effect of position change on oxygenation and respiratory mechanics in mechanically ventilated...

EFFECT OF POSITION CHANGE EFFECT OF POSITION CHANGE ON OXYGENATION AND ON OXYGENATION AND

RESPIRATORY MECHANICS IN RESPIRATORY MECHANICS IN MECHANICALLY VENTILATED MECHANICALLY VENTILATED

PATIENTS WITH RESPIRATORY PATIENTS WITH RESPIRATORY PROBLEMSPROBLEMS

على الوضع على تأثيرتغيير الوضع تأثيرتغييرعند التنفس آليات و عند األكسجة التنفس آليات و األكسجة

التنفس التنفس مرضى مرضىمن يعانون الذين من اآللي يعانون الذين اآللي

تنفسية تنفسية مشاكل مشاكل

Body positioning is one of the general kinds of nursing actions during care of patients.

Critically ill patients positioning maximizes ventilation to improve oxygenation which in turn would affect the individual’s ability to maintain an internal environment that allows normal cellular function

The critical care nurse plays a crucial role in the The critical care nurse plays a crucial role in the assessment, diagnosis, and management of assessment, diagnosis, and management of

patients with respiratory problems who develop patients with respiratory problems who develop hypoxemia. hypoxemia.

• الصحية السياسات الصحية واضعي السياسات واضعي

عام رأي عام تشكيل رأي تشكيل

Studies related to the adequate duration in each position and the frequency of turning patients for

maximizing ventilation to improve systemic oxygenation has not been attempted .

The importance of the

effect of body position

on ventilatory function

and gas exchange has

been appreciated.

Less information is available concerning the effect of position change on gas exchange in human body.

To determine the effect of To determine the effect of position change on position change on oxygenation and respiratory oxygenation and respiratory mechanics in patients with mechanics in patients with respiratory problems.respiratory problems.

MATERIALMATERIAL

Setting

Critical care units of the Main University Hospital in Alexandria.

SubjectsSubjects

Adult patients with respiratory problems receiving mechanical ventilatory support were studied

Intern nurses were trained to help the researcher in turning patients, four at a time

30304848

Patients excluded from the study

Low Low hemoglobinhemoglobin

ArrhythmiArrhythmiaa

Facial Facial

surgerysurgery

Skeletal Skeletal deformitydeformity

Head or Head or spine injuryspine injury

obesityobesity

AbdominalAbdominal distensiondistension

Carbon monoxide poisoning,Carbon monoxide poisoning, pulmonary hemorrhage,pulmonary hemorrhage,

pulmonary abscess. pulmonary abscess.

hyperthermiahyperthermia

Socio-economic

assessment sheet

Position record

Assessment sheet

Tools

*Knowledge assessment sheet*observation sheet

METHODSMETHODS

*HD, ABG, RM were evaluated immediately before and every half-hour after turning patient for a total of 6 hours for each patient

*Patients were turned to left, prone, right, supine position respectively

*Researcher trained nurses to help in patient turning

* Instructions were given about how to turn the ventilated patients in the proper way

Nurses’ instructionsPatients positioning

Dependent variables hemodynamics arterial blood gases and respiratory mechanics were assessed.

Four groups of patients were used in this experimental study

Independent variables of position were altered as each patient was moved from the supine, to left lateral, prone,and right lateral position.

The effect of this movement on the

##General characteristics General characteristics of the study sampleof the study sample

##Effects of turning onEffects of turning on

Results Results werewere

Oxygenation Respiratory Respiratory

mechanicsmechanics

Distribution of patients by ageDistribution of patients by age

10%

23%

30%

37%

20-40

40-60

>60

<20

63%

37%

malefemale

Distribution of patients by Distribution of patients by sexsex

Distribution of patients by socio-Distribution of patients by socio-economic leveleconomic level

