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Bastia L, Rozé H, Brochard L. Asymmetrical Lung Injury: Management and Outcome. Semin Respir Crit Care Med 2022; 43:369-378. [PMID: 35785812 DOI: 10.1055/s-0042-1744303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Among mechanically ventilated patients, asymmetrical lung injury is probably extremely frequent in the intensive care unit but the lack of standardized measurements does not allow to describe any prevalence among mechanically ventilated patients. Many past studies have focused only on unilateral injury and have mostly described the effect of lateral positioning. The good lung put downward might receive more perfusion while the sick lung placed upward receive more ventilation than supine. This usually results in better oxygenation but can also promote atelectasis in the healthy lung and no consensus has emerged on the clinical indication of this posture. Recently, electrical impedance tomography (EIT) has allowed for the first time to precisely describe the distribution of ventilation in each lung and to better study asymmetrical lung injury. At low positive-end-expiratory pressure (PEEP), a very heterogeneous ventilation exists between the two lungs and the initial increase in PEEP first helps to recruit the sick lung and protect the healthier lung. However, further increasing PEEP distends the less injured lung and must be avoided. The right level can be found using EIT and transpulmonary pressure. In addition, EIT can show that in the two lungs, airway closure is present but with very different airway opening pressures (AOPs) which cannot be identified on a global assessment. This may suggest a very different PEEP level than on a global assessment. Lastly, epidemiological studies suggest that in hypoxemic patients, the number of quadrants involved has a strong prognostic value. The number of quadrants is more important than the location of the unilateral or bilateral nature of the involvement for the prognosis, and hypoxemic patients with unilateral lung injury should probably be considered as requiring lung protective ventilation as classical acute respiratory distress syndrome.
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Affiliation(s)
- Luca Bastia
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Hadrien Rozé
- Thoracic Surgery and Lung Transplant Unit, Department of Anesthesiology and Critical Care, Bordeaux University Hospital, Haut Leveque Hospital, Pessac, France.,Centre de Recherche Cardio Thoracique INSERM 1045, Pessac, France
| | - Laurent Brochard
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Canada
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2
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Roldán R, Rodriguez S, Barriga F, Tucci M, Victor M, Alcala G, Villamonte R, Suárez-Sipmann F, Amato M, Brochard L, Tusman G. Sequential lateral positioning as a new lung recruitment maneuver: an exploratory study in early mechanically ventilated Covid-19 ARDS patients. Ann Intensive Care 2022; 12:13. [PMID: 35150355 PMCID: PMC8840950 DOI: 10.1186/s13613-022-00988-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/21/2022] [Indexed: 12/16/2022] Open
Abstract
Background A sequential change in body position from supine-to-both lateral positions under constant ventilatory settings could be used as a postural recruitment maneuver in case of acute respiratory distress syndrome (ARDS), provided that sufficient positive end-expiratory pressure (PEEP) prevents derecruitment. This study aims to evaluate the feasibility and physiological effects of a sequential postural recruitment maneuver in early mechanically ventilated COVID-19 ARDS patients. Methods A cohort of 15 patients receiving lung-protective mechanical ventilation in volume-controlled with PEEP based on recruitability were prospectively enrolled and evaluated in five sequentially applied positions for 30 min each: Supine-baseline; Lateral-1st side; 2nd Supine; Lateral-2nd side; Supine-final. PEEP level was selected using the recruitment-to-inflation ratio (R/I ratio) based on which patients received PEEP 12 cmH2O for R/I ratio ≤ 0.5 or PEEP 15 cmH2O for R/I ratio > 0.5. At the end of each period, we measured respiratory mechanics, arterial blood gases, lung ultrasound aeration, end-expiratory lung impedance (EELI), and regional distribution of ventilation and perfusion using electric impedance tomography (EIT). Results Comparing supine baseline and final, respiratory compliance (29 ± 9 vs 32 ± 8 mL/cmH2O; p < 0.01) and PaO2/FIO2 ratio (138 ± 36 vs 164 ± 46 mmHg; p < 0.01) increased, while driving pressure (13 ± 2 vs 11 ± 2 cmH2O; p < 0.01) and lung ultrasound consolidation score decreased [5 (4–5) vs 2 (1–4); p < 0.01]. EELI decreased ventrally (218 ± 205 mL; p < 0.01) and increased dorsally (192 ± 475 mL; p = 0.02), while regional compliance increased in both ventral (11.5 ± 0.7 vs 12.9 ± 0.8 mL/cmH2O; p < 0.01) and dorsal regions (17.1 ± 1.8 vs 18.8 ± 1.8 mL/cmH2O; p < 0.01). Dorsal distribution of perfusion increased (64.8 ± 7.3% vs 66.3 ± 7.2%; p = 0.01). Conclusions Without increasing airway pressure, a sequential postural recruitment maneuver improves global and regional respiratory mechanics and gas exchange along with a redistribution of EELI from ventral to dorsal lung areas and less consolidation. Trial registration ClinicalTrials.gov, NCT04475068. Registered 17 July 2020, https://clinicaltrials.gov/ct2/show/NCT04475068 Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-00988-9.
