position groups (see table 5). oxygen saturation, respiratory rate, and heart
Heart rates rate (p = 0.001) (Table 5).
The mean of heart rate in the prone group The prone position has a positive impact
was lower than that in the supine group (see on oxygen saturation, namely reaching the
table 5). The results of further analysis with normal range (>93%-100%) after 90 minutes
the Independent T-test showed that the heart post positioning. The results showed that
rate of the group prone and supine positions there was a significant difference after giving
at 30 minutes (T1) obtained p-value = 0.004 the prone position for 120 minutes undergoing
<α (0.05) and at 120 minutes (T7) obtained CPAP weaning (p = 0.001). In the study by
p-value = 0.001 <α (0.05) it can be explained Babaei et al. (2019) giving the prone position
that there was a significant difference in heart for 180 minutes to 62 infants with NCPAP, the
rate at 30 minutes (T1) and 120 minutes (T7) mean oxygen saturation in the prone position
between the prone and supine position groups was higher and stable than the supine position
(see table 5). (p = <0.001). This is because the prone
position provides better synchronization
between the thorax and abdomen, resulting
Discussion in increased tidal volume and a better oxygen
saturation impact (Malagoli et al., 2012).
The results showed that changes in oxygenation During the observation of 120 minutes,
status were seen in the first 30 minutes. The the mean heart rate was stable at T4 and
change in oxygenation status started from 30 T5, namely 75-90 minutes after giving the
minutes and stable at 120 minutes (100%), position. Ghorbani, Asadollahi, and Valizadeh
post-administration and the mean oxygen (2013) identified that giving the prone and
saturation at the prone position tended to be supine positions to 2 groups for 120 minutes
stable and save while compared to the supine in preterm infants with NCPAP-attached
position. Abdeyazdan, Nematollahi, Ghazavi, respiratory distress showed a change in heart
and Mohhamadizadeh (2010) stated preterm rate in the first group of prone positions,

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namely 135 ± 15.04 beats per minute and that can delay the wean off CPAP are
the supine group 144.27 ± 130.9 beats per maternal chorioamnionitis, anemia, infants
minute (p = 0.002). In the supine position, experiencing gastroesophageal reflux which
the heart rate during observation tended to be can prolong the duration of CPAP used
tachycardia with the average heart rate in 120 (Rastogi et al., 2012). In this study, infants
minutes, namely 158.30 + 8.50. The results who experienced reCPAP were 27–32 weeks’
of a study by Hough et al. (2016) involving gestation, birth weight. 800-2100 grams and
60 preterm infants identified the impact of experiencing sepsis / NEC. Preterm infants
giving a prone position in premature infants experienced failed to wean off CPAP with
with CPAP, there was an increase in lung the length of CPAP used were 7–15 days.
muscle in the first 2 hours (0.02) and stable According to a study by Rastogi et al. (2012),
for the first 4 hours (p = 0.03), the heart rate birth weight, chorioamnionitis, anemia, and
was more stable in the prone position. This GER played a significant role in weaned off
could be due to the prone position providing CPAP and the length of CPAP use. Wright,
better synchronization between the thorax Sherlock, Sahni, and Polin, (2018) babies
and abdomen, thus making the diaphragm with a gestation age of 25–28 weeks tend to
muscle shorten better (Malagoli et al., 2012). fail to wean off CPAP (45%), among them
Good coordination between the thorax and have low birth weight and born with cesarean
abdomen helps premature babies to adapt section. So that action was needed to prevent
better in improving the muscle for breathing. dependence on a long breathing device
The results of the observation of the and the occurrence of bronchopulmonary
respiratory rate showed that the prone position dysplasia (BPD). Dargaville et al. (2013)
group experienced changes in the normal stated that antenatal use of corticosteroids
range for each time change (p = 0.001). This in mothers who are threatened with giving
is supported by the study of Ghorbani et al. birth at 24–33 weeks’ gestation can reduce
(2013) who stated that there was a change in re-CPAP (> 90%).
the mean respiratory rate in preterm infants Limitation
with respiratory distress attached to NCPAP The limitation of the study was the author
during the 120-minute prone position, where did not investigate any differences in the
the tachypnea was initially more stable (p = use of the CPAP setting in the two hospitals,
0.002). In line with the study of Babaei et namely the use of BCPAP and CPAP that
al. (2019) giving the prone position for 180 use ventilator mode (NIV). Furthermore,
minutes to 62 infants with NCPAP, the mean the study should use the position of quarter
respiratory rate was better at 55.61 ± 6.4 (p = prone or semi-prone. Addittion, the author
<0.001). was not compare the demographics with
The weaning success of CPAP at the prone physiological parameters between 2 groups
position compared to the supine position is not that might be effect of weaning process.
significant. Respondents who experienced re-
CPAP in the supine group were 6 respondents.
The results of the further analysis showed no Conclusion
relationship between assignment and reCPAP.
The author has not found any literature Oxygen saturation in infants in prone position
on assigning a position to prevent reCPAP. tends to be more stable than infants in the
However, giving prone body position from supine position. The respiratory rate and
several study results can provide a positive heart rate were also more stable in the prone
impact for premature babies with respiratory than in the supine position group. There were
distress, namely better stability of oxygen significant differences in oxygen saturation,
saturation, respiratory rate, and heart rate. respiratory rate, and heart rate at 30 minutes
Several factors that influence the success (T1) and 120 minutes (T7) between the prone
of weaning CPAP are gestational age, age and supine position groups. Infants from the
of correction, and birth weight (Abdel- supine group had more reCPAP were 6 infants.
Hady et al., 2015). Meanwhile, factors There is no relationship between assignment

