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AACN Advanced Critical Care


Volume 20, Number 3, pp.228240
In the Public Domain

Physiological Rationale and


Current Evidence for Therapeutic
Positioning of Critically Ill Patients
Karen L. Johnson, RN, PhD
Tim Meyenburg, RN, MS, CNL

ABSTRACT
Prolonged bed rest is common in critically ill active repositioning (manual, continuous
patients, and therapeutic positioning is lateral rotation, and kinetic therapy). The
important to prevent further complications physiological rationale and current evidence
and to improve patient outcomes. Nurses for each position are described. Applicable
use therapeutic positioning to prevent com- evidence-based practice guidelines are sum-
plications of immobility. This article reviews marized. Special considerations for thera-
therapeutic positions including stationary peutic positioning of critically ill obese and
positions (supine, semirecumbent with head elderly patients are also discussed.
of bed elevation, lateral, and prone) and Keywords: critically ill, positioning

M ultiple factors relegate critically ill


patients to strict bed rest including
altered level of consciousness, drugs that pre-
Stationary Positions
Supine Position
In the supine position, ventilation and perfu-
vent mobility (paralytics, sedatives), trau- sion are greater in dependent areas of the lungs
matic injuries, and surgical complications than in the anterior areas. In healthy lungs,
(open chest or abdominal cavities). However, adequate matching of ventilation and perfu-
bed rest is associated with multiple compli- sion (V/Q match) can be achieved in the supine
cations that are well documented in the liter- position. In diseased lungs, prolonged place-
ature (Table 1). Because critical care nurses ment in the supine position can alter the V/Q
are keenly aware of these complications, match. For example, excess fluid associated
they use clinical judgment in their daily prac- with pulmonary edema accumulates in the
tice to place bedridden patients in the most dependent areas of the lungs and interferes
optimal position to prevent these complica-
tions and to improve patient outcomes. The
purpose of this article was to review options Karen L. Johnson is Director of Nursing, Research and
of therapeutic positioning in critically ill Evidence-Based Practice, University of Maryland Medical
Center, 22 S Greene St, 7 Gudelsky, Room C728, Baltimore, MD
patients. The physiological rationale and
21201. She is also Associate Professor, Trauma/Critical Care/
current evidence for stationary and active Emergency Nursing Masters Program, University of Maryland,
repositioning are described. In addition, School of Nursing, Baltimore (kjohnson8@umm.edu).
positioning of critically ill obese and elderly Tim Meyenburg is Clinical Nurse II, Surgical ICU, University
patients is discussed. of Maryland Medical Center, Baltimore.

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Table 1: Complications of Bed Rest


cally ventilated patients have reported that
aspiration of gastric contents occurs to a
Pulmonary1,2
greater degree when patients are in the supine
position than when they are in the semi-recum-
Atelectasis bent position with the HOB elevated to 30 to
Pneumonia 45.1214 Drakulovic and colleagues15 conducted
a prospective, randomized clinical trial to com-
Hypoxemia pare continuous HOB elevation of 45 to no
Cardiovascular elevation in the early mechanical ventilation
period and found a significantly greater inci-
Venous thromboembolism3 dence of VAP in patients who did not have
Syncope because of diminished baroreceptor HOB elevation. More recently, this work was
activity extended by Grap and colleagues,16 who found
that VAP was more likely to occur in patients
Skin integrity
who spent more initial mechanical ventilation
Pressure ulcers5 time with HOB elevation of less than 30.
Because of these studies, multiple clinical
with diffusion of gases across the alveolar- practice guidelines have stated that the semire-
capillary membranes. Perfusion, however, cumbent position with HOB elevation of 30
remains constant in the dependent areas. to 45 should be used for critically ill patients
Therefore, there is a V/Q mismatch that results to prevent aspiration pneumonia and VAP.
in an intrapulmonary shunt. These guidelines include those issued by the
The supine position results in anatomical American Association of Critical-Care Nurses
changes that alter ventilation and perfusion, (AACN),17 the Centers for Disease Control
especially in patients with enlarged hearts. In and Prevention,18 the Society of Critical Care
the supine position, the major part of the left Medicine,19 the American Thoracic Society,20
lower lobe and a significant part of the right and the Canadian Critical Care Society.21 In
lower lobe are located beneath the heart.6 addition to the benefits of HOB elevation, crit-
Enlarged hearts produce an increased pleural ical care nurses need to be aware of the con-
pressure in the dependent areas and contribute traindications of this position and to apply
to alveolar collapse.6 Studies using isotope ven- appropriate judgment. Contraindications to
tilation-perfusion scans in patients with car- HOB elevation, as identified in the AACN
diomegaly and no evidence of pulmonary VAP Practice Alert Audit Tool,17 are summa-
pathology have shown a 40% to 50% reduc- rized in Table 2.
tion in left lower lobe ventilation in a prolonged
supine position with no concomitant reduction
Table 2: Contraindications to HOB
in regional perfusion.7,8 Patients with acute res-
Elevation in Critically Ill Patients
piratory distress syndrome (ARDS) who are
mechanically ventilated while in the supine
Cardiovascular
position develop atelectasis in the dependent
areas of the lungs.9 Ventilation is impaired by Low cardiac index
airway secretions, lung edema, and cardiac and Hypotension
abdominal compression of the lungs while per-
fusion is maintained, and this results in intra- Neurological
pulmonary shunt and severe hypoxemia.10,11 Ischemic stroke