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Affiliation(s)
- Rollin Roldán
- Laboratorio de Fisiología Experimental, Facultad de Medicina Humana, Universidad de Piura, Lima, Peru.,Intensive Care Unit, Hospital Rebagliati, Lima, Peru.,Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Shalim Rodriguez
- Laboratorio de Fisiología Experimental, Facultad de Medicina Humana, Universidad de Piura, Lima, Peru.,Intensive Care Unit, Hospital Rebagliati, Lima, Peru
| | - Fernando Barriga
- Laboratorio de Fisiología Experimental, Facultad de Medicina Humana, Universidad de Piura, Lima, Peru.,Intensive Care Unit, Hospital Rebagliati, Lima, Peru
| | - Mauro Tucci
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Marcus Victor
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Electronics Engineering, Aeronautics Institute of Technology, São Paulo, Brazil
| | - Glasiele Alcala
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Renán Villamonte
- Laboratorio de Fisiología Experimental, Facultad de Medicina Humana, Universidad de Piura, Lima, Peru.,Intensive Care Unit, Hospital Rebagliati, Lima, Peru
| | - Fernando Suárez-Sipmann
- Intensive Care Unit, Hospital Universitario de La Princesa, Madrid, Spain.,Hedenstierna Laboratory, Surgical Sciences, Uppsala University, Uppsala, Sweden.,CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Marcelo Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Laurent Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, 209 Victoria Street, Room 4-08, Toronto, ON, M5B 1T8, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
| | - Gerardo Tusman
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina
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Match Me If You Can: The Relationship between Ventilation and Perfusion with Position Changes in Nonhomogenous Lung Injury. Ann Am Thorac Soc 2022; 19:320-326. [PMID: 35103560 DOI: 10.1513/annalsats.202102-210cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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4
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Meli A, Barbeta Viñas E, Battaglini D, Li Bassi G, Yang H, Yang M, Bobi J, Motos A, Fernández-Barat L, Chiumello D, Pelosi P, Torres A. Lateral position during severe mono-lateral pneumonia: an experimental study. Sci Rep 2020; 10:19372. [PMID: 33168922 PMCID: PMC7653044 DOI: 10.1038/s41598-020-76216-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 09/24/2020] [Indexed: 12/31/2022] Open
Abstract
Patients with mono-lateral pneumonia and severe respiratory failure can be positioned in lateral decubitus, with the healthy lung dependent, to improve ventilation-perfusion coupling. Oxygenation response to this manoeuvre is heterogeneous and derecruitment of dependent lung has not been elucidated. Nine pigs (32.2 ± 1.2 kg) were sedated and mechanically ventilated. Mono-lateral right-sided pneumonia was induced with intrabronchial challenge of Pseudomonas aeruginosa. After 24 h, lungs were recruited and the animals were randomly positioned on right or left side. After 3 h of lateral positioning, the animals were placed supine; another recruitment manoeuvre was performed, and the effects of contralateral decubitus were assessed. Primary outcome was lung ultrasound score (LUS) of the dependent lung after 3-h lateral positioning. LUS of the left non-infected lung worsened while positioned in left-lateral position (from 1.33 ± 1.73 at baseline to 6.78 ± 4.49; p = 0.005). LUS of the right-infected lung improved when placed upward (9.22 ± 2.73 to 6.67 ± 3.24; p = 0.09), but worsened in right-lateral position (7.78 ± 2.86 to 13.33 ± 3.08; p < 0.001). PaO2/FiO2 improved in the left-lateral position (p = 0.005). In an animal model of right-lung pneumonia, left-lateral decubitus improved oxygenation, but collapsed the healthy lung. Right-lateral orientation further collapsed the diseased lung. Our data raise potential clinical concerns for the use of lateral position in mono-lateral pneumonia.
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Affiliation(s)
- Andrea Meli
- Department of Pulmonology, Hospital Clínic of Barcelona, Barcelona, Spain.,University of Milan, Milan, Italy
| | - Enric Barbeta Viñas
- Department of Pulmonology, Hospital Clínic of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Denise Battaglini
- Department of Pulmonology, Hospital Clínic of Barcelona, Barcelona, Spain.,Department of Surgical Sciences and Integrated Diagnostics (DISC), IRCCS San Martino Policlinico Hospital, Genoa, Italy
| | - Gianluigi Li Bassi
- Department of Pulmonology, Hospital Clínic of Barcelona, Barcelona, Spain.,Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,University of Barcelona (UB), Barcelona, Spain
| | - Hua Yang
- Department of Pulmonology, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Minlan Yang
- Department of Pulmonology, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Joaquim Bobi
- Department of Pulmonology, Hospital Clínic of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Ana Motos
- Department of Pulmonology, Hospital Clínic of Barcelona, Barcelona, Spain.,Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,University of Barcelona (UB), Barcelona, Spain
| | - Laia Fernández-Barat
- Department of Pulmonology, Hospital Clínic of Barcelona, Barcelona, Spain.,Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,University of Barcelona (UB), Barcelona, Spain
| | - Davide Chiumello
- University of Milan, Milan, Italy.,Department of Anaesthesia and Critical Care Medicine, ASST Santi Paolo e Carlo, San Paolo Hospital, Milan, Italy
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), IRCCS San Martino Policlinico Hospital, Genoa, Italy
| | - Antoni Torres
- Department of Pulmonology, Hospital Clínic of Barcelona, Barcelona, Spain. .,Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain. .,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain. .,University of Barcelona (UB), Barcelona, Spain.
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5
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Jang MH, Shin MJ, Shin YB. Pulmonary and Physical Rehabilitation in Critically Ill Patients. Acute Crit Care 2019; 34:1-13. [PMID: 31723900 PMCID: PMC6849048 DOI: 10.4266/acc.2019.00444] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 02/19/2019] [Accepted: 02/22/2010] [Indexed: 12/28/2022] Open
Abstract
Some patients admitted to the intensive care unit (ICU) because of an acute illness, complicated surgery, or multiple traumas develop muscle weakness affecting the limbs and respiratory muscles during acute care in the ICU. This condition is referred to as ICU-acquired weakness (ICUAW), and can be evoked by critical illness polyneuropathy (CIP), critical illness myopathy (CIM), or critical illness polyneuromyopathy (CIPNM). ICUAW is diagnosed using the Medical Research Council (MRC) sum score based on bedside manual muscle testing in cooperative patients. The MRC sum score is the sum of the strengths of the 12 regions on both sides of the upper and lower limbs. ICUAW is diagnosed when the MRC score is less than 48 points. However, some patients require electrodiagnostic studies, such as a nerve conduction study, electromyography, and direct muscle stimulation, to differentiate between CIP and CIM. Pulmonary rehabilitation in the ICU can be divided into modalities intended to remove retained airway secretions and exercise therapies intended to improve respiratory function. Physical rehabilitation, including early mobilization, positioning, and limb exercises, attenuates the weakness that occurs during critical care. To perform mobilization in mechanically ventilated patients, pretreatment by removing secretions is necessary. It is also important to increase the strength of respiratory muscles and to perform lung recruitment to improve mobilization in patients who are weaned from the ventilator. For these reasons, pulmonary rehabilitation is important in addition to physical therapy. Early recognition of CIP, CIM, and CIPNM and early rehabilitation in the ICU might improve patients’ functional recovery and outcomes.
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Affiliation(s)
- Myung Hun Jang
- Department of Rehabilitation Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Myung-Jun Shin
- Department of Rehabilitation Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea.,Department of Rehabilitation Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Yong Beom Shin
- Department of Rehabilitation Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea.,Department of Rehabilitation Medicine, Pusan National University School of Medicine, Busan, Korea
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6
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Foy BH, Gonem S, Brightling C, Siddiqui S, Kay D. Modelling the effect of gravity on inert-gas washout outputs. Physiol Rep 2018; 6:e13709. [PMID: 29845761 PMCID: PMC5974727 DOI: 10.14814/phy2.13709] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/11/2018] [Accepted: 04/15/2018] [Indexed: 11/24/2022] Open
Abstract
Multiple-breath washout (MBW) is a pulmonary function test (PFT) that is used to infer lung function through measurement of ventilation heterogeneity (VH). However, the body position that a test is taken in may also influence VH, due to the "Slinky" effect of gravity on the lungs. In healthy subjects this has minimal effect, but in unhealthy groups, PFT outputs have been seen to change drastically with body position. In this study, we used a combined computational and clinical approach to better understand the response of outputs from the MBW to body position. A patient-specific model of the MBW was developed, then validated against clinically measured washout data, as well as broader results in the literature. This model was then used to compare changes in MBW outputs with respect to body position, showing that output changes sensitively predict regional airway size differences between lobes. We then highlight cases in which body position effects may bias MBW outputs, leading to elevated or masked responses to bronchoconstriction. We close by placing this result in context with broader clinical practice, and showing how it can help improve interpretation of test outputs.
