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We read with interest the paper by Dimitriou et al1 in which it was confirmed again that head up tilting to 45 degrees results in better oxygenation in stable preterm neonates. However compared with our study,2 in which the same effect was observed, there is a (probably) significant difference. Their infants were studied in the horizontal prone, in the horizontal supine and in the 45° head up tilt supine position whereas in our study all infants were studied in the prone position including the 45° head up tilt. We had then hypothesised that the combination of the prone position and the 45° head up tilt could facilitate diaphragmatic activity.
I do not think that this hypothesis can be totally dismissed by the results of Dimitriou et al1 as suggested by the authors, since their infants were studied in different positions—that is, supine in their study and prone in our study.
We thank Professor Dellagrammaticas for his comments on our study.1 Dellagrammaticas et al2 hypothesised that the combination of the prone posture and the 45 degree head up tilt position could facilitate diaphragmatic activity. We however, propose that the improvement in oxygenation seen in the head up tilt position1 was more likely to be due to a change in lung volume. In the head up tilt position, the weight of the abdominal contents on the diaphragm is reduced, tending to increase functional residual capacity.3 In contrast, ultrasonographic examination4 has demonstrated that the diaphragm was significantly thicker at end expiratory volume in the prone rather than the supine position, which is likely to result in reduced diaphragm strength. Indeed, we demonstrated1 Pimax (a measure of respiratory muscle strength) was lower in the prone compared to the supine position and the supine posture with 45° head tilt.
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