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Guidelines and recommendations

Anaesthesist2015 [Suppl 1] 64:S1S26 Th.Bein1 M.Bischoff1 U.Brckner2 K.Gebhardt1 D.Henzler3 C.Hermes4

DOI 10.1007/s00101-015-0071-1 K.Lewandowski5 M.Max6 M.Nothacker7 Th.Staudinger8 M.Tryba9
Published online: 3 September 2015
S.Weber-Carstens10 H.Wrigge11
The Author(s) 2015. This article is published 1Clinic for Anaesthesiology, University Hospital Regensburg, Regensburg, Germany
with open access at
2Physiotherapy Department, Clinic Donaustauf, Centre for Pneumology, Donaustauf, Germany

3Clinic for Anaesthesiology, Surgical Intensive Care Medicine, Emergency Care Medicine,

Pain Management, Klinikum Herford, Herford, Germany

4HELIOS Clinic Siegburg, Siegburg, Germany

5Clinic for Anaesthesiology, Intensive Care Medicine and Pain Management,

Elisabeth Hospital Essen, Essen, Germany

6Centre Hospitalier, Soins Intensifs Polyvalents, Luxembourg, Luxemburg

7Association of Scientific Medical Societies (AWMF), Marburg, Germany

8University Hospital for Internal Medicine I, Medical University of Wien,

General Hospital of Vienna, Vienna, Austria

9Clinic for Anaesthesiology, Intensive Care Medicine and Pain Management,

Klinikum Kassel, Kassel, Germany

10Clinic for Anaesthesiology and Surgical Intensive Care Medicine, Charit Universittsmedizin Berlin,

Campus Virchow Klinikum, Berlin, Germany

11Clinic and Policlinic for Anaesthesiology and Intensive Care Medicine,

University Hospital Leipzig, Leipzig, Germany

S2e guideline: positioning

and early mobilisation in
prophylaxis or therapy of
pulmonary disorders
Revision 2015: S2e guideline of the
German Society of Anaesthesiology
and Intensive Care Medicine (DGAI)

line was expanded to include the topic ar- cific situations. They are based on the
Preface ea early mobilisation. current state of scientific knowledge
Guidelines are systematically devel- and on procedures proven in practice.
The order to revise the S2 guideline posi- oped presentations and recommenda- 55Positioning and early mobilisation
tioning in prophylaxis or therapy of pul- tions with the purpose of assisting physi- are supporting concepts in the treat-
monary disorders, which was established cians and patients in deciding on appro- ment and prophylaxis of pulmonary
in 2008, was issued by the German So- priate measures for medical care (preven- disorders, wherein they are intend-
ciety for Anaesthesiology and Intensive tion, diagnostics, therapy and after care) ed to supplement basic medical mea-
Care Medicine (DGAI). Due to increasing under specific medical conditions. (As- sures (e.g. mechanical ventilation, flu-
clinical and scientific relevance, the guide- sociation of Scientific Medical Societies, id management, pharmacotherapy),
AWMF). but not to replace them.
The guideline is based on the following 55There is no single ideal position for
First published in German language in: Bein T, fundamental assumptions: all pulmonary disorders; rather the
Bischoff M, Brckner U et al. (2015) S2e-Leitli- 55Guidelines for use in positioning positioning plan must be customised
nie: Lagerungstherapie und Frhmobilisation
zur Prophylaxe oder Therapie von pulmona- therapy and early mobilisation in pro- individually to the circumstances sur-
len Funktionsstrungen. Revision 2015. Ansth phylaxis or therapy of pulmonary dis- rounding a patient and condition.
Intensivmed 56:428458 orders aid in decision-making in spe-