Semirecumbent Position With Traumatic brain injury


Head of Bed Elevation Processes of care
Head of bed (HOB) elevation is an important
component of the semirecumbent position that Procedure in progress in which HOB elevation
is inappropriate
must be considered for patients who are receiv-
ing enteral nutrition to prevent aspiration of Prone position
gastric contents and ventilator-associated
Medical order for no HOB elevation
pneumonia (VAP). Several studies using radio-
labeled enteral feeding solutions in mechani- Abbreviation: HOB, head of bed.

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JOHNSON AND MEYENBURG AACN Advanced Critical Care

It is important for critical care nurses to rec- backrest elevation was 19, 70% of the
ognize that HOB elevation above 30 may patients were in the supine position, and intu-
increase the risk of pressure ulcer formation. bated patients had lower backrest elevations
In a study of 57 patients in a surgical intensive than did nonintubated patients.29 One expla-
care unit (ICU), patients placed in semi- nation for nurses not complying with HOB
Fowlers position had higher sacral tissue elevation may be the inability to accurately
interface pressures when compared with those estimate backrest elevation.27
placed in other positions, regardless of the To address these issues, AACN issued a
type of pressure redistribution surface VAP Practice Alert in 2004.17 The Practice
selected.22 These results have been confirmed Alert included a procedure to audit backrest
in a more recent study involving healthy vol- elevation, suggestions for audit frequency,
unteers. Defloor23 evaluated tissue interface and a data collection tool. These efforts seem
pressures and found that pressures in the to have had a positive effect. A recent survey
sacral area were higher when the HOB was of 1200 critical care nurses who attended
elevated to 90 than when it was elevated to the AACN National Teaching Institute as
60. He found that the lowest tissue interface well as other national educational programs
pressures occurred when patients were placed reported that they maintained the HOB
in a semi-Fowlers position with the HOB ele- elevations 30 to 45 most of the time. More
vated up to 30 and the knees elevated to 30. than 85% of the respondents reported that
The Wound, Ostomy and Continence Nurses they maintain HOB elevations 30 to 45 for
Society recommends maintaining the HOB at their patients 86% of the time.30 The VAP
30 elevation for supine positions.24 There are Practice Alert was recently revised to include
very few studies to support the use of a special- additional sources of evidence and the levels
ized mattress to reduce elevated sacral pres- of evidence to support the Practice Alert
sures caused by HOB elevation, and the results Statements.
are inconclusive.25,26 The VAP Practice Alert Audit Tool contains
The optimal semirecumbent HOB elevation methods to estimate HOB elevation (Figure 1).
position that reduces the development of aspi-
ration pneumonia, VAP, and pressure ulcers is Use the built-in angle measurement for HOB elevation if
not known. Until there is further evidence, available.
nurses must use their judgment on the HOB ele- Use a simple protractor positioned on the horizontal
vation that is best for each individual patient. frame of the bed and the frame of the backrest at the
That judgment should be guided by the level of pivot point of the backrest.
Calculate the angle of the backrest elevation by mea-
evidence to support the degree of HOB eleva- suring the length of the backrest from the pivot area
tion. And to that end, as Grap and Munro27 (A on diagram below) to the top of the backrest (B). Then
point out, the level of evidence for the use of measure from the top of the backrest (B) straight down to
lower HOB elevation to prevent sacral pressure the horizontal frame of the bed (C). Divide the distance
ulcers (1 controlled trial, at least 2 descriptive from B to C by the distance from A to B and take the arc
case studies or expert opinion) is not as strong sine of that product. Angle of backrest  arc sine of
(A to B)/(B to C).
as that for HOB elevation to prevent aspiration
pneumonia and VAP (clinical or epidemiologi-
cal studies or strong theoretical rationale).
Although there is evidence to support HOB
elevation for critically ill patients in the semi-
recumbent position, HOB elevation does not
appear to be routinely implemented among
intubated patients. In a pilot study in 1999,
Grap and colleagues28 found that in 347 meas-
urements of 52 critically ill medical patients,
Example: The angle of backrest elevation for a backrest (A to B) which is
the mean backrest elevation was 22.9 and 32 in, which is 16 in above the frame (B to C), is equal to the arc sine of
that patients were in the supine position 86% 32/16  30 degrees.
of the time, despite the presence of enteral Figure 1: Methods for Estimating HOB Elevation.
feedings. In a subsequent study in 2003, HOB indicates head of bed elevation. Reprinted
involving 506 observations of 170 patients in with permission from the American Association of
several ICUs, the results were worse: Mean Critical-Care Nurses.115