17%

40%

43%

LowMiddleHigh

Position change and hemodynamicPosition change and hemodynamic

0

10

20

30

40

50

60

70

80

90

100

110

120

B.L.P 0.5 L.L.P 1 L.L.P 1.5 L.L.P 0.5 P.P 1 P.P 1.5 P.P 0.5 R.L.P 1 R.L.P 1.5 R.L.P 0.5 S.P 1 S.P 1.5 S.P

HRSBPDBPMAP

B.L.P=Base line position L.L.P=Left lateral position

P.P= Prone position R.L.P=Right lateral position

S.P= Supine position

Position change and respiratory Position change and respiratory mechanicsmechanics

0

5

10

15

20

25

30

35

40

45

B.L.P 0.5 L.L.P 1 L.L.P 1.5 L.L.P 0.5 P.P 1 P.P 1.5 P.P 0.5 R.L.P 1 R.L.P 1.5 R.L.P 0.5 S.P 1 S.P 1.5 S.P

PIPPpLCstatCdynR

B.L.P=Base line position L..L.P= Left lateral position

P.P= Prone position R.L.P= Right lateral position

S.P= Supine position

Position change and arterial blood gasesPosition change and arterial blood gases

0

20

40

60

80

100

120

140

160

180

200

220

240

260

280

300

320

340

B.L.P 0.5L.L.P 1L.L.P 1.5L.L.P 0.5P.P 1 P.P 1.5 P.P 0.5R.L.P 1R.L.P 1.5R.L.P 0.5 S.P 1 S.P 1.5 S.P

Paco2Sao2pHHco3Pao2Pao2/Fio2

B.L.P=base line position L.L.P=Left lateral position

P.P=Prone position R.L.P=Right lateral position

S.P=Supine position

Time L.L.P P.P R.L.P S.P

A- Differences from base line reading:

NO % NO % NO % NO %

Mean 20.8 17.0 118.8 97.2 121.2 99.1 77.6 63.5

1/2 hr S D 26.3 68.7 47.5 42.5

t-test 2.4* 5.2* 7.7* 5.5*

Mean 34.6 28.3 148.3 121.3 103.1 84.3 55.7 45.6

1 hr S D 27.9 69.6 47.8 31.9

t-test 3.7* 6.4* 6.5* 5.2*

Mean 47.4 38.8 174.5 142.8 125.1 102.4 46.3 37.9

1.1/2hr S D 29.1 89.5 68.1 30.7

t-test 4.9* 5.9* 5.5* 4.5*

B-Differences from previous readings:

Mean 20.8 17.0 118.8 97.2 121.2 99.1 77.6 63.5

1/2hr S.D 26.3 68.7 47.5 42.5

t test 2.4* 5.2* 7.7* 5.5*

Mean 13.8 11.3 29.5 24.1 -12.8 -10.5 -12.9 -17.9

1 hr S.D 7.3 27.4 20.3 15.2

t test 5.7* 3.2* -1.9 -4.3*

Mean 12.8 10.4 26.2 21.4 22.2 18.2 -9.4 -7.7

1.1/2 S.D 4.1 24.7 20.5 13.1

t test 9.4* 3.2* 3.3* -2.2

Differences in

PaO2 in patients with normal lungs according to time and position

t-test significant > 2.3



NO % NO % NO % NO %

Mean 7.6 8.7 52.2 59.7 60.9 69.5 39.3 44.9

1/2 hr S D 7.3 19.2 30.7 27.5

t-test 3.1* 8.2* 5.9* 4.3*

Mean 13.6 15.5 66.2 75.7 54.6 62.4 30.7 35.1

1 hr S D 11.5 21.3 34.0 21.6

t-test 3.5* 9.3* 4.8* 4.3*

Mean 21.8 24.8 77.5 88.5 51.0 58.3 28.5 32.6

1.1/2hr S D 16.4 24.6 33.2 16.7

t-test 4.0* 9.5* 4.6* 5.1*


Mean 7.6 8.7 52.2 59.7 60.9 69.5 39.3 44.9

1/2hr S.D 7.3 19.2 30.7 27.5

t test 3.1* 8.2* 5.9* 4.3*

Mean 6.0 6.8 14.0 16.0 -6.2 -7.1 -8.6 -9.8

1 hr S.D 5.5 14.3 12.3 10.9

t test 3.3* 2.9* -1.5 -2.4*

Mean 8.1 9.3 11.2 12.8 -3.6 -4.2 -2.2 -2.5

1.1/2 S.D 6.7 8.8 8.8 9.4

t test 3.7* 3.9* -1.2 -0.7

Differences in PaO2 in patients with bilateral lung disease according to time and position




