PROLONGED SLOW EXPIRATION (PSE) AND PRONE POSITION INTERVENTION IN CHILDREN : A LITERATURE REVIEW

Nursing interventions to reduce the impact of respiratory problems in children aged < 24 months in inpatient rooms are not only a science but also an art. This study aimed to determine the effectiveness of Prolonged Slow Expiration (PSE) and prone position in improving respiratory function in hospitalized children aged < 24 months with respiratory distress in inpatient rooms. This literature review examined thirteen peer-reviewed journals based on inclusion criteria. The results of the review showed that PSE and prone position can reduce the respiratory frequency, maintain the neuromechanical diaphragm, and increase tidal volume. PSE was more effective at lowering the bronchiolitis scale score, preventing the child from experiencing moderate to severe respiratory distress, and decreasing relative sputum production. The prone position is more effective in increasing SaO2 even when using mechanical ventilation (MV), can increase maximal inspiratory pressure (MIP) and tissue oxygenation index (TOI), provides sleeping comfort, improves cardiorespiratory function, reduces moderate to severe respiratory distress, and can perform intubation. It can be concluded that PSE is a safe and easy therapy to administer to mild respiratory distress patients but has not a significant effect on children < 24 months with moderate to severe respiratory distress in inpatient rooms. Received: 19 September 2020 Revised: 28 November 2020 Accepted: 29 June 2021


INTRODUCTION
Currently, children are susceptible to various diseases. UNICEF (2019) stated that respiratory problems are the main cause of death in children in poor and developing countries. Nayani et al. (2018) supported the nation and reported that respiratory problems were the global death in children aged under 5 years. In Indonesia, respiratory distress was the second health problem in 4.4% or 1,017,290 children (Kemenkes RI, 2019). Generally, child respiratory problems are caused by immaturity of the lungs of premature babies and respiratory infections that originate from various pathogens that attack the trachea, bronchi, bronchioles, and alveoli followed by severity ranging from mild to severe (Orloff et al., 2019) (Rahmawati et al., 2020).
It is important for nurses to provide independent interventions for children to reduce respiratory distress (Baudin et al., 2019). Interventions given to neonates, infants, and toddlers aim to prevent disturbances in airway clearance, ineffective breathing patterns, and increased oxygenation (Puji, 2018). The interventions are provided with a therapeutic technique through prolonged slow expiration (PSE) (Nogueira et al., 2019) and the prone position (Cheifetz, 2017).
PSE and prone position are non-pharmacological therapies that can be given to children which are not only a science but also an art in independent nursing practice (Liu et al., 2018). PSE is nonpharmacological-advanced chest physiotherapy that can stimulate children's diaphragm to clear the lungs from secretions and increase oxygenation (Mishra et al., 2020). The prone position is a nonpharmacological action that can improve the lung mechanism to increase oxygenation (Orloff et al., 2019). Both PSE therapy and prone position provide benefits in maintaining lung expansion and increasing oxygenation in children (Schaan et al., 2020).
This literature review aims to distinguish both interventions and determine the best time when nurses can provide both therapies to children. We have not found published literature discussing the benefits and effectiveness of PSE therapy and the prone position in hospitalized children aged < 24 months with respiratory distress in inpatient wards. Therefore, it is considered necessary to synthesize published evidence of the effectiveness of PSE therapy and prone position and explain the indications of both therapies in dealing with children's respiratory distress aged < 24 months in inpatient wards (Liu et al., 2018).

Study design
This is a literature review of the effectiveness of Prolonged Slow Expiratory (PSE) therapy and prone position in children aged < 24 months with respiratory distress in inpatient wards. The development of the research question follows the PICO guideline as presented in Table 1 below.

Search Strategy
Alternative term for population (P) used "Children Under 24 Months with Respiratory Distress in Inpatient Rooms" OR "Pediatric with Respiratory Distress in Hospital" OR "Pediatric Acute Respiratory Syndrome in PICU" OR "Children with RDS in Neonate Intensive Care Unit" OR "Children with Pneumonia in Hospital" OR "Pneumonia in Child" OR "Child with Bronchiolitis in Patient Room" OR "Pediatric with Respiratory Distress in PICU" OR "RDS in Children" OR "Pediatric Acute Lung Injury in PICU" OR "Pediatric with acute respiratory infection in Patient Room; Researchers did not use alternative terms for intervention (I); Alternative terms for comparison (C), researchers used "Semi Prone Position" OR "Quarter Prone Position"; Alternative terms for the outcome (O), researchers used "Respiratory Rate" OR "Oxygen saturation" OR "Hard to breathe" OR "Oxygenation" OR "Cough with phlegm" OR "Wheezing".