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Stationary Lateral Positions not been fully elucidated. Possible mechanisms


The decision to place critically ill patients in may include better drainage of pulmonary
the left or right lateral decubitus position is secretions,45 reopening of atelectactic units in
based on relevant lung pathology and hemo- the dorsal regions of the lungs,49 and minimiz-
dynamic stability. Studies have shown that ing ventilator-induced lung injury.50 The opti-
when patients with unilateral lung disease mal response and beneficial effect of prone
(pneumonia, atelectasis) are placed with the positioning may occur during the early edema-
consolidated lung in the dependent position, tous phase of ARDS when atelectasis and lung
there is a mismatch of ventilation to perfusion edema predominate.51 Despite these improve-
that results in hypoxemia.3136 Placement of the ments in pulmonary gas exchange, 2 recent
diseased lung in the dependent lateral position studies reported no survival benefit for the use
results in greater perfusion to a diseased poorly of the prone position in ARDS.48,52 The ration-
ventilated lung and impairs gas exchange. ale for this lack of a survival benefit is not clear
Therefore, patients with unilateral lung but it should be noted that the average range of
pathology should be placed in a lateral posi- tidal volume given to patients in these studies
tion with the good lung down. Even though was 9 mL/kg, which may have contributed to
this is the golden rule for patients with unilat- ventilator-induced lung injury.53
eral disease, there are contraindications to this Alsaghir and Martin54 recently conducted a
position in certain lung pathologies. For exam- systematic review and meta-analysis to assess
ple, in patients with pulmonary abscesses or the effect of the prone position, as compared to
pulmonary hemorrhage, it is important to the supine position, on improvement in oxy-
keep the affected lung in the dependent posi- genation, number of days on the ventilator, VAP,
tion so that drainage will not migrate toward and mortality. They included 5 randomized con-
the healthy lung.37,38 In addition, patients with trolled trials (n  1316) comparing greater than
interstitial emphysema should be placed with 6 hours of prone position in adult patients with
the affected lung in the dependent position to ARDS. Prone positioning showed significant
prevent hyperinflation.38 and persistent improvement in PaO2/FIO2 in all
Although there is evidence to support lat- phases of ARDS (Table 3). However, significant
eral positioning in patients with unilateral statistical heterogeneity of treatment effect was
pulmonary disease, less is known about the found, meaning that the results were highly vari-
effects of lateral positioning on oxygenation able across studies. Sources of clinical hetero-
in patients with bilateral pulmonary disease. geneity included when proning was initiated and
At 10 to 30 minutes after a lateral position the duration of the prone position. Treatment
change, cardiac output and heart rate may effect heterogeneity may mask substantial bene-
not be the same as in the supine position, but fit for some, little benefit for others, and harm
these changes in most mechanically venti- for a few.58 There were no significant differences
lated patients are not clinically significant.3943 in number of days on mechanical ventilation or
Early evidence demonstrated that cardiovas- the incidence of VAP (Table 3). Although no sig-
cular changes can be highly individualized nificant difference in short-term or long-term
and may be most prominent in patients with mortality was reported, a couple of studies
low cardiac output and in patients who are showed that prone position significantly
hypothermic and/or receiving vasoactive reduced mortality in patients with higher illness
medications.41 More recent evidence suggests severity (Table 4). Future randomized controlled
that lateral positioning of critically ill trials focusing on early initiation of the prone
patients who are hypoxemic or have low car- position while controlling for time in the prone
diac output does not further endanger tissue position are warranted.
oxygenation.44 Currently there are no clinical practice
guidelines that recommend the use of prone
Prone Position positioning to decrease VAP. However, recent
Research demonstrates that prone positioning guidelines released by the Society of Critical
in critically ill patients with acute lung injury Care Medicine recommend prone positioning
and/or ARDS improves pulmonary gas in patients with ARDS who require potentially
exchange45,46 and reduces the rate of VAP.47,48 injurious levels of FIO2 or have elevated plateau
The physiological mechanisms responsible for pressures, who are not at high risk for adverse
improvement in pulmonary gas exchange have consequences of positional changes, in facilities

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JOHNSON AND MEYENBURG AACN Advanced Critical Care

Table 3: Results of Meta-analysis on Effects of Prone Positioning on PaO2/FIO2, Days on


