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  • The Internet Journal of Rehabilitation
  • Volume 1
  • Number 1

Original Article

Improvement Of Patient’s Ventilation By Correcting The Slid Recumbent Position In The ICU

K Grigoriadis, I Efstathiou, I Petrianos, D Bakalidou, A Armaganidis, G Vasileiadis

Citation

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.

Abstract

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 PO2, (partial oxygen pressure), improvement (ΔPO2= 16.15 +/- 4.8 mmHg) when the repositioning is greater than 14 cm. In case that the sliding is smaller, the overall effect on patient’s respiration is negligible. On the contrary if there is overcorrection with the coccyx over the hinge of the bed, there is a negative result in PO2 (ΔPO2= -10.3 +/- 4.32 mmHg), extremely crucial for the patients of the Intensive Care Unit (ICU).

 

lntroduction

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.

Eligibility criteria

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.

Exclusion criteria

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

(Figure 1)

Figure 1
Figure 1. Correction of patient’s slid 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.

Results

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).

Figure 2
Figure 2. The overcorrection of the patients’ position.

Figure 3
Table 1. Grouping of patients according to their ΔPO according to their PO after the repositioning .

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)

Figure 4
Graph 1. This graph shows the PO improvement (ΔPO) in relation to the repositioning of the patients (β S- α S).

Discussion

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)

Figure 5
Graph 2. The different values of ΔPO are depicted in the graph as well as their Standard Deviation.

Conclusion

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)

Figure 6
Graph 3. All patients that their position was overcorrected had a negative ΔPO.

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.

References

1. Grap MJ, Munro CL, Bryant S, Ashtiani B.
Predictors of backrest elevation in critical care.
Intensive Crit Care Nurs. 2003 Apr;19(2):68-74.
PMID: 12706732 [PubMed - indexed for MEDLINE]
2. Grap MJ, Munro CL, Hummel RS 3rd, Elswick RK Jr, McKinney JL, Sessler CN.
Effect of backrest elevation on the development of ventilator-associated pneumonia.
Am J Crit Care. 2005 Jul;14(4):325-32; quiz 333.
PMID: 15980424 [PubMed - indexed for MEDLINE]
3. Vila B, Servera E, Marín J, Díaz J, Giménez M, Komaroff E, Bach J.
Non-invasive ventilatory assistance during exercise for patients with kyphoscoliosis: a pilot study.
Am J Phys Med Rehabil. 2007 Aug;86(8):672-7.
PMID: 17667198 [PubMed - indexed for MEDLINE]
4. Buyse B, Meersseman W, Demedts M.
Treatment of chronic respiratory failure in kyphoscoliosis: oxygen or ventilation?
Eur Respir J. 2003 Sep;22(3):525-8.
PMID: 14516146 [PubMed - indexed for MEDLINE]
5. Wang C, Shang M, Huang K, Tong Z, Kong W, Jiang C, Dai H, Zhang H, Weng X.
Sequential non-invasive mechanical ventilation following short-term invasive mechanical ventilation in COPD induced hypercapnic respiratory failure.
Chin Med J (Engl). 2003 Jan;116(1):39-43.
6. Collaborating Research Group for Non-invasive Mechanical Ventilation of Chinese Respiratory Society.
Pulmonary infection control window in treatment of severe respiratory failure of chronic obstructive pulmonary diseases: a prospective, randomized controlled, multi-centred study.
Chin Med J (Engl). 2005 Oct 5;118(19):1589-94.

Author Information

K. Grigoriadis, PT
Department of Physical and Rehabilitation Medicine, “Attikon” University Hospital

I. Efstathiou, PT
Department of Physical and Rehabilitation Medicine, “Attikon” University Hospital

I. Petrianos, PT
Department of Physical and Rehabilitation Medicine, “Attikon” University Hospital

D. Bakalidou, PT, MSc
A-TEI

A. Armaganidis, MD, PhD
Prof., Intensive Care Unit, “Attikon” University Hospital

G.I. Vasileiadis, MD, PhD
Department of Physical and Rehabilitation Medicine, “Attikon” University Hospital

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