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Affiliation(s)
- Brody H. Foy
- Department of Computer ScienceUniversity of OxfordOxfordOxfordshireUnited Kingdom
| | - Sherif Gonem
- Respiratory Biomedical Research CentreUniversity of Leicester/National Institute of Health ResearchLeicesterLeicestershireUnited Kingdom
| | - Chris Brightling
- Respiratory Biomedical Research CentreUniversity of Leicester/National Institute of Health ResearchLeicesterLeicestershireUnited Kingdom
| | - Salman Siddiqui
- Respiratory Biomedical Research CentreUniversity of Leicester/National Institute of Health ResearchLeicesterLeicestershireUnited Kingdom
| | - David Kay
- Department of Computer ScienceUniversity of OxfordOxfordOxfordshireUnited Kingdom
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7
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Mehta JN, Parmar LD. The effect of positional changes on oxygenation in patients with head injury in the intensive care unit. J Family Med Prim Care 2017; 6:853-858. [PMID: 29564277 PMCID: PMC5848412 DOI: 10.4103/jfmpc.jfmpc_27_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Following head injury, cardiopulmonary functions are impaired and this disturbs the oxygenation transport pathway. Expanding cardiopulmonary physical therapy to encompass the oxygen transport system as a whole has implication for treatment as well as assessment and treatment outcome. Therefore, the aim of the study is to assess the oxygenation level in head injury patients with relation to body positioning in the intensive care unit (ICU). Methodology: Thirty consecutive patients with head injury with hemodynamically stable were included from the surgical ICU, ages ranging from 15 to 50 years. Noninvasive vital parameters (oxygen saturation [SpO2], pulse rate [PR], respiratory rate [RR], and blood pressure [BP]) were observed and recorded in different body positions at regular intervals of 5 min for 15 min in each position. Results: There was increment in SpO2 value in all positions from 0 min to end of 15 min in supine (98.63 ± 0.36–98.73 ± 0.30), right-side lying (98.77 ± 0.30–98.93 ± 0.20), left-side lying (98.73 ± 0.29–99.03 ± 0.24), and recline sitting (30°–70°) (99.03 ± 0.24–99.50 ± 0.22). However, there was statistically significant increment in recline sitting (30°–70°) compared to other positions (P = 0.036) while other parameters (PR, RR, and BP) were getting stabilized at lower values at end of 15 min in every positions tested. Conclusion: We conclude that upright position bring about significant increase in arterial SpO2 compared to any other positions. Other vital parameters were seen to stabilize at lower values at the end of 15 min in every position tested.
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Affiliation(s)
- Jigar Nayankumar Mehta
- Department of Physiotherapy, K M Patel Institute of Physiotherapy, Shree Krishna Hospital Karamsad, Vadodara, Gujarat, India
| | - Lata D Parmar
- Department of Physiotherapy, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
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8
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Abstract
BACKGROUND Critically ill patients require regular body position changes to minimize the adverse effects of bed rest, inactivity and immobilization. However, uncertainty surrounds the effectiveness of lateral positioning for improving pulmonary gas exchange, aiding drainage of tracheobronchial secretions and preventing morbidity. In addition, it is unclear whether the perceived risk levied by respiratory and haemodynamic instability upon turning critically ill patients outweighs the respiratory benefits of side-to-side rotation. Thus, lack of certainty may contribute to variation in positioning practice and equivocal patient outcomes. OBJECTIVES To evaluate effects of the lateral position compared with other body positions on patient outcomes (mortality, morbidity and clinical adverse events) in critically ill adult patients. (Clinical adverse events include hypoxaemia, hypotension, low oxygen delivery and global indicators of impaired tissue oxygenation.) We examined single use of the lateral position (i.e. on the right or left side) and repeat use of the lateral position (i.e. lateral positioning) within a positioning schedule. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 5), MEDLINE (1950 to 23 May 2015), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 to 23 May 2015), the Allied and Complementary Medicine Database (AMED) (1984 to 23 May 2015), Latin American Caribbean Health Sciences Literature (LILACS) (1901 to 23 May 2015), Web of Science (1945 to 23 May 2015), Index to Theses in Great Britain and Ireland (1950 to 23 May 2015), Trove (2009 to 23 May 2015; previously Australasian Digital Theses Program (1997 to December 2008)) and Proquest Dissertations and Theses (2009 to 23 May 2015; previously Proquest Digital Dissertations (1980 to 23 May 2015)). We handsearched the reference lists of potentially relevant reports and two nursing journals. SELECTION CRITERIA We included randomized and quasi-randomized trials examining effects of lateral positioning in critically ill adults. We included manual or automated turns but limited eligibility to studies that included duration of body position of 10 minutes or longer. We examined each lateral position versus at least one comparator (opposite lateral position and/or another body position) for single therapy effects, and the lateral positioning schedule (repeated lateral turning) versus other positioning schedules for repetitive therapy effects. DATA COLLECTION AND ANALYSIS We pre-specified methods to be used for data collection, risk of bias assessment and analysis. Two independent review authors carried out each stage of selection and data extraction and settled differences in opinion by consensus, or by third party adjudication when disagreements remained unresolved. We planned analysis of pair-wise comparisons under composite time intervals with the aim of considering recommendations based on meta-analyses of studies with low risk of bias. MAIN RESULTS We included 24 studies of critically ill adults. No study reported mortality as an outcome of interest. Two randomized controlled trials (RCTs) examined lateral positioning for pulmonary morbidity outcomes but provided insufficient information for meta-analysis. A total of 22 randomized trials examined effects of lateral positioning (four parallel-group and 18 cross-over designs) by measuring various continuous data outcomes commonly used to detect adverse cardiopulmonary events within critical care areas. However, parallel-group studies were not comparable, and cross-over studies provided limited data as the result of unit of analysis errors. Eight studies provided some data; most of these were single studies with small effects that were imprecise. We pooled partial pressure of arterial oxygen (PaO2) as a measure to detect hypoxaemia from two small studies of participants with unilateral lung disease (n = 19). The mean difference (MD) between lateral positions (bad lung down versus good lung down) was approximately 50 mmHg (MD -49.26 mmHg, 95% confidence interval (CI) -67.33 to -31.18; P value < 0.00001). Despite a lower mean PaO2 for bad lung down, hypoxaemia (mean PaO2 < 60 mmHg) was not consistently reported. Furthermore, pooled data had methodological shortcomings with unclear risk of bias. We had similar doubts regarding internal validity for other studies included in the review. AUTHORS' CONCLUSIONS Review authors could provide no clinical practice recommendations based on the findings of included studies. Available research could not eliminate the uncertainty surrounding benefits and/or risks associated with lateral positioning of critically ill adult patients. Research gaps include the effectiveness of lateral positioning compared with semi recumbent positioning for mechanically ventilated patients, lateral positioning compared with prone positioning for acute respiratory distress syndrome (ARDS) and less frequent changes in body position. We recommend that future research be undertaken to address whether the routine practice of repositioning patients on their side benefits all, some or few critically ill patients.