Mechanical Ventilation, and Incidence of Ventilator-Associated Pneumoniaa

Number Weighted Mean


Outcome Variables of Studies n Difference 95% CI References

PaO2/FIO2 (12 h2 d) 4 866 51.5 6.9596.05 48, 5557

PaO2/FIO2 (4 d) 3 754 43.87 13.8673.88 48, 56, 57

PaO2/FIO2 (10 d) 4 833 24.89 15.334.48 48, 52, 56, 57

Days on mechanical 2 831 .42 d 1.56 to 0.72 48, 56


ventilation

Incidence of VAP 3 967 0.78% 0.401.51 48, 56, 57

Abbreviations: CI, confidence interval; n, sample size; PaO2/FIO2, ratio of partial pressure of oxygen in arterial blood to the fraction of inspired
oxygen; VAP, ventilator-associated pneumonia.
a
Data are from Alsaghir and Martin.54

that have experience with such practices.19 variety of sensory cues prompt a change in body
Adverse consequences include dislodgement of position. These sensory cues prevent detrimen-
the artificial airway and enteral feeding tubes, tal effects of prolonged periods of immobility.
loss of venous access, development of facial Individuals who have neurological or sensori-
edema and pressure ulcers, and difficulties motor impairments must rely on others to repo-
with cardiopulmonary resuscitation. Potential sition them to prevent hazards of immobility.
contraindications to the use of the prone posi-
tion, as summarized by Ball and colleagues,59 Manual Repositioning
are listed in Table 5. Repositioning is conceptualized as turning the
For critical care units that use prone posi- patient from side to side when lying in bed or
tioning, evidence-based guidelines for bedside on a similar surface.6365 Within this context,
nurses should be in place. These guidelines the patient is placed in a side-lying position
should include indications and contraindica- with the pelvis rotated approximately 30
tions, preprone assessment and safety prac- from the supine position.65 The current stan-
tices, strategies for placing the patient in the dard of care is to reposition patients every
prone position, assessment guidelines for mon- 2 hours. This standard is based on 2 studies
itoring patient response to the prone position, conducted in the early 1960s in healthy indi-
and limb positioning while in the prone posi- viduals.66,67 Repositioning every 2 hours is the
tion. The reader is referred to several pub- nursing standard for all immobilized critically
lished clinical practice guidelines on the use of ill patients as documented in nursing text-
prone positioning in critically ill patients.5961 books68,69 and national guidelines.70 A survey of
ICU physicians revealed that 83% of respon-
Active Repositioning dents agreed that the standard of ICU care is
Healthy individuals change positions, even dur- to turn patients every 2 hours.71 However, a
ing sleep, approximately every 12 minutes.62 A prospective longitudinal observational study

Table 4: Results of Meta-analysis on Effects of Prone Positioning on Mortalitya

Outcome Variables Number of Studies n Odds Ratio 95% CI References

ICU mortality 3 466 0.79 0.451.39 52, 55, 57

28- to 30-day mortality 3 1231 0.95 0.711.28 48, 52, 57

90-day mortality 4 1271 0.99 0.771.27 48, 52, 56, 57

Mortality with SAPS II 50 2 113 0.29 0.120.70 52, 57

Abbreviations: CI, confidence interval; ICU, intensive care unit; n, sample size; SAPS, Simplified Acute Physiology Score.
a 54
Data are From Alsaghir and Martin.

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Table 5: Potential Contraindications to


conducted at 3 ICUs in 2 states demonstrated
Prone Positioning
this standard was not met.71 In this same study,
74 patients were observed for an average of
Cardiovascular 7.7 hours. Ninety-seven percent of the patients
Hemodynamic instability did not receive the minimum standard of body
repositioning every 2 hours. About half (47%)
Mean arterial pressure  60 mm Hg or systolic
blood pressure  90 mm Hg, regardless of of the observed patients were in the supine
fluid resuscitation or inotropes position for 4 to 8 hours, and 23% of the
patients were not repositioned for more than 8
Recent cardiopulmonary arrest
hours. A more recent study in 40 ICUs in the
Short-term bleeding United Kingdom revealed similar findings:
Ventricular assist devices Patients were in the supine position for 46%
of the observations, with an average time of
Intra-aortic balloon pump
4.85 hours between turns.72 If repositioning
Recent cardiothoracic surgery/unstable mediastinum every 2 hours is the standard of care, these
Trauma results prompt the question, why is the stan-
dard not being met?
Head injury There has been limited investigation into
Spinal cord precautions/injury the reasons why patients are not repositioned.
Multiple trauma
Nurses in long-term care facilities were sur-
veyed and said the chief reasons for not rou-
External pelvic fixation or pelvic fractures tinely repositioning patients were lack of
Rib fractures specific assignment to the task and a lack of
time and staff.73 Although there have been no
Traction
studies published that explain why critically
Neurological ill patients are not repositioned every 2 hours,
Increased intracranial pressure lack of time and staff are the most likely
explanations. Additional factors may include
Seizures
patient intolerance, hemodynamic instability,
Head and neck and pain. Evidence exists to support that
Increased intraocular pressure repositioning critically ill patients is painful.
In AACNs Thunder Project II, a study of
Maxillofacial surgery 6201 critically ill patients revealed that turn-
New tracheostomy (24 h) ing was the most painful routine procedure
Respiratory
performed for adults.74 A smaller, but more
recent, study found similar results as critically
Asthma ill patients reported turning to be the most
Open chest painful routine procedure they experienced.75
This study and others highlight the problem:
Abdominal
Not all patients receive preemptive pain relief
Recent abdominal surgery before repositioning.76,77
Recent stoma formation Strategies to remind staff of the need to turn,
such as playing music over the intercom when
Open abdomen
patients are to be turned and posting signs on
Large abdomen doors alerting staff of patient pressure ulcer
Musculoskeletal risk, have been implemented with some short-
term success.78 The reality is that rigid turning
Kyphoscoliosis schedules in the ICU are difficult to maintain
Advanced osteoarthritis because of treatments, therapies, diagnostic
Rheumatoid arthritis
tests, procedures, and nursing care that require
the patient to be in a supine position.
Others Although the initial question may be to ask
Pregnancy (second/third trimester) why the standard of every 2-hour turning is
not met, perhaps the real question should be,
Weight  135 kg
does repositioning every 2 hours impact