Selection Criteria
The inclusion criteria of this study included 2012-2020journal collection, quantitative and qualitative researches, using only original research, the full text of children with respiratory distress in children, children who have additional breath sounds, children aged 0 to 24 months, children in the intensive care unit and inpatient rooms, and children receiving PSE therapy and prone position. The exclusion criteria included conference papers, symposia, discussion papers, and children with respiratory arrest. Researchers have described the filters in Flowchart 1. A total of 13 studies were included in the review, including 5 studies that reviewed PSE and 8 studies that reviewed the prone position. To determine the effectiveness of the prone position compared with the supine process against SpO2 in very low birth weight babies using invasive breathing devices

Flowchart 1. Journal Search Strategy
The prone position did not make the patient apnea and not decrease oxygen saturation. To see inspiratory effort, respiratory metabolism, diaphragm movement when given the prone position versus the supine position in children with severe bronchiolitis who use noninvasive ventilation The prone position was effective in reducing inspiratory efforts and respiratory metabolism; did not occur in the esophagus; and maintained the neuromechanical efficiency of the diaphragm.

6
Effects of Prone Sleeping on Cerebral Oxygenation in Preterm Infants.  To determine the speed of inserting the ETT during the management of respiratory distress in a patient in the semi-Management of respiratory distress during intubation in the semi-prone position was more effective than the supine position; researchers experienced the ease of clearing the airway.

No
Title ( To assess the respiratory rate (RR) between the prone versus semi-fowler positions The prone position had a greater effect on neonates and infants than toddlers with severe respiratory distress in reducing the respiratory frequency.

9
The   To see the effect of the prone position on the breathing force, oxygenation, and breathing rate between the prone position and the supine position The prone position for the neonate in the NICU can increase the SpO2 but cannot decrease respiratory rate.

RESULT
The incidence of respiratory distress in children aged less than 24 months is still high in poor and developing countries. Kemenkes RI (2019) reported that one of the causes of the high mortality rate in children is due to respiratory disorders in children, therefore it is noteworthy to implement independent nursing interventions to improve lung function in children (Mishra & Samuel, 2018). After selecting journals based on the inclusion and exclusion criteria, it was retrieved 13 articles published in 2012-2020 were included in this review. Table 2 shows the data extraction of the articles.
Research studies on the provision of Prolonged Slow Expiratory (PSE) therapy and prone position can be given to children aged < 24 months with respiratory problems. PSE therapy is usually given to infants aged 0 to less than 24 months of age who experience improvement in oxygen saturation and generally it is for children who undergo care in the neonatal intensive care unit (NICU) and high care unit (HCU) (Mishra & Samuel, 2018). Nurses need to remember that giving this therapy aims to clear the patient's airway due to an excess secretion (Mishra & Samuel, 2018) and they must pay attention to the anatomy, physiology, and psychology of children (Bellanti & Settipane, 2018). Giving PSE can not only be given to children who have mild respiratory distress but also to the patient's hemodynamic within normal limits (Mishra et al., 2020). PSE can be combined with another chest physiotherapy to reduce the amount of sputum (Conesa-Segura et al., 2019), can increase tidal volume, and reduce the respiratory rate so that it does not obstruct the patient's airway (Lanza et al., 2013).
Giving the prone position to children aged < 24 months with respiratory distress due to lung immaturity in premature babies, early acute lung injury, and infections caused by bacteria and viruses such as pneumonia, bronchiolitis, and COVID-19, actually provides benefits because it can increase oxygen saturation even after using a mechanical ventilator. However, this position should be stopped when PaO2/FiO2 ≥ 150; OI < 12; OSI < 10 in children suffering from COVID-19 (Kneyber et al., 2020). The prone position can also reduce the respiratory rate in children (Elhussain et al., 2018), Tissue Oxygenation Index (TIO), make better quality of sleep (Shepherd et al., 2019), prevent diuresis, and maintain fluid balance in children (Dall' Agnese et al., 2019), as well as increase the neuromechanical efficiency of the diaphragm, decrease esophageal pressure (Baudin et al., 2019), and decrease maximal inspiratory pressure (MIP) so as not to obstruct the patient's breathing (Malagoli et al., 2012) (Table 2).
Before implementation, nurses also need to know the medical diagnosis, respiratory measurement scale, duration, and effectiveness of each therapy for the patient's body (Diagram 1).

DISCUSSION
Acute respiratory disorders of children in intensive inpatient rooms every year amounted to 14.46%. The nurse's inability to think critically can lead to worsening child conditions (Yin et al., 2016). Of the 13 studies that have been reviewed, it was proven the effectiveness of PSE therapy and prone position to improve the respiratory status of hospitalized children aged < 24 months in inpatient rooms. In this study, researchers have also attempted to develop steps to make it easier for nurses to provide PSE and prone position therapy based on literature searches and can be seen in Table 3.