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Affiliation(s)
- Nicky Hewitt
- Alfred HealthDeakin Alfred Health Nursing Research Centre55 Commercial Road, PrahanMelbourneVictoriaAustralia3125
- Faculty of Health, Deakin UniversitySchool of Nursing and MidwiferyGeelongAustralia
- St. Vincent's HospitalDepartment of Critical Care MedicinePO Box 2900MelbourneVictoriaAustralia3065
| | - Tracey Bucknall
- Faculty of Health, Deakin UniversitySchool of Nursing and MidwiferyGeelongAustralia
- Alfred HealthDeakin University Centre for Quality and Patient Safety Research ‐ Alfred Health Partnership55 Commercial RoadMelbourneAustralia
| | - Nardene M Faraone
- St. Vincent's HospitalDepartment of Critical Care MedicinePO Box 2900MelbourneVictoriaAustralia3065
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Bein T, Bischoff M, Brückner U, Gebhardt K, Henzler D, Hermes C, Lewandowski K, Max M, Nothacker M, Staudinger T, Tryba M, Weber-Carstens S, Wrigge H. S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders : Revision 2015: S2e guideline of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI). Anaesthesist 2015; 64 Suppl 1:1-26. [PMID: 26335630 PMCID: PMC4712230 DOI: 10.1007/s00101-015-0071-1] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioneda revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientificrelevance the guidelines were extended to include the issue of "early mobilization"and the following main topics are therefore included: use of positioning therapy and earlymobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.
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Affiliation(s)
- Th Bein
- Clinic for Anaesthesiology, University Hospital Regensburg, 93042, Regensburg, Germany.
| | - M Bischoff
- Clinic for Anaesthesiology, University Hospital Regensburg, 93042, Regensburg, Germany
| | - U Brückner
- Physiotherapy Department, Clinic Donaustauf, Centre for Pneumology, 93093, Donaustauf, Germany
| | - K Gebhardt
- Clinic for Anaesthesiology, University Hospital Regensburg, 93042, Regensburg, Germany
| | - D Henzler
- Clinic for Anaesthesiology, Surgical Intensive Care Medicine, Emergency Care Medicine, Pain Management, Klinikum Herford, 32049, Herford, Germany
| | - C Hermes
- HELIOS Clinic Siegburg, 53721, Siegburg, Germany
| | - K Lewandowski
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Management, Elisabeth Hospital Essen, 45138, Essen, Germany
| | - M Max
- Centre Hospitalier, Soins Intensifs Polyvalents, 1210, Luxembourg, Luxemburg
| | - M Nothacker
- Association of Scientific Medical Societies (AWMF), 35043, Marburg, Germany
| | - Th Staudinger
- University Hospital for Internal Medicine I, Medical University of Wien, General Hospital of Vienna, 1090, Vienna, Austria
| | - M Tryba
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Management, Klinikum Kassel, 34125, Kassel, Germany
| | - S Weber-Carstens
- Clinic for Anaesthesiology and Surgical Intensive Care Medicine, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, 13353, Berlin, Germany
| | - H Wrigge
- Clinic and Policlinic for Anaesthesiology and Intensive Care Medicine, University Hospital Leipzig, 04103, Leipzig, Germany
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11
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Syed KA, Blankstein M, Bhandari M, Nakane M, Zdero R, Schemitsch EH. The effect of patient position during trauma surgery on fat embolism syndrome: An experimental study. Indian J Orthop 2014; 48:203-10. [PMID: 24741144 PMCID: PMC3977378 DOI: 10.4103/0019-5413.128769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this study was to compare the effect of supine versus lateral position on clinical signs of fat embolism during orthopedic trauma surgery. Dogs served as the current study model, which could be extended and/or serve as a basis for future in vivo studies on humans. It was hypothesized that there would be an effect of position on clinical signs of fat embolism syndrome in a dog model. MATERIALS AND METHODS 12 dogs were assigned to supine (n = 6) and lateral (n = 6) position groups. Airway pressures, heart rate, blood pressure, cardiac output, pulmonary artery pressure, pulmonary artery wedge pressure, right atrial pressure, arterial and venous blood gases, white blood count, platelet count and neutrophil count were obtained. Dogs were then subjected to pulmonary contusion in three areas of one lung. Fat embolism was generated by reaming one femur and tibia, followed by pressurization of the canal. RESULTS No difference was found in any parameters measured between supine and lateral positions at any time (0.126 < P < 0.856). CONCLUSIONS The position of trauma patients undergoing reamed intramedullary nailing did not alter the presentation of the features of the lung secondary to fat embolism.
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Affiliation(s)
- Khalid A Syed
- Division of Orthopaedic Surgery, Musculoskeletal Health and Arthritis Program, Toronto Western Hospital, Toronto, Canada
| | - Michael Blankstein
- Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Mohit Bhandari
- Department of Clinical Epidemiology and Biostatistics, McMaster Health Sciences Centre, Hamilton, Canada
| | - Masaki Nakane
- Department of Anesthesia, St. Michael's Hospital, Toronto, Canada
| | - Radovan Zdero
- Martin Orthopaedic Biomechanics Laboratory, St. Michael's Hospital, Toronto, Canada,Department of Mechanical and Industrial Engineering, Ryerson University, Toronto, Canada,Address for correspondence: Dr. Radovan Zdero, Biomechanics Lab, St. Michael's Hospital, Li Ka Shing Building (West Basement, Room B116), 209 Victoria Street, Toronto, ON, M5B-1W8, Canada. E-mail:
| | - Emil H Schemitsch
- Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Canada,Martin Orthopaedic Biomechanics Laboratory, St. Michael's Hospital, Toronto, Canada
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Abstract
PRACTICAL RELEVANCE There is an increasing demand for effective postoperative and post-injury rehabilitation for any cat with compromised physical function due to injury, surgery or disease. CLINICAL CHALLENGES The design of a suitable rehabilitation programme that will assist the recovery process, as well as ensure the return of neuromusculoskeletal control to the highest levels of function possible, requires a good understanding of feline behaviour, accurate assessment of the cat's condition and the correct implementation of a range of physiotherapeutic modalities. AUDIENCE This two-part review article is directed at the primary care veterinary team. The clinical application of a variety of physiotherapeutic modalities in the rehabilitation of cats is examined in this second part. EVIDENCE BASE Although evidence supporting the benefits of physiotherapy and rehabilitation with cats is sparse, many techniques, treatments and rehabilitation regimens successfully used on human patients are being readily adapted for animal use. Treatment recommendations described in this review are primarily based on the author's experience, and that of colleagues, except where specific reference is made to published evidence.