Der Anaesthesist Suppl 1 2015 | S1

Guidelines and recommendations

55A sharp distinction of the indica- 55Begin: within a week after an acute ry, severe lung injury, atelectasis,
tion prophylaxis versus therapy is incident or recently occurred or wors- shock lung, acute respiratory fail-
not possible for all eligible pulmo- ened symptoms ure, postoperative respiratory fail-
nary disorders. As in other therapeu- 55Imaging (X-ray or computed tomog- ure, lung failure, lung insufficien-
tic fields, there is frequently a smooth raphy (CT) scan of chest): bilateral in- cy, respiratory failure, respirat-
transition between prophylaxis , ear- filtrations that cannot be explained ory insufficiency, ventilator-associ
ly treatment and therapy. alone by effusion, pneumothorax or ated/induced lung injury, ventila-
55On the basis of the present guideline, nodules tor-associated/induced pneumo-
the majority of patients with pulmo- 55Cause of the oedema: respirato- nia, prevention/prophylaxis pneu-
nary disorders should respond well to ry distress cannot be explained alone monia.
therapy in conjunction with a whole through acute heart failure or volume zzHospital infections: cross infec-
therapeutic plan. overload (in the case of a lack of risk tion, nosocomial infection, hospi-
55Effective teamwork, the introduc- factors, the presence of hydrostatic tal infection.
tion of practical algorithms and prop- oedema by means of echocardiogram zzVentilated patients, intensive care
er management of emergency situa- must not be precluded) patients: critically ill, critical illness,
tions are the requirement for the safe 55Oxygenation: three degrees of severi- catastrophic illness, critical care,
implementation of positioning meth- ty are differentiated intensive care, intensive care unit
ods and, in particular, for early mo- 55mild: partial arterial pressure of ox- (ICU), respiratory care units, arti-
bilisation. In doing so, the integra- ygen (PaO2)/fractional inspiratory ficial respiration, mechanical ven-
tion of these concepts into everyday concentration of oxygen (FIO2)=200 tilation.
work procedures will lead to a routine 299mmHg and positive end-expira- zzPositioning: prone position, su-
course of action and increased expe- tory pressure (PEEP)/continuous pos- pine position, lateral position, sit-
rience. itive airway pressure (CPAP)5cm ting/semi-seated position, horizon-
55The use of positioning and early mo- H2O tal position, semi-recumbent po-
bilisation throughout the duration of 55moderate: PaO2/FIO2=100 sition, positioning, rotation, body
therapy requires the continual critical 199mmHg and PEEP5cm H2O position, patient positioning, po-
review of the indication and customi- 55severe: PaO2/FIO2100mmHg and sitioning therapy, kinetic therapy,
sation to the individual progression of PEEP5cm H2O. continuous lateral rotation, back-
the disease. rest elevation, axial/body position
55Objectives and methods of the treat- All statements in the existing guideline change, facedown position, side po-
ment plan must be presented in a were revised and the formulations were sition, posture.
transparent manner for all involved adapted pursuant to the Berlin definition. zzEarly mobilisation: early ambula-
(physicians, caregivers, physical ther- tion, accelerated ambulation, oc-
apists, relatives and, to the extent pos- Preparation process cupational therapy, physical thera-
sible, the patient). py, mobility therapy, exercise ther-
This guideline is the result of systemat- apy, early mobilisation, early exer-
Guideline topics ic literary research as well as the subse- cise, early activity, physical therapy
quent critical evaluation of evidence us- modalities.
The guideline refers to the following top- ing scientific methods. The methodical 2. Systematic research of scientific litera-
ics of focus: approach of the guideline development ture (University Library Regensburg),
55The use of positioning and early mo- process corresponds to the requirements but also previously available guide-
bilisation in prophylaxis of pulmo- for evidence-based medicine as they were lines, recommendations and expert
nary disorders. defined by the AWMF as a standard. With opinions.
55The use of positioning and early mo- respect to positioning, recently published 3. The evaluation of these publications
bilisation in treating pulmonary dis- papers were studied starting in 2005; the according to the evidence criteria of
orders. newly incorporated aspect of early mobil- the Oxford Centre for Evidence-based
55Undesired effects and complications isation comprises all previously published Medicine (levels of evidence, www.
of positioning and early mobilisation. literature up to and including 06/2014., as of 2001). Due to the fact
55Practical aspects when using posi- The guideline was prepared in the fol- that the guideline is a revision and not
tioning and early mobilisation. lowing steps: a new development, this schema was
1. Definition of the search terms for all also applied.
The statements made in the guideline topics of focus and determination of 4. Consensus process
with respect to acute respiratory distress the relevant databases:
syndrome (ARDS) refer to the Berlin def- zzPulmonary disorders: (adult; The first author of the guideline was em-
inition [90]. This includes the following acute) respiratory distress syn- ployed as a speaker and commissioned by
criteria for the diagnosis of ARDS: drome/ARDS, acute lung inju- the DGAI committee to designate addi-