NO % NO % NO % NO %

Mean 13.4 11.9 68.2 61.0 46.3 41.4 31.7 28.4

1/2 hr S D 7.7 26.7 25.2 21.2

t-test 3.5* 5.1* 3.7* 3.2*

Mean 24.6 22.0 84.7 75.8 9.2 8.2 33.7 30.1

1 hr S D 9.1 35.1 19.1 30.5

t-test 5.4* 4.8* 1.0 2.2

Mean 36.2 32.4 97.3 87.0 -5.9 -5.3 34.9 31.2

1.1/2hr S D 13.7 36.9 17.1 28.5

t-test 5.3* 5.3* -0.7 2.4


Mean 13.4 11.9 68.2 61.0 46.3 41.4 31.7 28.4

1/2hr S.D 7.7 26.7 25.2 21.2

t test 3.5* 5.1* 3.7* 3.2*

Mean 11.3 10.1 16.5 14.8 -37.1 -33.2 2.0 1.7

1 hr S.D 7.1 9.4 20 12.6

t test 3.2* 3.5* -3.7* 0.3

Mean 16.9 15.1 12.6 11.2 -15.1 -13.5 1.2 1.1

1.1/2 S.D 10.0 5.3 2.9 3.8

t test 3.4* 4.7* -10.5* 0.7

Differences in PaO2 in patients with right lung disease according to time and position




NO % NO % NO % NO %

Mean -17.1 -14.5 25.1 21.3 49.8 42.3 28.5 24.2

1/2 hr S D 20.7 18.1 26.5 27.2

t-test -2.0 3.4* 4.6* 2.6*

Mean -32.0 -27.2 41.7 35.4 56.1 47.6 25.9 22.0

1 hr S D 15.3 26.5 17.8 16.2

t-test -5.1* 3.9* 7.7* 3.9*

Mean -38.8 -32.9 60.7 51.5 60.3 51.2 26.0 22.0

1.1/2hr S D 25.3 30.1 18.3 12.5

t-test -3.8* 4.9* 8.1* 5.1*


Mean -17.1 -14.5 25.1 21.3 49.8 42.3 28.5 24.2

1/2hr S.D 20.7 18.1 26.5 27.2

t test -2.0 3.4* 4.6* 2.6*

Mean -14.9 -12.7 16.6 14.1 6.3 5.2 -2.6 -2.2

1 hr S.D 13.2 10.3 22.3 16.1

t test -2.8* 3.9* 0.7 -0.4

Mean -6.8 -5.8 19.0 16.1 14.9 12.7 1.0 0.9

1.1/2 S.D 11.7 12.1 12.4 4.4

t test -1.4 3.9* 2.9* 0.1

Differences in PaO2 in patients with left lung disease according to time and position