Action Definition and Work Steps Indications and Contraindications Prolonged Slow Expiratory (PSE)
The newest chest physiotherapy technique used in clinical practice in hypersecretory children to remove secretions and reduce hyperventilation (Nogueira et al., 2019). PSE work steps (Mishra et al., 2020): a.
Provide information and education to parents prior to action and prepare equipment before action is taken. b.
Wash hands before action. c.
The patient is positioned in a supine position in a comfortable condition and the vital signs are normal, the body is relaxed, and the patient's behavior is calm. d.
During the procedure, place one hand over the chest cavity and the other hand over the abdominal cavity, just above the umbilicus. e.
In the final expiration phase, the therapist exerts a compressive force from the hypothenar (palm) and at the same time presses from the upper hand (the hand above the chest cavity), and gives pressure from the lower hand (the hand above the abdominal cavity). f. This compression is maintained for 4-5 seconds followed by slow release. g.
One set of three compressions is given three times with a pause of 30 seconds between each compression.
Reducing the secretion of sputum in the child's body b.
Can be given to children with "repeated wheezing" Contraindications: a. Cannot be given to children with airway obstruction b.
Cannot be given to infants with gastroesophageal reflux disease, babies who have undergone thoracic and/or abdominal surgery and have been diagnosed with heart disease or neuropathy

Action Definition and Work Steps Indications and Contraindications Prone Position
This is a simple action by reversing the patient's body position to increase oxygenation throughout the patient's body, especially in patients with respiratory disorders and hypoxemia (Jagadeeswari & Soniya, 2020).
The work steps of prone position (Guérin et al., 2013): a. Provide information and education to parents before taking action and prepare equipment before action. b.
Assess the patient's condition from oxygen saturation, respiration rate, lung roentgen in the patients, and make sure the length of the ventilator circuit according to patient needs. c.
Check the fit of the endotracheal tube and NGT/OGT tube and protect the patient's knees, forehead, chest, and iliac crest to prevent pressure sores. d.
Keep nurses clean by washing hands before taking action. e.
Work with 3 to 4 nurses to change the patient to a prone position to maintain the patient's head, endotracheal tube, and ventilator. f.
Be sure to take priority direction of the patient's central vein when turning the patient over. g.
The patient is transferred to the sagittal plane and remains in this position for a while. The goal is to make it easier to attach the heart electrodes to its back and attach a base to prevent the risk of pressure sores.
Can be given to patients who have moderate to severe ARDS b.
Can be given to children using MV (mechanical ventilation) Contraindications: a. Cannot be done in children with postthoracic surgery, tracheostomy, patients receiving renal and abdominal therapy b.
Patients with a history of congenital heart disease and Intraventricular Hemorrhage (IVH) The review of PSE therapy noted that there was an increase in tidal volume in children during treatment at the NICU and HCU. Sound "wheezing" was reduced in both lungs and the lungs did not experience an exacerbation. PSE therapy was able to stimulate the release of sputum in children over 12 months of age and can reduce the respiratory rate in children with congenital pneumonia when it was given routinely within 24 hours of treatment. In addition, newborns who have respiratory problems can also be given PSE therapy as long as they use non-invasive oxygen devicessuch as nasal canula oxygen with an APGAR value > 7 for 5 minutes and 10 minutes of birth, and have stable child vital signs. The children were calm and oxygen saturation > 96% or within normal limits. PSE therapy can be combined with other chest physiotherapies such as clapping and postural drainage to remove thick and reduce pain in the chest cavity when it is expelled. PSE therapy can also be done with other methods of nCPT (PSE, retrograde rhino-pharyngeal cleaning chest physiotherapy technique) and it was proven of no side effects in children. A measurement to see the effectiveness of PSE therapy can be done before and after the use of the Wang Score or CS by comparing the results before and after therapy. The prone position also provides benefits to children aged < 24 months who experience respiratory problems, i.e., reducing child pneumonia from moderate to severe pneumonia and increasing SpO2 from ≤ 80% to > 94% of children with very low birth weight (VLBW) in premature babies, as well as preventing apnea and reducing the frequency of breathing when the children experiencing hyperpnea (Elhussain et al., 2018).
The limitation of this study is only generally reviewing the effects of PSE therapy and prone position on respiratory function in hospitalized children aged under 24 months with respiratory distress in inpatient rooms. Further reviews are expected to evaluate which therapies give the best result when hospitalized children aged < 24 months experience respiratory distress in inpatient rooms.

CONCLUSION AND RECOMMENDATION
PSE therapy and prone position are effective in reducing the respiratory frequency and improving lung function to speed up the healing process in children aged < 24 months with respiratory distress, and therefore this is a recommended nursing intervention in pediatric wards. It is worth noting that both therapies are also safe and have no side effects. However, PSE therapy can only be applied to children with normal vital signs and showing mild respiratory distress symptoms, while the prone position can be applied to a more varied condition. In addition, the provision of PSE therapy will be more effective when combined with other types of chest physiotherapies while the prone position does not require a combination of other actions. In practice, PSE is an active intervention that is only given for a certain period of time, while the prone position can be done for a longer time.