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under nasal continuous positive airway

and reCPAP. Positioning is a strategy for pressure (N-CPAP): A cross over clinical trial.
treating premature infants and has a positive Cukurova Medical Journal, 44(4), 1250–
impact on both neuromotor, musculoskeletal 1255. https://doi.org/10.17826/cumj.512192
and physiological functions. So that the
nurse can give positioning especially prone Baker, B. (2015). Evidence-based practice to
position saved about 120 minute. In addition, improve outcomes for late preterm infants.
It is very important to created stability of the Journal of Obstetric, Gynecologic, and
infant’s oxygenation status during the CPAP Neonatal Nursing, 44(1), 127–134. https://
weaning process. Nurses can better apply doi.org/10.1111/1552-6909.12533
and documented monitor the positioning
of preterm infants undergoing the CPAP Boxwell, G. (2010). Neonatal intensive care
weaning process. nursing 2nd ed. Routledge.
Acknowledgment Chawla, S., Natarajan, G., Shankaran, S.,
Thanks to the pediatric nurses in the Carper, B., Gantz, M. G., Das, A., Ronald, N.
NICU room at Fatmawati Hospital and Gatot (2017). Markers of successful extubation in
Subroto Army Hospital who were involved extremely preterm infants, and morbidity
in the study. Thanks were also extended to after failed extubation. HHS Public Access.
all mothers of premature infants who were US: Hospitals of Leices ter.
willing to become respondents. https://doi.org/10.1016/j.jpeds.2017.04.050

Committee on Fetus and Newborn. (2014).

References Respiratory support in preterm infants at
birth. Pediatrics, 133(1), 171–174. https://
Abdel-Hady, H., Shouman, B., & Nasef, doi.org/10.1542/peds.2013-3442
N. (2015). Weaning preterm infants from
continuous positive airway pressure: Dahlan, M.S. (2016). Besar sampel dalam
evidence for best practice. World Journal penelitian kedokteran dan kesehatan, seri 2
of Pediatrics, 11(3), 212–218. https://doi. (Edisi 4). Epidemiologi Indonesia.
org/10.1007/s12519-015-0022-6.\
Dargaville, P. A., Aiyappan, A., De Paoli,
Abdeyazdan, Z., Nematollahi, M., Ghazavi, A. G., Dalton, R. G. B., Kuschel, C.
Z., & Mohhamadizadeh, M. (2010). The A., Kamlin, C. O., Davis, P. G. (2013).
effects of supine and prone positions on Continuous positive airway pressure failure
oxygenation in premature infants undergoing in preterm infants: Incidence, predictors and
mechanical ventilation. Iranian Journal consequences. Neonatology, 104(1), 8–14.
of Nursing and Midwifery Research, https://doi.org/10.1159/000346460
15(4), 229–233. Retrieved December 23,
2020, from http://www.ncbi.nlm.nih.gov/ Dunn, M.S., Kaempf, J., de Klerk A, de Klerk
pubmed/22049286%0A R, Reilly M., Howard D., Ferrelli K., O’Conor
J, Soll R.F., Vermont Oxford Network
Amatya, Shaili, Rastogi, D., Bhutada, A., & DRM Study Group. (2011). Randomized
Rastogi, S. (2014). Weaning of nasal CPAP trial comparing 3 approaches to the initial
in preterm infants: Who, when and how? A respiratory management of preterm neonates.
systematic review of the literature. World Pediatrics,128(5):e1069-e1076. https://doi.
Journal of Pediatric, 11(1):7–13. https://doi. org/10.1542/peds.2010-3848
org/10.1007/s12519-014-0535-4
Efendi, D., Sari, D., Riyantini, Y., Anggur,
Babaei, H., Mohammadi Pirkashani, L., D., & Lestari, P. (2019). Pemberian posisi
& Soleimani, B. (2019). omparison of the (positioning) dan nesting pada bayi prematur :
effect of supine and prone positions on evaluasi implementasi perawatan di neonatal
physiological parameters of preterm infants intensive care unit (NICU). JKI, 22(3),169–