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Affiliation(s)
- Brian Sharp
- The Queen Mother Hospital for Animals, Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Hertfordshire AL9 7TA, UK.
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13
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Physiotherapy in critically ill patients. REVISTA PORTUGUESA DE PNEUMOLOGIA 2011; 17:283-8. [PMID: 21782380 DOI: 10.1016/j.rppneu.2011.06.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Accepted: 06/06/2011] [Indexed: 01/04/2023] Open
Abstract
Prolonged stay in Intensive Care Unit (ICU) can cause muscle weakness, physical deconditioning, recurrent symptoms, mood alterations and poor quality of life. Physiotherapy is probably the only treatment likely to increase in the short- and long-term care of the patients admitted to these units. Recovery of physical and respiratory functions, coming off mechanical ventilation, prevention of the effects of bed-rest and improvement in the health status are the clinical objectives of a physiotherapy program in medical and surgical areas. To manage these patients, integrated programs dealing with both whole-body physical therapy and pulmonary care are needed. There is still limited scientific evidence to support such a comprehensive approach to all critically ill patients; therefore we need randomised studies with solid clinical short- and long-term outcome measures.
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14
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Physiological rationale and current evidence for therapeutic positioning of critically ill patients. AACN Adv Crit Care 2009; 20:228-40; quiz 241-2. [PMID: 19638744 DOI: 10.1097/nci.0b013e3181add8db] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Prolonged bed rest is common in critically ill patients, and therapeutic positioning is important to prevent further complications and to improve patient outcomes. Nurses use therapeutic positioning to prevent complications of immobility. This article reviews therapeutic positions including stationary positions (supine, semirecumbent with head of bed elevation, lateral, and prone) and active repositioning (manual, continuous lateral rotation, and kinetic therapy). The physiological rationale and current evidence for each position are described. Applicable evidence-based practice guidelines are summarized. Special considerations for therapeutic positioning of critically ill obese and elderly patients are also discussed.
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15
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Thomas PJ, Paratz JD, Lipman J, Stanton WR. Lateral positioning of ventilated intensive care patients: a study of oxygenation, respiratory mechanics, hemodynamics, and adverse events. Heart Lung 2007; 36:277-86. [PMID: 17628197 DOI: 10.1016/j.hrtlng.2006.10.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2006] [Revised: 10/09/2006] [Accepted: 10/30/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To investigate the effect of 90 degrees lateral positioning on oxygenation, respiratory mechanics, and hemodynamics in ventilated intensive care patients. METHODS Thirty-four subjects (mean age = 46.1 +/- 17.3 years) with no, unilateral, or bilateral pulmonary infiltrates on chest radiograph participated. Arterial blood gas, respiratory mechanic, and hemodynamic data were analyzed at the supine starting position (T0), then 30 minutes and 2 hours into the lateral turn (T30 and T120, respectively) and 30 minutes post return to the supine position (T150). RESULTS No difference was found in PaO(2)/FiO(2) due to positioning patients from supine to lateral (P = .15) regardless of the underlying lung pathology. Dynamic compliance decreased during lateral positioning, particularly in the subjects with no lung pathology (T0 = 56 +/- 18.6 > (T30 = 49.9 +/- 18; T120 = 49.2 +/- 17) L/cmH(2)0, P < .01) or unilateral lung pathology (T0 = 41.4 +/- 11.2 > (T30 = 36.6 +/- 8.8; T120 = 37.3 +/- 9.5) L/cmH(2)0, P < .01). Blood pressure and heart rate were unaffected, but cardiac index significantly increased at T30 (T0 = 3.7 +/- 1.2, T30 = 4.8 +/- 1.3 L/min/m(2), P < .01). While the incidence of adverse events was high (21%), they were primarily minor and transient. CONCLUSIONS In this heterogeneous population, lateral positioning had no beneficial effect on gas exchange. However, in ventilated patients who were hemodynamically stable, it was well tolerated and not associated with significant serious adverse events.
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Affiliation(s)
- Peter J Thomas
- Department of Physiotherapy, Royal Brisbane and Women's Hospital, Brisbane, Australia
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16
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Thomas PJ, Paratz JD. Is there evidence to support the use of lateral positioning in intensive care? A systematic review. Anaesth Intensive Care 2007; 35:239-55. [PMID: 17444315 DOI: 10.1177/0310057x0703500214] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
A systematic review of randomised clinical trials was conducted to investigate the efficacy and safety of use of the lateral position in the management of ventilated intensive care patients. One review article and 11 empiric studies, which were mostly of low methodological quality, met the eligibility criteria. Large individual variations in PaO2 response to lateral positioning were demonstrated. Greatest improvement in PaO2 occurred in patients with unilateralpulmonary infiltrates positioned with the bad lung up versus bad lung down (average difference = 33.6 mmHg (range 0-58), effect size 1.13 (95% CI: 0.44, 1.19, P = 0.001)) or supine (average difference=27 mmHg (range 5-42), effect size 0.58 (95% CI: 0.11, 1.06, P = 0.017)). This effect appeared to be most prominent in patients with widespread, unilateral infiltrates. Lung compliance was not affected by lateral positioning. Haemodynamic compromise was evident with lateral positioning of greater than 60 degrees to the right side in patients requiring vasopressors and/or with right ventricular dysfunction; or with lateral positioning in postoperative coronary artery bypass graft patients. No studies were found that had investigated the effect of routine applications of the lateral positioning to improve, prevent or treat pneumonia, decrease mortality or influence other long-term outcomes. The results of this review demonstrate the limited evidence available to support the use of lateral positioning in the intensive care environment. More data reporting the long-term effects of lateral position on long-term outcomes would aid clinical decision making and may improve the application of patient positioning in critical care environments.
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Affiliation(s)
- P J Thomas
- School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Queensland, Australia
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17
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Luna CM, Monteverde A, Rodríguez A, Apezteguia C, Zabert G, Ilutovich S, Menga G, Vasen W, Díez AR, Mera J. [Clinical guidelines for the treatment of nosocomial pneumonia in Latin America: an interdisciplinary consensus document. Recommendations of the Latin American Thoracic Society]. Arch Bronconeumol 2005; 41:439-56. [PMID: 16117950 DOI: 10.1016/s1579-2129(06)60260-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- C M Luna
- Asociación Argentina de Medicina Respiratoria, Buenos Aires, Argentina.