NO % NO % NO % NO %

1/2 hr Mean 24.8 17.1 141.9 98.2 156.4 108.2 100.9 69.8

S D 25.8 57.4 70.8 55.2

t-test 2.9* 7.4* 6.6* 5.5*

1 hr Mean 47.3 32.7 183.8 127.2 141.0 97.6 73.5 50.9

S D 37.4 66.6 71.6 43.3

t-test 3.8* 8.3* 5.9* 5.1*

1.1/2hr Mean 59.8 41.4 218.6 151.3 160.9 111.3 60.7 42.0

S D 33.8 96.7 85.6 36.0

t-test 5.3* 6.8* 5.6* 5.1*


Mean 24.8 17.1 141.9 98.2 156.4 108.2 100.9 69.8

1/2hr S.D 25.8 57.4 70.8 55.2

t-test 2.9* 7.4* 6.6* 5.5*

Mean 22.5 15.6 41.9 29.0 -8.8 -6.1 -27.4 -19.0

1 hr S.D 22.8 44.3 14.3 16.9

t-test 3.0* 2.8* -1.8 -4.9*

Mean 12.5 8.7 34.8 24.1 19.6 13.7 -12.8 -8.9

1.1/2hr S.D 6.4 33.7 21.3 18.2

t-test 5.9* 3.1* 2.8* -2.1

Differences in hypoxemic oxygen index (PaO2/FIo2) in patients with normal lungs according to time and position




NO % NO % NO % NO %

1/2 hr Mean 12.0 7.9 90.4 59.3 95.9 62.9 60.3 39.6

S D 11.9 52.0 43.2 41.1

t-test 3.0* 5.2* 6.7* 4.4*

1 hr Mean 20.2 13.3 108.2 71.0 76.4 50.1 45.0 29.5

S D 17.1 38.1 50.9 40.3

t-test 3.6* 8.5* 4.5* 3.4*

1.1/2 Mean 34.9 22.9 124.7 81.9 70.6 46.3 43.8 28.8

S D 30.5 40.1 49.7 39.1

t-test 3.4* 9.3* 4.3* 3.4*


Mean 12.0 7.9 90.4 59.3 95.9 62.9 60.3 39.6

1/2hr S.D 11.9 52.0 43.2 41.1

t test 3.0* 5.2* 6.7* 4.4*

Mean 8.2 5.4 17.8 11.7 -19.5 -12.8 -15.3 -10.1

1 hr S.D 8.6 23.5 28.6 20.6

t test 2.9* 2.3* -2.1 -2.2

Mean 14.7 9.6 16.5 10.8 -5.8 -3.8 -1.1 -0.7

1.1/2 S.D 15.2 12.6 20.7 12.0

t test 2.9* 3.9* -0.8 -0.3

Differences in hypoxemic oxygen index (PaO2/FIo2) in patients with bilateral lung disease according to time and position




NO % NO % NO % NO %

1/2 hr Mean 29.6 13.2 142.3 63.3 91.6 40.7 56.2 25.0

S D 19.8 69.1 44.7 30.1

t-test 3.0 4.1* 4.1* 3.7*

1 hr Mean 51.5 22.9 175.8 78.2 19.9 8.5 62.7 27.9

S D 18.0 89.4 31.1 50.3

t-test 5.7* 3.9* 1.2 2.5

1.1/2hr Mean 72.3 32.2 202.3 90.0 -11.8 -15.6 65.8 29.3

S D 15.9 96.6 29.3 45.4

t test 9.1* 4.2* -0.8 2.9


Mean 29.6 13.2 142.3 63.3 91.6 40.7 56.2 25.0

1/2hr S.D 19.8 69.1 44.7 30.1

t-test 3.0 4.1* 4.1* 3.7*

Mean 21.9 9.7 33.5 14.9 -72.7 -32.3 5.2 2.3

1 hr S.D 10.6 21.4 34.3 21.9

t-test 4.1* 3.2* -4.2* 0.5

Mean 21.4 9.5 26.5 11.8 -30.6 -13.6 3.1 1.4

1.1/2hr S.D 11.2 11.4 4.2 8.7

t-test 3.8* 4.7* -4.8* 0.7

Differences in hypoxemic oxygen index (PaO2/FIo2) in patients with right lung disease according to time and position




