Teaching powerpoint number 2. Please review how continuous lateral rotation is beneficial to our sickedrst

2. The Importance of Positioning
The upright position is essential to maximize lung volume, flow rates, and VQ matching in gas
exchange. This position is the only means of optimizing fluid shifts such that circulating blood
volume and volume regulating mechanisms are maintained.
Lungs in good health The next best position is
obtain the best match sitting straight upright.
when the body is standing (Bryant et al 1965; West 1985)
upright

3. I Schematic of gas exchange at the alveolar AV interface
If there is an imbalance in distribution perfusion, you
have a VQ mismatch
VQ matching is influenced by body position, gravity and
lung injury

4. What can we do for the critically ill patient?
Conventional treatment is to turn side to side but
what can we do when they are too
hemodynamically unstable to tolerate turning?
Leaving them supine is not the answer.

5. In the stationary supine position, 17% of the lung rests beneath
the compressing forces of the heart. This results in a more
positive pleural pressure resulting in alveolar collapse.
Schematic
representation
of a CT scan
obtained in the
supine position.
( Malbouisson, 2000)
White area is the lung lower lobe Gray area is the lung lower
tissue not compressed by the heart lobe tissue compressed by
the heart
If the heart is enlarged, up to 37% of the lungs might be affected by these
forces. ( Malbouisson, 2000)

6. Effect of Abdominal Contents on the Ventilated Patient
In the healthy person in the
supine position, the diaphragm
acts as a barrier to the pressure
exerted by abdominal
contents, preventing interference
with air distribution in the
dependent segments of the lung.
Abdominal contents exert a
significant amount of pressure on
the diaphragm when the patient is
supine, sedated, ventilated and
mechanically ventilated.
This adversely affects FRC and
contributes to shunt. The larger the
abdomen, the greater negative
effect on ventilation.
( Froese & Bryant 1974) Xray of abdominal distention

7. The Primary Function of the Lung is Gas Exchange
Gas exchange occurs in
the AV capillary
membrane by diffusion.
Four factors maintain the
physiological balance:
1. Capillary hydrostatic
pressure-mechanical force
of fluid pushing against
the cellular membranes.
2. Capillary oncotic
pressure-Osmotic effect
that holds fluid in the
capillary.
3. Capillary permeability.
4. Surfactant lining the
alveoli which repels water
preventing fluid from
entering the alveoli.
(Kubo, A. 2008)

8. Pathophysiology of Acute Lung Injury
Diffuse non-uniform structural damage to the AC membrane causes
severe pulmonary edema, shunting and hypoxemia. A massive
inflammatory response is caused by chemical mediators. In ALI and
ARDs, this response is amplified
The AC membrane becomes
permeable resulting in an influx of
fluid, proteins and blood cells from
the capillary bed into the
alveoli, resulting in pulmonary
edema.
These chemical mediators also
damage the alveolar endothelium
where surfactant is produced.
Without surfactant, the alveoli
collapse causing atelectasis The
lungs lose compliance and
ventilation decreases due to
atelectasis. The resulting right to
left shunt results in unoxygenated
blood returning to the left
heart, worsening hypoxemia.

9. The P/F ratio is a measure of intrapulmonary shunting, and is
obtained by comparing arterial to inspired oxygen. This
value can be calculated by dividing the arterial oxygen
tension ( PO2) by the fraction of inspired oxygen (FIO2)
Example: PO2 90/ FIO2 .40= 225 (Oh Oh! )
Don’t forget the decimal in the FIO2 when doing the
calculation.
The values for ALI and ARDs are as follows:
Acute lung injury P/F<300
Acute respiratory distress P/F<200

10. The S/F ratio is a correlation to the P/F ratio and is
calculated using the O2 Sat instead of the PO2.
EPIC calculates and records the S/F ratio .
The values are a little different:
Acute lung injury S/F Ratio <315
Acute Respiratory Distress S/F Ratio<235
S/F ratios are a reasonable correlate to identify early ALI
and ARDs
(Rice et al, 2009)