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patient outcomes? The optimal interval for have attempted to elucidate the underlying
turning acutely or critically ill patients is not physiological mechanisms by which rotation
known. Only one study examined this issue. therapy may decrease the development of VAP.
Defloor and colleagues79 investigated the Bein and colleagues88 investigated the effects of
effects of different turning intervals in a ran- continuous rotational therapy on ventilation-
domized controlled trial involving patients in perfusion in 10 patients with ARDS. By using
11 long-term care facilities. They found that the inert-gas elimination technique, they found
turning patients every 4 hours combined with that 20 minutes of rotation improved gas
the use of a specialized foam mattress signifi- exchange by decreasing low ventilation to
cantly reduced the incidence of pressure ulcers perfusion lung units. They also found that
compared with turning every 2 hours on stan- patients with more severe ARDS did not
dard hospital mattresses. It would be difficult improve oxygenation (PaO2/FIO2) with rotation
to advocate turning patients every 4 hours therapy than did patients with less severe dis-
rather than every 2 hours based on this 1 study ease. They speculated that these results were
because there were several methodological due in part to the pathophysiological changes
issues with this study including lack of alloca- with ARDS over time as the lung evolves from
tion of interventions, inadequate blinding of a wet, heavy, atelectatic lung to a brittle
participants and data collectors, and lack of an fibrotic lung. In the early stage of ARDS,
intent to treat analysis. rotation therapy may be effective in altering
the distribution of ventilation and perfusion.
Rotation Therapy However, late ARDS pathophysiological changes
Rotation therapy, including continuous lateral render position changes ineffective. Further
rotation therapy (CLRT), involves the use of studies are needed to explain the physiological
specialized beds to mechanically turn the basis of rotation therapy.
patient from side to side. CLRT uses continuous Current clinical practice guidelines by the
turning of a patient up to 40 on each side with Centers for Disease Control and Prevention
6 to 8 turns an hour. The bed frame rotates the make no recommendations for the use of rota-
patient from side to side. Research demon- tion therapy for the prevention of VAP in criti-
strates that patients must be rotated at least 18 cally ill and immobilized patients.18 However,
hours a day to achieve maximum benefit.8085 more recent guidelines published by the Cana-
Four systematic reviews and meta-analyses dian Critical Care Society recommend clini-
have shown that rotation therapy decreases cians consider the use of kinetic beds to
the relative risk of VAP but has no benefit on prevent VAP.21
reducing ICU length of stay or decreasing mor-
tality.81,86,87 Several methodological issues used Positioning of the Critically
in these studies must be highlighted. Many Ill Obese Patient
studies lack (or at least did not report) the use Obesity is defined as a body mass index (BMI;
of rigorous methods to ensure adherence to weight [kg]/height [m2]) greater than or equal
manual turning routines in the control groups. to 30.89 According to recent data from the
It is not apparent that manual turning was Centers for Disease Control and Prevention,
strictly monitored or enforced.71 Given the more than 20% of American adults are obese
results of 2 studies that revealed critically ill and the number is expected to increase.90 Con-
patients were not turned every 2 hours,71,72 sequently, as the general population of obese
rotation therapy studies may have been com- individuals has increased, so too has the popu-
paring specialty beds with a control group that lation of critically ill obese patients. Position-
was not turned adequately. Therefore, the ing these patients can be challenging.
reduction in VAP with the use of rotation ther- Currently, most positioning interventions for
apy may actually be due to being turned, obese patients are only modifications of those
rather than the specialty bed itself. Future used for nonobese patients.91,92
studies need to include protocols that demon- A task force of the National Association of
strate strict adherence to manual turning. Bariatric Nurses developed best practices for
Despite the number of studies published on safe handling of obese patients.93 These guide-
rotation therapy, it remains unclear which lines recommend the establishment of unit-
patients are the best candidates for this ther- based multidisciplinary bariatric task forces to
apy. This may be in part because few studies identify high risk tasks and to outline solutions