S2 | Der Anaesthesist Suppl 1 2015

Abstract Zusammenfassung

tional participants of the guideline group. Anaesthesist2015 [Suppl 1] 64:S1S26 DOI 10.1007/s00101-015-0071-1
In two consensus conferences as well as The Author(s) 2015. This article is published with open access at
during two telephone conferences, the
Th.Bein M.Bischoff U.Brckner K.Gebhardt D.Henzler C.Hermes K.Lewandowski
core statements and recommendations
M.Max M.Nothacker Th.Staudinger M.Tryba S.Weber-Carstens H.Wrigge
were coordinated with the entire guide-
line group under the direction of a mod- S2e guideline: positioning and early mobilisation
erator from AWMF by means of a nom- in prophylaxis or therapy of pulmonary disorders.
inal group process. The individual steps Revision 2015: S2e guideline of the German Society of
were recorded in entirety and editorial- Anaesthesiology and Intensive Care Medicine (DGAI)
ly prepared by the speaker of the guide- Abstract
line group together with Dr. M. Bischoff The German Society of Anesthesiology and evidence with scientific methods. The meth-
and Ms. K. Gebhardt. The guideline was Intensive Care Medicine (DGAI) commissione- odological approach for the process of de-
adopted by the DGAI committee on 30 da revision of the S2 guidelines on position- velopment of the guidelines followed the re-
April 2015. ing therapy for prophylaxis or therapy of pul- quirements of evidence-based medicine, as
monary function disorders from 2008. Be- defined as the standard by the Association of
cause of the increasing clinical and scientifi- the Scientific Medical Societies in Germany.
Members of the guideline group crelevance the guidelines were extended to Recently published articles after 2005 were
include the issue of early mobilizationand examined with respect to positioning thera-
The guideline was coordinated by the the following main topics are therefore in- py and the recently accepted aspect of early
speaker of the group, Prof. Dr. Thomas cluded: use of positioning therapy and early- mobilization incorporates all literature pub-
Bein, Clinic for Anaesthesiology, Univer- mobilization for prophylaxis and therapy of lished up to June 2014.
pulmonary function disorders, undesired ef-
sity Hospital Regensburg. fects and complications of positioning ther- Keywords
Dr. Monika Nothacker, Association apy and early mobilization as well as practi- positioning therapy early mobilisation
of Scientific Medical Societies (AWMF), cal aspects of the use of positioning thera- prone position pulmonary disorder
Marburg assumed the methodological py and early mobilization. These guidelines backrest elevation continuous lateral
guidance of guideline development. are the result of a systematic literature search rotation
and the subsequent critical evaluation of the
The guideline group comprised the fol-
lowing members:
Dr. Melanie Bischoff (DGAI), Uta S2e-Leitlinie: Lagerungstherapie und Frhmobilisation zur
Brckner (German Association for Phys- Prophylaxe oder Therapie von pulmonalen Funktionsstrungen.
iotherapy), Kris Gebhardt (DGAI), Prof. Revision 2015: S2e-Leitlinie der Deutschen Gesellschaft
Dr. Dietrich Henzler (DGAI), Carsten fr Ansthesiologie und Intensivmedizin (DGAI)
Hermes (German Association for Special-
ised Nursing Care and Functional Servic- Zusammenfassung
Durch die Deutsche Gesellschaft fr Ans- wertungmit wissenschaftlichen Methoden.
es), Prof. Dr. Klaus Lewandowski (DGAI), thesiologie und Intensivmedizin (DGAI) wur- Das methodische Vorgehen des Leitlinienent-
Prof. Dr. Martin Max (DGAI), Prof. Dr. de der Auftrag erteilt, die seit 2008 bestehen- wicklungsprozesses entspricht den Anforde-
Thomas Staudinger (Austrian Association de S2-Leitlinie Lagerungstherapie zur Pro- rungen an die evidenzbasierte Medizin, wie
for Internal and General Intensive Care phylaxe oder Therapie von pulmonalen Funk- sie von der Arbeitsgemeinschaft der Wissen-
Medicine and Emergency Medicine), tionsstrungen zu revidieren. Aufgrund zu- schaftlichen Medizinischen Fachgesellschaf-
nehmender klinischer und wissenschaft- ten als Standard definiert wurden. Bezglich
Prof. Dr. Michael Tryba (DGAI), PD Dr.
licher Relevanz wurde die Leitlinie um den der Lagerungstherapie wurden neu publi-
Steffen Weber-Carstens (DGAI) and Prof. Themenkomplex Frhmobilisation erwei- zierte Arbeiten ab 2005 untersucht; der neu
Dr. Hermann Wrigge (DGAI). tert. Damit bezieht sie sich auf folgende the- aufgenommene Aspekt der Frhmobilisati-
matische Schwerpunkte: Einsatz von Lage- on umfasst die gesamte bisher publizierte Li-
Selection of literature rungstherapie und Frhmobilisation zur Pro- teratur bis einschlielich 06/2014. Der vorlie-
phylaxe pulmonalerFunktionsstrungen, Ein- gende Beitrag gibt die Kurzversion der Leitli-
satz von Lagerungstherapie und Frhmobili- nie wieder.
Extensive literary research was conduct-
sation zur Therapie pulmonaler Funktionsst-
ed by the speaker of the guideline group rungen, unerwnschte Wirkungen und Kom- Schlsselwrter
at the University Library of Regensburg plikationen von Lagerungstherapie und Frh- Lagerungstherapie Frhmobilisation
in collaboration with the director of the mobilisation sowie praktische Aspekte beim Bauchlagerung Pulmonale
medical section (Dr. Helge Knttel) based Einsatz von Lagerungstherapie und Frhmo- Funktionsstrung Oberkrper
bilisation. Diese Leitlinie ist das Ergebnis ei- Hochlagerung Kontinuierliche laterale
on preformulated keywords. The search
nersystematischen Literaturrecherche sowie Rotationstherapie
was conducted via the German Institute der anschlieenden kritischen Evidenzbe-
for Medical Documentation and Informa-
tion (DIMDI). This includes 40 extra da-
tabases in addition to Medline, Embase, All papers published in the databas- English-language publications were taken
Cochrane and SciSearch. es as of 17 May 2005 (final date of last re- into account. The literary search primar
search) were inspected. Only German or ily related to controlled studies, systemat-