11. Principals of CLRT
It’s easier to prevent atelectasis and maintain functional residual capacity than to try to
restore alveolar patency. CLRT continuously moves one lung over the other, causing
extravasation of lung water, mobilizing secretions and decreasing the risk of alveolar
collapse. The movement from side to side maintains a higher FRC in the mechanically
ventilated patient and so CLRT is able to influence the amount of pressure necessary to
open collapsed alveoli.
(Kubo, 2008)
CLRT rotation puts the “good” lung in a
dependent position to optimize gas exchange
and improve oxygenation.
When the “bad” lung is down, there is a slow
but steady recruitment of collapsed alveoli as
secretions begin to mobilize, occurring as
rotation moves the body in a slow steady arc .
Published practice guidelines recommend
rotating at an 80 to 100% arc (This translates
to 35-40 degrees to each side) at a setting of 8
to 10 rotations an hour, for a total of 18 hours
out of 24 for the full benefit, These
recommendations are based on several
research studies.
(Vollman, 2004)

12. Unstable spinal cord injury
Increased intracranial pressure
Long bone fractures with traction
Draining ventriculostomy
Possibly CVVHD (depending on access)
Open abdominal wound
Palliative care

13. FIO2 > 0.50
PEEP > 8
P/F Ratio S/F Ratio
ALI < 300 ALI <315
ARDS <200 ARDS <235
Lobar collapse, atelectasis, excessive secretions
Hemodynamic instability with manual turning
Decreased mental status
Increased sedation or paralytics needed to ventilate
Progressing to maximum ventilatory support
Requiring the use of nitric or epoprostenol
Oscillator vent

14. CLRT to Upright Mobility Protocol

15. Initiate within 24 hours of intubation. Assess vital
signs, ECG, and SPO2 for 2 complete rotations and for
every change in rotation after a 5 minute equilibrium
period.
Rotate at 80-100%, 10-12 cycles per hour for a target
of 18 hours per day.
Adjust by increasing the pause times before decreasing
the rotation angle.
Increase rotation angle by using the training mode.
This increases rotation by 10% every hour.
Insure that sedation is adequate.

16. Stop rotation and assess the skin every 4 hours and
offload pressure areas with pillows. Return to rotation
when redness subsides. Don’t rotate with pillows
propped beneath back.
Check ABGs with the patient stopped at center.
Documentation
Percent of rotation
Hours rotated per day
Pulmonary assessment
ABGs
P/F ratio or S/F ratio
Chest Xray results

17. Change in B/P or other hemodynamic parameters:
Assess filling pressures ( CVP, PP variation) to
determine if a fluid bolus is needed.
Assess vasodilatory problems: sepsis, neurogenic shock
pattern, low diastolic pressure and/or SVR, SVRi ( if
available) for adequacy of pressor support.
Assess adequacy of inotropic support ( HR, CO if
available, mixed venous sat)
Remember: Changes in hemodynamics during
rotation are due to alterations in the
determinants of cardiac output and NOT due to
the rotation
( Washington & MacNee, 2005)

18. Changes in SpO2
Adjust pause times so that the pause is shortened on
the side where the desaturation occurs.
Suction more frequently. Rotation mobilizes
secretions.
Make certain the pleth reading is accurate.
Assess the level of desaturation when the bad lung is
down. Consult with a physician to determine what
level of desaturation is acceptable.
Remember: With rotation, shunt should decrease and
saturation levels should improve.
( Washington, 2005)

19. Improves vital capacity and functional residual
capacity. Increases spontaneous tidal volumes, and
decreases the pressure on the diaphragm exerted by
abdominal contents.
Reconditions impaired baroreceptor responses to
changes in volume status, decreasing orthostatic
stress.
Raise the head of the bed 45 degrees twice a day at
9AM and 9PM. Correlate it with the morning wake up
and evening assessment.
Remember to decrease the sedation if tolerated after
morning wake-ups. Maintain a Riker score of 3 to 4.
Decreasing sedation will improve mobility outcomes.

20. Improved Chest Xray
Improved ABGs
Improvement in P/F Ratio or S/F Ratio
Patient able to move and turn self
Sedatives decreased
At this point, the patient is ready to advance
to progressive upright mobility

21. Anzueto et al, Critical Care Medicine;1997
12 healthy baboons were randomized to CLRT or control for 11 days. Mechanically
ventilated, sedated and paralyzed with supportive care. Studies done were
xrays, cultures, BAL samples, oxygenation indices, pulmonary function and
lung volumes.
Results: Day 7 the control group showed patchy atelectasis; day 11 2two animals
showedpersistent Xray abnormalities;BAL on days 7&11 showed large WBC
increases;Lung pathology showed bronchiolitiswith 5 of the 7 subjects
developing bronchopneumonia.
Ahrens et al, AJCC 2004
Multicenter study that included 255 patients with a PF ratio < 250, GCS <11 and
mechanically ventilated.
Results: VAP and atelectasis were markedly reduced in CLRT patients within 5 days and the
PF ratio had improved within 2 days.
Kirschenbaum et al, Critical Care Medicine (2002)
37 vent dependent MICU patients, randomized to CLRT and control.
Results: 17.6% of CLRT group developed pneumonia compared with 50% of the control
group,