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especially for repositioning patients in bed. adjustable footboard against which the patient
Caregivers must be knowledgeable about avail- can push to move up in the bed, and an over-
able technology to assist with positioning, how bed trapeze that the patient can grasp to lever-
to access it quickly, and the weight capacity of age into a higher position.98
beds and reclining chairs. The VISN 8 Web site Special care must be taken when placing the
of the Department of Veterans Affairs has a obese patient with large pendulous abdomens
valuable resource available on its Web site,94 in a lateral position. If allowed to hang over
the Safe Bariatric Patient Handling Toolkit, the side of the bed, they can have the effect of
that contains assessment criteria, algorithms, pulling the patient off the bed via gravity.99
equipment lists, and a policy template. A task Care must also be taken, in both men and
that is challenging and places caregivers at high women, to protect the breasts from compres-
risk for injury is repositioning an obese patient sion injury.
up in bed for turning to the side. The use of The effects of the prone position in obese
manufactured slings can greatly reduce these patients have not been thoroughly examined.
risks and allow for repositioning the obese The process of placing the obese patient in this
patient while in bed. An algorithm on reposi- position presents challenges and safety risks for
tioning obese patients in bed (side to side, up in the patient as well as members of the health care
bed) can be helpful for critical care nurses who team. Adequate numbers of staff and appropri-
care for these patients (Figure 2). ate equipment that can tolerate the weight shifts
of obese patients are required.98 A recent case
Positioning Obese Patients to Promote study of an obese patient with ARDS reported
Adequate Oxygenation that the prone position improved alveolar venti-
In obese individuals, there are structural and lation.100 Rossetti and colleagues101 in a study
functional changes that impact ventilation. A conducted on ICU patients with ARDS found
BMI greater than 30 kg/m2 is directly associ- that patients with increased body weight had
ated with reductions in all lung volumes, par- greater improvement in oxygenation than did
ticularly in expiratory reserve volume and those with less weight. Further research is neces-
functional reserve capacity.95 Adipose tissue sary to strengthen and to support the use of the
deposits in the abdomen, diaphragm, and prone position for obese patients.
intercostal muscles can prevent proper chest There are specific mattress products that
wall expansion and diaphragmatic excur- offer CLRT for obese patients. These products
sion.91 The airway may be narrowed from adi- reduce friction and shear and provide for turn-
pose tissue deposits in the upper airway, which ing to maximize respiratory function.92,98 They
can complicate airway management. These include air mattresses that have multiple air
structural changes may lead the obese patient chambers that inflate and deflate to laterally
to experience a hypoventilation syndrome rotate the patient. One example of this is the
with chronic hypoxia or obstructive sleep Plexus TruTurn Elite Therapeutic Turning Mat-
apnea.91 Obese patients are at risk for more tress (Gaymar Industries, Orchard Park, New
ventilator days than are nonobese patients and York). Nurses should be cognizant of avoiding
are more likely to aspirate gastric secretions the use of the term big boy bed as this an
because of increased gastric secretions, upper unnecessary assault on the patients dignity.94
airway changes, and poor lung volumes.96
These patients are at greater risk for the devel- Positioning Obese Patients
opment of atelectasis and pneumonia from to Promote Skin Integrity
shallow breathing patterns.92 Head of bed ele- Obese patients are more susceptible to pres-
vation of at least 30 improves ventilatory sure ulcers than are nonobese patients for a
effort and tidal volume in patients with large variety of reasons including poorly vascular-
abdomens and reduces the incidence of aspira- ized adipose tissue, additional mass and skin
tion in mechanically ventilated patients.97 surface area, limited mobility, improper equip-
However, this HOB elevation is often associ- ment, and inadequate staff members and staff
ated with the patient sinking to the foot of who lack training in caring for obese patients.
the bed (Figure 2). This requires additional Standard hospital beds may not provide
personnel to help reposition the patient to the enough pressure relief for the obese patient or
head of the bed. Useful strategies to counteract may be so narrow that the rails cause pressure
this problem may include the use of an against arms, legs, and hips.102 Properly sized

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Figure 2: Bariatric Reposition in Bed: Side to Side and Up in Bed. From the Safe Bariatric Patient Handling
Toolkit (www.visn8.med.va.gov/patientsafetycenter/safePTHandling/toolkitBariatrics.asp).