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18
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Luna C, Monteverde A, Rodríguez A, Apezteguia C, Zabert G, Ilutovich S, Menga G, Vasen W, Díez A, Mera J. Neumonía intrahospitalaria: guía clínica aplicable a Latinoamérica preparada en común por diferentes especialistas. Arch Bronconeumol 2005. [DOI: 10.1157/13077956] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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19
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Abstract
OBJECTIVE To assess the possible influence of body position on oxygen saturation after bronchoscopy (BC) with bronchoalveolar lavage (BAL). DESIGN Prospective, open, randomized study. SETTING The respiratory unit of a first level, community hospital. PATIENTS Forty-one consecutive patients in which BC with BAL, using at least 150 mL of BAL fluid, was performed. METHOD We randomly assigned 21 patients to lie in lateral decubitus (LD) with the lung where BAL was performed uppermost after BC, and 20 to lie in supine position (SP). Oxygen saturation (SO2) was measured for all patients from 10 min before to 30 min after the end of the BC. Saturation parameters were compared for both groups. RESULTS Mean SO2 was significantly lower after than before the BC, both for LD and SP groups (LD: 91.4+/-3% vs. 94.9+/-2%, respectively; P=0.0001) (SP: 91.6+/-3 vs. 95.8+/-3%, respectively; P=0.0003). We did not find significant differences between LD and SP groups, after BC, regarding mean SO2 (91.4+/-3% vs. 91.6+/-3%), minimum SO2 (86.2+/-4.5% vs. 86.6+/-5.4%, respectively) or percentages of registry time at saturations below 90% (26.3+/-35.9% vs. 27.6+/-38.2%, respectively) (P:NS for all values). CONCLUSION BC with BAL caused significant oxygen desaturation in our patients. We have not been able to demonstrate a significant influence of body position on SO2 after BAL.
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Affiliation(s)
- Rafael Golpe
- Unidad de Neumología, Hospital Comarcal, C/ Corredoira, s/n, 27400 Monforte de Lemos, Lugo 27400, Spain.
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20
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Affiliation(s)
- K Stiller
- Physiotherapy Department, Royal Adelaide Hospital, Adelaide, South Australia 5000, Australia.
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21
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Choe KH, Kim YT, Shim TS, Lim CM, Lee SD, Koh Y, Kim WS, Kim DS, Ryu JS, Kim WD. Closing volume influences the postural effect on oxygenation in unilateral lung disease. Am J Respir Crit Care Med 2000; 161:1957-62. [PMID: 10852773 DOI: 10.1164/ajrccm.161.6.9909067] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In normal adults, both blood flow and ventilation are distributed preferentially to the dependent lung zones. In adults with unilateral lung disease, arterial oxygenation improves when they are positioned with their good lung down because of improved matching of ventilation and perfusion. When the closing volume is increased, dependent airways are closed during tidal breathing, so that reduced ventilation-perfusion ratio and hypoxia develops and ventilation is preferentially distributed to the upper lung zones. We undertook an observational study on the effects of lateral recumbency on arterial oxygenation in adult patients with unilateral lung disease and tested the hypothesis that oxygenation in lateral recumbency might be influenced by an increase in closing volume. Arterial blood gases were analyzed in the supine, right and left lateral decubitus positions and the AaPO(2) was calculated in 44 randomly selected patients 49.9 +/- 18.7 yr of age with unilateral pneumonia (23 cases) or pulmonary tuberculosis (21 cases). In 26 patients, individual Pa(O(2)) with the normal lung in the dependent position was higher than that with the diseased lung; the opposite was true for 18 patients. The difference in Pa(O(2)) and AaPO(2) between the two positions was statistically significant in both groups. In 16 patients (10 men and six women 49.2 +/- 18.2 yr of age), we measured closing volume and determined the fractional ventilation to each lung by (133)Xe lung scan in the three positions. In these 16 patients, the difference in Pa(O(2)) between the normal and the diseased lung in the dependent position was related significantly to the difference in the fractional ventilation going to the normal lung between the dependent and the supine position (r = 0.642, p = 0. 007). The latter was related significantly to the % predicted closing volume (CV/VC) (r = -0.597, p = 0.015). This study has shown that closing volume, as well as posture, might be involved in determining oxygenation in lateral recumbency in patients with unilateral lung disease.
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Affiliation(s)
- K H Choe
- Pulmonary and Critical Care Division, Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
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22
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Abstract
Severe ULD presents a challenge in ventilator management because of the marked asymmetry in the mechanics of the two lungs. The asymmetry may result from significant decreases or increases in the compliance of the involved lung. Traditional ventilator support may fail to produce adequate gas exchange in these situations and has the potential to cause further deterioration. Fortunately, conventional techniques can be safely and effectively applied in the majority of cases without having to resort to less familiar and potentially hazardous forms of support. In those circumstances when conventional ventilation is unsuccessful in restoring adequate gas exchange, lateral positioning and ILV have proved effective at improving and maintaining gas exchange. Controlled trials to guide clinical decision making are lacking. In patients who have processes associated with decreased compliance in the involved lung, lateral positioning may be a simple method of improving gas exchange but is associated with many practical limitations. ILV in these patients is frequently successful when differential PEEP is applied with the higher pressure to the involved lung. In patients in whom the pathology results in distribution of ventilation favoring the involved lung, particularly BPF, ILV can be used to supply adequate support while minimizing flow through the fistula and allowing it to close. The application of these techniques should be undertaken with an understanding of the pathophysiology of the underlying process; the reported experience with these techniques, including indications and successfully applied methods; and the potential problems encountered with their use. Fortunately, these modalities are infrequently required, but they provide a critical means of support when conventional techniques fail.
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Affiliation(s)
- A R Thomas
- Department of Medicine, University of Arizona/Maricopa Medical Center, Phoenix, Arizona, USA
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Gawlinski A, Dracup K. Effect of positioning on SvO2 in the critically ill patient with a low ejection fraction. Nurs Res 1998; 47:293-9. [PMID: 9766458 DOI: 10.1097/00006199-199809000-00009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Critically ill patients with a low ejection fraction may be vulnerable to decreased mixed venous oxygen saturation (SvO2) resulting from position change. OBJECTIVES The objectives of this study were to describe the effects of changes in positioning on SvO2 in critically ill patients with a low ejection fraction (< or = 30%) and to describe the contribution of variables of oxygen delivery (DO2) and oxygen consumption (VO2) to the variance in SvO2. METHOD An experimental two-group repeated-measures design was used to study 42 critically ill patients with an ejection fraction of less than or equal to 30% (M= 19.5%). Patients were assigned randomly to one of two position sequences: supine, right lateral, left lateral; or supine, left lateral, right lateral. Data on SvO2 were collected at baseline, each minute after position change for 5 minutes, and at 15 and 25 minutes. RESULTS Repeated-measures multivariate analysis of variance showed a difference in SvO2 among the three positions across time (p< .0001), with the greatest differences occurring within the first 4 minutes and in the left lateral position. Stepwise multiple regression showed that VO2 accounted for a greater proportion of the variance in SvO2 with position change than did DO2 (54% [p = .001] vs. 31% [p= .001]). CONCLUSIONS Changes in SVO2 occur with positioning in critically ill patients with a low ejection fraction. These changes are transient and are the result of changes in VO2 rather than changes in DO2.
