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

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.