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equipment reduces the risk of pressure ulcers diminished respiratory muscle strength, poor
through pressure reduction and promotion of mucociliary clearance, increased upper airway
independence, decreases staff workload, and colonization, swallow dysfunction, and dimin-
increases satisfaction of the obese patient.103 Air ished respiratory muscle strength. Elevation of
and foam matrix mattresses minimize friction the HOB should be at least 30 to minimize the
and shear and therefore reduce the development incidence of VAP16 and to improve oxygena-
of pressure ulcers.91,92,98,104,105 Appropriate bed tion.109 In a study of healthy elderly patients,
frames can be selected for safe mobilization and Hardie and colleagues110 found that oxygena-
positioning of the bedridden patient. Trapezes tion was better in the sitting position than in
are useful for patient positioning because they the supine position; however, further studies in
allow patients to participate in their own care, critically ill patients showing the same results
reduce the number of staff required for transfer, are needed.
and reduce the risk of friction and shear with
repositioning.102 A bariatric ceiling lift with a Positioning Elderly Patients
seated sling can be used to transfer patients to Promote Skin Integrity
from bed to chair if the patient cannot fully or Critically ill elderly patients are at high risk for
partially assist. the development of pressure ulcers.108,111 Fur-
A multidisciplinary team effort is required thermore, and ironically, some research sug-
to determine which positioning interventions gests that obesity can reduce the incidence of
are required for critically ill obese patients. pressure ulcers in elderly populations when
This team effort should be expanded to compared with optimal weight patients and
encourage proper interventions to ensure underweight patients.112 The authors of the pre-
safety for the patient and caregivers.92,98,104 A ceding study postulate that adipose tissue could
prospective, cross-sectional descriptive study potentially provide a type of subcutaneous
reported that at least 2 staff members were cushion dispersing pressure over more tissue.
needed to assist with positioning, and those This research illustrates the point that it is
with a BMI greater than 40 kg/m2 were most imperative to provide individualized care to the
likely to need at least 4 staff for positioning.98 elderly critical care patient when addressing
On the basis of these results, the investigators risks for pressure ulcer development. Evidence
recommend using BMI as a trigger for order- exists to support the use of interventions for
ing rented or stored equipment to promote general patient populations to address these
timely arrival and intervention. risks, such as patient turning in bed, CLRT,
and positioning on a specialty surface113,114;
Positioning of the Critically however, research into the elderly populations
Ill Elderly Patient response to these interventions is lacking.
The overall mortality rate for critically ill Age-related decreased peripheral perfusion
patients older than 65 years is higher than to the lower extremities in the elderly is a risk
that for patients younger than 45 years factor for the development of pressure ulcers
(36.8% vs 14.8%, respectively).106 Causes for on the heels of elderly patients on bed rest.
increased mortality include acute respiratory Cushioning devices, such as foam heel protec-
failure, use of mechanical ventilation, and tors and pillows, are important in the preven-
development of complications.107 Pressure tion of heel ulcers.
ulcers can increase an elderly patients chances
of mortality in an ICU by 2 to 4 times.108 Summary
Regarding such staggering differences in mor- Nurses use clinical judgment based on physio-
tality statistics, these numbers are compelling, logical and scientific evidence to position criti-
particularly when they can be addressed, in cally ill patients to prevent complications of
part, by patient positioning. immobility and to achieve optimal patient out-
comes. Therapeutic positioning in stationary
Positioning Elderly Patients to positions is done to optimize ventilation and
Promote Adequate Oxygenation perfusion and to promote effective pulmonary
There are structural and functional changes gas exchange. In patients with unilateral dis-
that occur with aging that impact ventilation ease, optimal gas exchange occurs when the
and increase the risk of respiratory failure and patient is placed with the good lung down.
VAP including reduction in expiratory force, Less physiological and scientific evidence exists

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JOHNSON AND MEYENBURG AACN Advanced Critical Care