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Affiliation(s)
- A Gawlinski
- University of California, Los Angeles, Medical Center, USA
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25
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Badia JR, Sala E, Rodriguez-Roisin R. Positional changes and drug interventions in acute respiratory failure. Respirology 1998; 3:103-6. [PMID: 9692518 DOI: 10.1111/j.1440-1843.1998.tb00106.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Acute respiratory failure is often a life-threatening condition that determines the outcome of acutely ill patients. This review discusses the physiological basis and results of two complementary approaches for the management of such patients: positional changes and drug interventions. In unilateral pulmonary disease locating the healthy lung in a dependent position may improve gas exchange; in bilateral involvement, as occurs in the acute respiratory distress syndrome (ARDS), both the theoretical principles and the observed benefits fully support the use of the prone position. The effect of vasoactive drugs on pulmonary circulation and gas exchange is also reviewed. Selective vasodilators, such as inhaled nitric oxide and prostacycline-12, may provide a useful alternative in ARDS.
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Affiliation(s)
- J R Badia
- Servei de Pneumología i Allèrgia Respiratòria, Hospital Clínic de Barcelona, Universitat de Barcelona, Spain
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26
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Agustí AG, Cardús J, Roca J, Grau JM, Xaubet A, Rodriguez-Roisin R. Ventilation-perfusion mismatch in patients with pleural effusion: effects of thoracentesis. Am J Respir Crit Care Med 1997; 156:1205-9. [PMID: 9351623 DOI: 10.1164/ajrccm.156.4.9612113] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Pleural effusion (PE) often causes abnormal pulmonary gas exchange. Thoracentesis is commonly used to relieve dyspnea in patients with PE, but its effect upon arterial oxygenation is varied and poorly understood. This investigation sought to: (1) characterize the distribution of ventilation-perfusion (VA/Q) ratios in patients with PE and (2) assess the effects of PE drainage by thoracentesis upon pulmonary gas exchange. We studied nine patients (two females) with a mean age of 39+/-20 (SD) yr. All of them had PE of recent clinical onset (< 2 wk of symptoms), without other apparent medical conditions. Before thoracentesis, PaO2 was 82.3+/-10.2 mm Hg and AaPO2 was 28.7+/-10.0 mm Hg. Patients had broadened unimodal VA/Q distributions with small amounts of blood flow perfusing lung units with low VA/Q ratios (< 0.1) (1.4+/-2.2%) and mild intrapulmonary shunt (6.9+/-6.7%). PaO2 was significantly related to the amount of shunt (rho = -0.82; p < 0.01) but not to the percentage of blood flow perfusing low VA/Q units. While thoracentesis drained 693+/-424 ml of fluid and caused a significant fall in mean pleural pressure (by -10.7 +/- 7.1 mm Hg; p < 0.01), PaO2, AaPO2, and shunt remained unchanged; only the amount of blood flow perfusing low VA/Q ratios increased slightly (2.4+/-2.6%; p < 0.05). This study shows that: (1) intrapulmonary shunt is the main mechanism underlying arterial hypoxemia in patients with PE and (2) effective thoracentesis has minor short-term effects upon pulmonary gas exchange. These findings are in accord with delayed (> 30 min) pulmonary volume re-expansion after thoracentesis with or without the coexistence of mild ex vacuo pulmonary edema.
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Affiliation(s)
- A G Agustí
- Departament de Medicina, Hospital Clínic, Universitat de Barcelona, Spain
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27
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Swanlund SL. Body positioning and the elderly with adult respiratory distress syndrome: implications for nursing care. J Gerontol Nurs 1996; 22:46-50. [PMID: 8632129 DOI: 10.3928/0098-9134-19960201-12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Elderly patients with lung diseases also experience age-related pulmonary structural changes. Because of the age-related pulmonary structural changes, this age group requires specialized nursing interventions. Therapeutic body positioning may lead to increased arterial oxygen tension and decreased supplemental oxygen needs.
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28
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Aitken LM. Comparison of pulmonary artery pressure measurements in the supine and 60 degrees lateral positions. Aust Crit Care 1995; 8:21, 24-9. [PMID: 8704390 DOI: 10.1016/s1036-7314(95)70295-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Pulmonary artery pressure monitoring, with the patient in both the supine and lateral positions, is an essential element in the assessment of critically ill patients. Previous work offers conflicting results regarding the accuracy of measurements obtained with the patient in the lateral position. The purpose of this study was to determine if accurate pulmonary artery pressure measurements can be obtained in the cardiac surgical patient. Thirty-five patients underwent repositioning between the supine and both the left and right 60 degrees lateral position while being mechanically ventilated and then breathing spontaneously. Pulmonary artery pressure measurements were recorded prior to, two minutes following and ten minutes following repositioning. Despite some variation in results the pulmonary capillary wedge pressure measurement was reliable ten minutes after repositioning in both the spontaneously breathing and mechanically ventilated patient. Other pulmonary artery pressure measurements were not so reliable in the lateral position. This study concludes that clinical practitioners can obtain accurate pulmonary capillary wedge pressure measurements in post-operative cardiac surgical patients positioned in either the left or right 60 degrees lateral position. Further research is however required, with larger numbers from all sub-groups of the critical care population. Physiological and pathophysiological characteristics which preclude reliable pulmonary artery pressure measurements need to be identified.
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30
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Mélot C. Contribution of multiple inert gas elimination technique to pulmonary medicine. 5. Ventilation-perfusion relationships in acute respiratory failure. Thorax 1994; 49:1251-8. [PMID: 7878564 PMCID: PMC475336 DOI: 10.1136/thx.49.12.1251] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- C Mélot
- Intensive Care Department, Erasme University Hospital, Brussels, Belgium
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31
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Evans D. The use of position during critical illness: current practice and review of the literature. Aust Crit Care 1994; 7:16-21. [PMID: 7727906 DOI: 10.1016/s1036-7314(94)70675-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
This descriptive study looked at how nurses positioned the critically ill person in the Intensive Care Unit. Its objective was to identify what positions were utilised, and whether severity of illness influenced this choice. The findings show nurses are conservative in their use of position during critical illness. There was only limited use of elevation of the backrest of the bed or rotation to the side during the side lying position. As the severity of illness increased, more horizontal positions were utilised. These findings and review of the literature highlights a need for further research into specific aspects of the use of position during critical illness.
