K Grigoriadis, I Efstathiou, I Petrianos, D Bakalidou, A Armaganidis, G Vasileiadis
K Grigoriadis, I Efstathiou, I Petrianos, D Bakalidou, A Armaganidis, G Vasileiadis. Improvement Of Patient’s Ventilation By Correcting The Slid Recumbent Position In The ICU. The Internet Journal of Rehabilitation. 2009 Volume 1 Number 1.
Until today the proper positioning of the patient in bed was restricted in the elevation of the back of his bed. The fact of the patient’s sliding requires to count in the newly acquired posture in bed while evaluating the respiratory capacity. There is a statistical correlation (r= 0.656) in the mean
The correct positioning of the patient in bed is essential during the whole period of his hospitalization1.
Regarding the rehabilitation of the respiratory system, the acquisition of proper position will help in the removal of the bronchial secretion, in the good functioning of the diaphragm and in better pulmonary aeration. In the past decades the medical literature has established some undeniable rules 2, 3.
In order that the patient in the ICU avoids the intubation or recover his own breathing capacity (after being on mechanical respiration), he has to maximize his tidal volume. According to the current bibliography the patient must be placed in supine position with the upper part of the body at 30 o– 45o for optimal ventilation 4.
In current bibliography the missing element is the determination of the distance between patient’s coccyx and the hinge of the bed that will permit full expansion of the thoracic cavity. The purpose of this study is to calculate this distance in the patients of the ICU.
Material and methods
All patients who composed the study sample were ICU patients of “Attikon” University Hospital in Athens.
Their identification was based on their primary bed position. The distance between the hinge of the bed and patient’s greater trochanter was obviously big. They had their own breathing capacity while they were supported by a mixture of air with 35 to 45% O2. They had been stable without receiving any medical treatment for their respiratory system for the last 3 hours before the measurements. Blood PO2 was collected from the radial artery and verified by a second measurement after 15 min. A Premium type 3000 analyzer was used.
In case that the measurements differed more than 5% between the first measurement and the second, the patient was considered respiratory instable and was excluded from the study.
After repositioning the patient and a lapse of 15min we repeated the procedure of blood collection-analysis.
The following parameters were studied:
α PO2, α S α* PO2 β ΡO2, β S
α = measurements while in the slid position
α*= verification of measurements while in the slid position
β = measurements in the corrected position
47 patients were enrolled in the study. After the second measurement 40 were considered respiratory stable and preceded to next phase of the study.
According to their PO2 improvement after the repositioning, they were placed in one of the following groups: (Table 1)
Group A Mean PO2 improvement (ΔPO2) of 16.15 +/- 4.8 mmHg. The repositioning was ΔS (β S- α S) = 17.7 +/- 3 cm (n = 19).
Group B PO2 remained practically the same (ΔPO2 = 0.09 +/- 0.94 mmHg) with ΔS= 11.63 +/- 3 cm (n= 10).
Apart from the abovementioned groups, a third one was created, Group C, which encompassed all cases in which after the repositioning, the greater trochanter was found in a higher place than the hinge of the bed. This newly aqcuired position was arbitrary called “overcorrection position”. (Figure 2)
Group C Mean PO2 negatively changed (ΔPO2= -10.3 +/- 4.32 mmHg). The repositioning lead to overcorrection of the patients’ position (n= 11).
On a scatter plot groups A and B present a possible correlation between ΔPO2 and ΔS of the patient. The correlation coefficient r for these two groups of values is 0.656. This value demonstrates that these two parameters are highly correlated. (Graph 1)
It is extremely important that the patient in the ICU keeps a high PO2 during the whole period of his hospitalization. One way to achieve this is by correcting patient’s slid on bed.
In our study patients of group A that had been repositioned ΔS= 17.7 +/- 3 cm, displayed an important improvement in their PO2 (ΔPO2 = 16.15 +/- 4.8 mmHg). This may be attributed to the correction of the thoracic kyphosis which leads to better lungs’ expansion and occurs when the patient’s body is better aligned with the two parts of the bed (ie. the hinge of the bed is in contact with patient’s coccyx).
In patients of group B that the repositioning was ΔS= 11.63 +/- 3 cm, the overall effect on patient’s respiration was negligible (ΔPO2= 0.09 +/- 0.94 mmHg). In these patients the sliding didn’t cause any important change in lung volume, so the repositioning didn’t alter the blood gases.
Finally in patients of group C the negative change in PO2 (ΔPO2 = -10.3 +/- 4.32 mmHg) leads us to hypothesize that the newly acquired position makes it difficult for the lungs to expand. Probably the forward tilt of the pelvis increases the muscle tension of the abdominal muscles which in turn increases the work of the diaphragm and intercostal muscles during inspiration. This hypothesis needs further investigation in the future. (Graph 2)
Our findings suggest that it is important to correct the position of patients in the ICU that had slid for a big distance. The profit in blood PO2 from the repositioning is substantial. (In one patient it reached 21.3 mmHg.) This correction in PO2 level is extremely crucial for the ICU patients especially for those trying to wean from mechanical respiration5, 6.
On the other hand in case that the sliding is small (<14 cm), the repositioning doesn’t have a great impact on patient’s PO2. (Graph 3)
Finally, a third observation is that overcorrection of the patient’s position, which will lead to the forward tilt of the pelvis, will have a negative impact on PO2. This deterioration will probably lead to a new intubation.