22. Choi& Nelson, Journal of Critical care (1992)
Meta-analysis of 6 studies involving 419 patients.
Results: Significant reduction in incidence of pneumonia and atelectasis with CLRT.
Significant reduction in ventilator time and LOS in ICU with CLRT.
Goldhill, AJCC (2007)
Meta-analysis of 35 studies between 1987-2004. Found that rotational therapy decreased
the incidence of pneumonia but had no effect on duration of mechanical ventilation,
LOS in ICU or hospital mortality. Conclusion: Rotational therapy is useful in
preventing and treating respiratory complications but inconclusive on which rotation
parameters are most effective. The author notes that rotational parameters and time
of rotation were inconsistent from study to study, or not reported.
Raoof et al, Chest ( 1999)
24 MICU patients with atelectasis were assigned to either rotation or manual turning
every 2 hours.
Results: 82.3% of the rotation group had resolution of atelectasis vs 14.3% of the control
group with manual turning.

23. Feegler et al, Research Dimension (2009)
Prospective trial with patients meeting CLRT criteria started on rotation within 24 hours
of intubation. Control segment looked at retrospective patients who had met the
criteria in the previous year.
Results: The first phase of the study looked at early initiation of CLRT and found that
ventilator days were decreased by 2.2 days and average hospital LOS was decreased
by 3.6 days in the CLRT group when compared to the control group. The second phase
looked at delayed placement on CLRT (within 5 days of ventilation) and found that
early placement on CLRT significantly reduced ventilator days, ICU LOS and hospital
LOS in the 2 CLRT groups.
Staudinger et al, Critical Care medicine (2010)
Prospective randomized clinical study. 150 ventilated patients were randomized to CLRT
or standard care if ventilated < 48 hours and free of pneumonia.
Results: CLRT patients had reduction in ventilator time ( 8 days VS 14) decreased LOS (25
days vs 45 days) and decreased rated of VAP, though not statistically significant—12 in
the rotation group vs 23 in the control group (p=.08)

25. CLRT has been shown to decrease rates of
VAP, shorten ventilator days and decrease both
ICU and hospital lengths of stay.
CLRT is a therapy that allows recruitment of
collapsed alveoli and improves oxygenation by
mobilizing secretions and decreasing VQ
mismatch.
MICU has 24 CLRT beds . A situation unmatched
by any ICU in the area.
So lets get our patients rotating! One good turn
deserves another!

26. Ahrens, T, Kollef, M, Stewart, J, Shannon, W.
Effect of kinetic therapy on pulmonary complications. Am. Journal of Critical Care. (2004)
13:376-383
Bryan, AG, Bentivoglio, LG, Beerel, F, MacLeish, M, Zidulkia, A, Bates, DV.
Factors affecting regional distribution of ventilation and perfusion in the lung. Journal
Applied Physiology (1964) 19:395-402
Froese, A, Bryan, AC. Effects of anesthesia and paralytics on diaphragmatic mechanics in
man. Anesthesiology (1974) 41: 242-55
Kubo, A. Progressive Mobility in the ICU: Self Directed Study, University of Kansas
Hospital, 2008
Malbouisson, LM, Busch, CJ, Puybassert, L, Cluzel, P, Rouby, JJ.
Role of the heart in the loss of aeration characterizing lower lobes in acute respiratory
distress syndrome. American Journal of respiratory Critical care (2000) 161-2005-12
Rice, T, Wheeler, A, Bernard, G, Hayden, D, Schoenfeld, D, Ware, L.
Comparison of the Spo2/Fio2 ratio and the Pao2/Fio2 ratio in patients with acute lung
injury or ARDS. Chest (2007) 132:410-17
Vollman, K. The right position at the right time; mobility makes a difference
Intensive and Critical Care Nursing (2004) 20: 179-82
Washington, G, Macnee, C. Evaluation of outcomes: the effects of continuous lateral
rotation therapy. Journal of Nursing Care Quality (2005) 20(3): 273-282