NO % NO % NO % NO %

1/2 hr Mean -28.2 -13.2 41.6 19.5 91.0 42.7 50.7 23.8

S D 32.8 22.3 46.2 42.0

t-test -2.1 4.6* 4.8* 3.0*

1 hr Mean -55.3 25.9 71.6 33.6 100.0 46.9 46.0 21.5

S D 22.7 32.2 23.5 26.2

t-test -6.0* 5.5* 10.4* 4.3*

1.1/2hr Mean -67.0 31.4 102.7 48.1 95 39.9 37.6 17.6

S D 39.5 35.4 22.4 32.4

t-test -4.2* 7.1* 10.4* 2.8*


Mean -28.2 -13.2 41.6 19.5 91.0 42.7 50.7 23.8

1/2hr S.D 32.8 22.3 46.2 42.0

t-test -2.1 4.6* 4.8* 3.0*

Mean -27.1 -12.7 30.0 14.1 9.0 4.2 -4.7 -2.2

1 hr S.D 23.5 15.8 38.6 26.1

t-test -2.8* 4.7* 0.6 -0.4

Mean -11.6 -5.5 31.1 14.6 20.8 9.8 -8.4 -3.9

1.1/2 S.D 19.6 20.9 19.2 18.0

t-test -1.5 3.6* 2.7* -1.1

Differences in hypoxemic oxygen index (PaO2/FIo2) in patients with left lung disease according to time and position


position changes had a significant effect on oxygenation in mechanically

ventilated patients

A hierarchy of body positioning alternatives is based on the physiologic justification of the various positions.

These positions range from the most to the least physiologic.

The improvement in arterial blood gases depends The improvement in arterial blood gases depends on site and extent of lung pathologyon site and extent of lung pathology

NormalNormal

lungslungs

BilateralBilateral

diseasedisease

UnilateralUnilateral

diseasedisease

ABG are improved in all positions ABG are improved in all positions

The best position is prone The best position is prone

The subsequent are right and then leftThe subsequent are right and then left

The same improvement in duration andThe same improvement in duration and

frequency but less than in normal lungfrequency but less than in normal lung

Are improved with the good lung down Are improved with the good lung down

Are worsened with the affected lung downAre worsened with the affected lung down

In bothIn both

Healthy

lungs

Diseased lungs

Prone and side lying positions enhance

the efficiency of O2 transport

and thereby minimize or avoid use of high

concentration of supplemental oxygen

and positive end expiratory pressure.

body positioning isbody positioning is

a 24-hours concerna 24-hours concern

For any For any critically ill critically ill

patientpatient

Patients with normal Patients with normal lungs and patients with lungs and patients with bilateral lung diseasebilateral lung disease

Turn

Left

1.5 hr

Prone

1.5 hrRight

1.5 hr Supine

1.5 hr

Patients with right lateral Patients with right lateral lung diseaselung disease

Turn

Left

1.5 hr

Prone

1.5 hr Right

0.5hr

Supine

1.5 hr

patients with left lateral patients with left lateral lung diseaselung disease

Turn

Prone

1.5 hr Right

1.5 hr Supine

1.5 hr

No left

Position change is aPosition change is a simple simple way to reduce shunting and way to reduce shunting and improve oxygenation improve oxygenation

It allows reduction in FIOIt allows reduction in FIO2 2

and PEEP and reducing their and PEEP and reducing their complicationscomplications

*do your patients

a good turn

*Try the position

changes early in

the course of

illness

*do your patients

a good turn

*Try the position

changes early in

the course of

illness Turning a critically ill Turning a critically ill patients is not difficult. It patients is not difficult. It requires four trained nursesrequires four trained nurses

More studies are neededto evaluate

Using

larger

sample

Frequent Frequent

cyclescycles

using

different

duration

Steep position

Other range Other range of positionsof positions

Hospital

administration

Schools of

nursing

CriticalCritical

care unitscare units

*pre-service*pre-service training programs training programs (for newly critical care nurses)(for newly critical care nurses)*in-service*in-service training programs training programs

(for already critical care nurses) (for already critical care nurses)

Books and scientific magazinesBooks and scientific magazines

The care of critically ill patients The care of critically ill patients in their programsin their programs

TurnTurn TurnTurn

TurnTurn TurnTurn

effect of position change on oxygenation and respiratory mechanics in mechanically ventilated...

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