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32
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Chang SC, Chang HI, Shiao GM, Perng RP. Effect of body position on gas exchange in patients with unilateral central airway lesions. Down with the good lung? Chest 1993; 103:787-91. [PMID: 8449069 DOI: 10.1378/chest.103.3.787] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
In this study, we evaluated the effect of body position (erect, supine, and two decubitus positions) on gas exchange (alveolar-arterial PO2 difference [AaPO2]) in 35 patients who had various degrees of lung collapse roentgenographically caused by unilateral central airway lesions, with special reference to the difference in AaPO2 between two lateral decubitus positions. The patients were divided into two groups. Group 1 was composed of 23 patients with FEV1/FVC > 70 percent. In group 2, there were 12 patients with FEV1/FVC < 70 percent. Our results showed that the mean AaPO2 of group 1 patients was least in the lateral decubitus position with normal lung down (AaPO2N), followed by those in the supine position (AaPO2S), in the lateral decubitus position with lesioned lung down (AaPO2L), and in the erect position (AaPO2E). There was no significant difference in AaPO2 obtained in four positions. However, a significantly negative correlation was found between AaPO2NL (AaPO2N minus AaPO2L) and patient's FEV1 (p < 0.05). In group 2 patients, the mean AaPO2E was least, followed by AaPO2L, AaPO2N, and AaPO2S. The changes of body position did not significantly affect gas exchange in group 2 patients. Unlike previous reports, the present study showed that AaPO2N was not exclusively less than AaPO2L in our patients. AaPO2N was higher than AaPO2L in 11 of 23 in group 1 and in 5 of 12 in group 2 patients. In summary, our results indicated that positional changes did not significantly affect gas exchange in the patients with lung collapse roentgenographically caused by unilateral central airway lesions and the dogma "Down with the good lung" could not be applied to these patients flawlessly.
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Affiliation(s)
- S C Chang
- Chest Department, Veterans General Hospital-Taipei, Taiwan, Republic of China
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Dreyfuss D, Djedaini K, Lanore JJ, Mier L, Froidevaux R, Coste F. A comparative study of the effects of almitrine bismesylate and lateral position during unilateral bacterial pneumonia with severe hypoxemia. THE AMERICAN REVIEW OF RESPIRATORY DISEASE 1992; 146:295-9. [PMID: 1489115 DOI: 10.1164/ajrccm/146.2.295] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The management of patients with unilateral pneumonia and severe hypoxemia often represents a therapeutic challenge. Mechanical ventilation with the diseased lung uppermost may improve gas exchange, but it is not devoid of adverse effects. No hemodynamic measurements have been reported in patients ventilated in this manner; therefore, whether or not the improvement in PaO2 is counterbalanced by hemodynamic deterioration remains unknown. Almitrine bismesylate is a drug that seems able to improve gas exchange in patients with chronic obstructive pulmonary disease or the adult respiratory distress syndrome. The increase in PaO2 after its administration has been attributed to an improvement in ventilation-perfusion relationships. Its use has never been reported during unilateral pneumonia with severe hypoxemia. We therefore compared its effects with those of lateral position in eight consecutive mechanically ventilated patients with unilateral pneumonia. Blood gas and hemodynamic measurements were performed both at maintenance FIO2 and at an FIO2 of 1.0. Almitrine (1 mg/kg over 1 h) had no effect on PaO2 under either FIO2 condition. Cardiac output remained unchanged, but mean pulmonary artery pressure increased from 22.5 +/- 1.2 to 26.5 +/- 1.3 mm Hg (p < 0.02). By contrast, lateral position had striking effects on PaO2, which increased from 100 +/- 14 mm Hg in supine position to 156 +/- 23 mm Hg (p < 0.01) when the abnormal lung was placed uppermost at maintenance FIO2 and from 207 +/- 21 (supine) to 300 +/- 28 mm Hg (lateral) (p < 0.01) at FIO2 1.0.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- D Dreyfuss
- Service de Réanimation Médicale, Hôpital Louis Mourier, Colombes, France
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34
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Abstract
We describe positional changes in oxygenation in two patients with respiratory failure due to massive pulmonary embolism. In both patients, oxygenation improved when the "sick" lung was dependent and deteriorated when the "healthy" lung was in the dependent position. These positional changes are different from previously reported changes in unilateral pulmonary disease. We speculate that a combination of unilateral pulmonary embolism and mechanical ventilation was responsible for the improvement in gas exchange when the "sick" lung was placed in the dependent position. The relative contribution of these two components to the development of this phenomenon is unclear.
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Affiliation(s)
- M S Badr
- Pulmonary Section, University of Wisconsin Hospitals and Clinics, Madison
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35
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Gillespie DJ, Rehder K. Effect of positional change on ventilation-perfusion distribution in unilateral pleural effusion. Intensive Care Med 1989; 15:266-8. [PMID: 2745869 DOI: 10.1007/bf00271064] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The effect of pleural effusion on lung function and gas exchange has not been adequately defined. We used the multiple "inert" gas technique to study gas exchange and ventilation-perfusion relationships in both the left and the right lateral decubitus positions in a patient with a moderate unilateral (left) pleural effusion. With position change, only a small change in oxygenation (3 mm Hg) and no change in carbon dioxide tension occurred. The ventilation-perfusion relationships were also nearly identical for both body positions. We conclude that a pleural effusion of moderate size has little effect on overall gas exchange and ventilation-perfusion relationships and that complex mechanisms of the respiratory system compensate for the effusion.
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Affiliation(s)
- D J Gillespie
- Division of Thoracic Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota
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36
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Glauser FL, Polatty RC, Sessler CN. Worsening oxygenation in the mechanically ventilated patient. Causes, mechanisms, and early detection. THE AMERICAN REVIEW OF RESPIRATORY DISEASE 1988; 138:458-65. [PMID: 3057967 DOI: 10.1164/ajrccm/138.2.458] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Hypoxemia or worsening oxygenation is a common problem in the ICU. Ventilator-related problems, patient-related problems, including progression of the underlying disease process or superimposed disorders, and interventions, procedures, and medications can all adversely affect the patient's oxygenation status. Each of these causes should be sought for in a rapid and expeditious manner and appropriate corrective actions taken.
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Affiliation(s)
- F L Glauser
- Department of Medicine, Medical College of Virginia/McGuire Veterans Administration Hospital, Richmond, Virginia 23298-0001
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