for optimal positioning of patients with bilat- 10. Rouby JJ, Constantin JM, Roberto de A Girardi C, Zhang
M, Lu Q. Mechanical ventilation in patients with acute res-
eral disease. More research is needed. Strong piratory distress syndrome. Anesthesiology. 2004;101:
evidence exists that HOB elevation prevents 228234.
11. Hubmayr RD. Perspective on lung injury and recruit-
VAP. More research is needed to identify the ment: a skeptical look at the opening and collapse
optimal degree of HOB elevation that story. Am J Respir Crit Care Med. 2002;165:16471653.
prevents VAP and development of pressure 12. Ibanez J, Penafiel A, Raurich JM, Marse P, Jorda R, Nata F.
Gastroesophageal reflux in intubated patients receiving
ulcers. Although research has demonstrated enteral nutrition: effect of supine and semirecumbent
that prone positioning in patients with ARDS positions. JPEN J Parenter Enteral Nutr. 1992;16:419422.
improves pulmonary gas exchange, the exact 13. Torres A, Serra-Battles J, Rose E, Piera C, Puig de la Bella-
casa J, Cobos A. Pulmonary aspiration of gastric contents
physiological mechanisms responsible for in patients receiving mechanical ventilation: the effect of
improvement in pulmonary gas exchange have body position. Ann Intern Med. 1992;116:540543.
14. Orozco-Levi M, Torres A, Ferrer M, et al. Semirecum-
not been elucidated. Even though prone posi- bent position protects from pulmonary aspiration but
tioning optimizes oxygenation, the use of not completely from gastroesophageal reflux in
this position has not been shown to impact mechanically ventilated patients. Am J Respir Crit Care
Med. 1995;152(4, pt 1):13871390.
mortality. The current standard of repositioning 15. Drakulovic MS, Torres A, Bauer T, Nicolas J, Nague S,
patients is every 2 hours, yet there is little physi- Ferrer M. Supine body position as a risk factor for noso-
ological or scientific evidence to support this comial pneumonia in mechanically ventilated patients:
a randomized trial. Lancet. 1999;354:18511858.
standard. Furthermore, it appears that the stan- 16. Grap MJ, Munro C, Hummel R, Elswick R, McKinney J,
dard is often not met. Research is needed to Sessler C. Effect of backrest elevation on the develop-
ment of ventilator-associated pneumonia. Am J Crit
provide evidence that turning frequency Care. 2005;14:325333.
impacts outcomes. Research has shown that 17. American Association of Critical-Care Nurses. Practice
rotation therapy decreases VAP. However, Alert: ventilator-associated pneumonia. http://www
.aacn.org/WD/Practice/Docs/Ventilator_Associated
methodological issues arise because of lack of _Pneumonia_1-2008.pdf. Accessed February 7, 2009.
rigorous methods to assess adherence to group 18. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R;
assignments in randomized controlled trials Centers for Disease Control and Prevention; Healthcare
Infection Control Practices Advisory Committee. Guide-
comparing rotation therapy with conventional lines for preventing health-careassociated pneumo-
turning methods. More research is needed to nia, 2003: recommendations of CDC and the Healthcare
Infection Control Practices Advisory Committee.
understand physiological and scientific basis of MMWR Recomm Rep. 2004;53:136.
optimal positioning in select critically ill patient 19. Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM,
populations, such as obese and elderly patients. Jaeschke R. Surviving sepsis campaign: international
guidelines for management of severe sepsis and septic
shock: 2008. Crit Care Med. 2008;36:296327.
20. American Thoracic Society. Guidelines for the manage-
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AACN
ADVANCED CRITICAL CARE
Test writer: Denise Hayes, RN, MSN, CRNP
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Physiological Rationale and Current Evidence Test ID#: ACC2032


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3. 7. 11.
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CE Test Questions

Physiological Rationale and Current Evidence


for Therapeutic Positioning of Critically Ill Patients
Objectives:
Upon completion of this article, the reader will be able to:
1. Understand the role of therapeutic repositioning in preventing complications and improving critically ill patient out-
comes.
2. Describe the physiological rationale for stationary and active repositioning.
3. Recognize special considerations for therapeutic repositioning of critically ill obese and elderly patients.

1. What complication of bed rest is caused by diminished 8. According to Alsaghir and Martin, what is an effect of
baroreceptor activity? prone positioning?
a. Hypoxemia a. Decreased number of mechanical ventilation days
b. Venous thromboembolism b. Decreased VAP incidence
c. Syncope c. Improved PaO2/FIO2
d. Atelectasis d. Decreased mortality
2. How does prolonged placement in the supine position 9. Which is a potential contraindication to prone
affect patients with diseased lungs? positioning?
a. They have a normal ventilation/perfusion ratio. a. New tracheostomy (24 h)
b. They develop alveolar dead space. b. Weight of 130 kg
c. They have a high ventilation/perfusion ratio. c. Systolic blood pressure of 100 mm Hg
d. They develop an intrapulmonary shunt. d. Mean arterial pressure of 70 mm Hg
3. What head of bed (HOB) elevation do multiple clinical 10. In AACNs Thunder Project II, what was the most
practice guidelines recommend for critically ill painful routine procedure performed in adults?
patients in the semirecumbent position? a. Endotracheal tube suctioning
a. 10 to 25 degrees b. Arterial blood gases
b. 30 to 45 degrees c. Turning
c. 50 to 65 degrees d. Venipuncture
d. 75 to 90 degrees 11. In addition to expiratory reserve volume, what lung
4. Which is a contraindication to HOB elevation? volume is primarily reduced in patients with a body
a. Enteral nutrition mass index greater than 30 kg/m2?
b. Mechanical ventilation a. Functional reserve capacity
c. Hypertension b. Forced vital capacity
d. Ischemic stroke c. Inspiratory reserve volume
5. What is a possible risk of HOB elevation above d. Residual volume
30 degrees? 12. What structural and functional change of aging
a. Low sacral tissue interface pressures increases the risk of respiratory failure and VAP?
b. Pressure ulcers a. Increased expiratory force
c. Aspiration pneumonia b. Swallow dysfunction
d. Ventilator-associated pneumonia (VAP) c. Decreased upper airway colonization
6. A patient with which diagnosis should be positioned d. Increased respiratory muscle strength
with the unaffected lung in the dependent position?
a. Pneumonia
b. Interstitial emphysema
c. Pulmonary abscess
d. Pulmonary hemorrhage
7. Which position improves pulmonary gas exchange in
patients with acute lung injury and/or acute respiratory
distress syndrome?
a. Supine
b. Semirecumbent with HOB elevation
c. Left lateral decubitus
d. Prone

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