Volume 9 Issue 1 April 2021 95

 Ayu Simorangkir: Prone Position Improve Physiological Parameters of Preterm Infants Weaning from CPAP

181. https://doi.org/10.7454/jki.v22i3.619 changes in lung volumes in stable premature

infants: A randomized controlled trial. The
Emaliyawati, E., Fatimah, S., & Lidya, L. Journal of Pediatrics, 1–8. https://doi.
(2018). Pengaruh Terapi Musik Lullaby org/10.1016/j.jpeds.2019.07.074
terhadap Heart Rate, Respiration Rate,
Saturasi Oksigen pada Bayi Prematur. Jurnal Maffei, G., Gorgoglione, S., & Vento, G.
Keperawatan Padjadjaran, 5(3). https://doi. (2017). Noninvasive ventilation: Systematic
org/10.24198/jkp.v5i3.648 approach and new perspectives for preterm
infants. Journal of Clinical Neonatology, 6(3),
Ghorbani, F., Asadollahi, M., & Valizadeh, 135. https://doi.org/10.4103/jcn.jcn_121_16
S. (2013). Comparison the effect of sleep
positioning on cardiorespiratory rate in Malagoli, R.C., Fagundes, F., Santos, A.,
noninvasive ventilated premature infants. Oliveira, E. A., Cândida, M., & Bouzada,
Nursing and Midwifery Studies, 1(4), 182– F. (2012). Influence of prone position on
187. https://doi.org/10.5812/nms.10318 oxigenation, respiratory rate and muscle
strength in preterm infants being weaned from
Güler, F. & Çalışır, H. (2020). The effect of mechanical ventilation. Rev Paul Pediatr,
positioning on adaptation to spontaneous 30(22), 251–6251. https://doi.org/10.1590/
breathing in premature infants after weaning S0103-05822012000200015
from mechanical ventilation: a randomized
controlled trial. The Journal of Pediatric Montgomery, K., Choy, N. L., Steele, M., &
Research, 7(2),102-109. https://doi. Hough, J. (2014). The effectiveness of quarter
org/10.4274/jpr.galenos.2019.19042 turn from prone in maintaining respiratory
function in premature infants. Journal of
Hendrawati, S., Fatimah, S., Fitri, R., Paediatrics and Child Health, 50(12), 972–
Nurhidayah, I. (2017). Kajian Kebutuhan 977. https://doi.org/10.1111/jpc.12689
Family Centered Care dalam Perawatan Bayi
Sakit Kritis di Neonatal Intensive Care Unit. Rastogi, S., Rajasekhar, H., Gupta, A.,
Jurnal Keperawatan Padjadjaran, 5(2). Bhutada, A., Rastogi, D., & Wung, J.-T.
https://doi.org/10.24198/jkp.v5i2.453 (2012). Factors affecting the weaning from
nasal CPAP in preterm neonates. International
Ho, J.J., Subramaniam, P, Davis, P.G. (2020). Journal of Pediatrics, 12(1), 1–7. https://doi.
Continuous positive airway pressure (CPAP) org/10.1155/2012/416073
for respiratory distress in preterm infants. Torabian, H., Alinejad, S., Bayati, A., Rafiei,
Cochrane Database Systematic Review,(10), F., & Khosravi, S. (2019). Comparison of
1-40. https://doi.org/10.1002/14651858. the effects of supine and prone positions on
CD002271 oxygen saturation and vital signs in premature
infants: A crossover clinical trial. Iranian
Hough, J., Trojman, A., & Schibler, A. Journal of Neonatology, 10(2), 30–36. https://
(2016). Effect of time and body position on doi.org/10.22038/ijn.2019.32928.1465
ventilation in premature infants. Pediatric
Research, 80(4), 499–504. https://doi. Wright, C. J., Sherlock, L., Sahni, R., &
org/10.1038/pr.2016.116 Polin, R. A. (2018). Preventing CPAP failure:
Evidence-Based and physiologically sound
Lam, R., Schilling, D., Scottoline, B., practices from delivery room to the NICU.
Platteau, A., Niederhausen, M., Lund, K. C., Clinical Perinatology, 176(1), 139–148.
McEvoy, C. T. (2019). The effect of extended https://doi.org/10.1016/j.clp.2018.01.011
continuous positive airway pressure on

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