PROSpect: Prone and Oscillation Pediatric Clinical Trial

Inclusion criteria:

Intubated and mechanically ventilated with high moderate-severe PARDS for <48 hours per PALICC guidelines (chest imaging consistent with acute pulmonary parenchymal disease and OI ≥12 or OSI ≥10). We require two blood gases meeting moderate-severe PARDS criteria (separated by at least 4 ± 2 hours during which time the clinical team is actively working to recruit lung volume and optimize the patient's hemodynamic status per PALICC guidelines; specifically, incremental and decremental PEEP changes to optimize lung volume). A second blood gas is not required for OI ≥16.

Exclusion criteria:

• Perinatal related lung disease

• Unrepaired congenital diaphragmatic hernia or congenital/acquired diaphragmparalysis

• Respiratory failure explained by cardiac failure or fluid overload

• Cyanotic heart disease

• Cardiomyopathy

• Unilateral lung disease

• Primary pulmonary hypertension

• Intubated for status asthmaticus

• Obstructive airway disease (e.g., Severe airways disease without parenchymalinvolvement or disease characterized by hypercapnia with FiO2 <0.30 and/or evidenceof increased resistance visible on the flow - time scalar and/or presence ofintrinsic PEEP)

• Active air leak

• Bronchiolitis obliterans

• Post hematopoietic stem cell transplant; specifically, patients receiving continuoussupplemental oxygen for three or more days prior to intubation; receivingnoninvasive ventilation for more than 24 hours prior to intubation; receiving morethan one vasoactive medication at time of meeting inclusion criteria; spending morethan four days in the PICU prior to intubation; supported on or with immediate plansfor renal replacement therapies; with two or more allogeneic transplants; whorelapsed after the transplant; or with diffuse alveolar hemorrhage

• Post lung transplant

• Home ventilator dependent with baseline Oxygen Saturation Index (OSI) >6

• Neuromuscular respiratory failure

• Critical airway (e.g., post laryngotracheal surgery or new tracheostomy) oranatomical obstruction of the lower airway (e.g., mediastinal mass)

• Facial surgery or trauma in previous 2 weeks

• Head trauma (managed with hyperventilation)

• Intracranial bleeding

• Unstable spine, femur or pelvic fractures

• Open abdomen

• Currently receiving more than 6 consecutive hours of either prone positioning orHFOV

• Supported on ECMO during the current admission

• Family/medical team not providing full support (patient treatment considered futile)

• Previously enrolled in current study

• Enrolled in any other interventional clinical trial not approved for co-enrollment

• Known pregnancy