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Guidelines and recommendations

Table 1 Characterisation of the literature ies were ultimately included and evaluat- cal assessment in a formal consensus pro-
used for the revision of the guideline ed based on the aforementioned evidence cess (nominal group process). Thus, the
Overviews/reviews 47 schema. In the course of subsequently essential findings extracted from litera-
Systematic reviews 25 designating 29 relevant publications as ture and assessed according to evidence
Meta-analyses 16 well as a guideline (editorial deadline: 31 are initially briefly outlined in the guide-
Randomised controlled studies 32 December 2014), ultimately 329 publica- lines. The recommendation statement in-
Cohort studies/controlled case 135 tions were analysed. Of these, 149 articles cluding the evaluation is then made. The
series were included in the final version of the grading of the recommendation is thus
Editorials 10 revision, which results in a total of 319 in- deducible and comprehensible from the
Case reports 13 cluding the 170 articles adopted from the previously presented and evaluated clin-
Experimental/animal experimental 6 first version (.Table1). ically scientific statements. Recommen-
publications dation classifications may deviate from
Expert opinions 23 Organisational and the evidence level if the guideline group
General overview 8 methodological process of the deems this necessary based on ethical or
Guidelines/recommendations 4 preparation of the guideline clinical aspects, the evaluation of side ef-
Total: 319 fects or clinically practical application, for
The preparation of the guideline was example in the case of cost/benefit con-
methodologically supported by Dr. Mon- siderations.
ic reviews, meta-analyses, case series, case ika Nothacker, AWMF. In two conferenc- Furthermore, strong recommenda-
reports and comments/editorials. The fo- es in June and November 2014 as well as tions for therapeutic forms or methods
cus was on publications involving adult during two telephone conferences in Jan- may be expressed, for which the available
patients. Articles from the paediatric field uary and March 2015, the core statements evidence is not sufficient, but which are
were only included if statements were rec- of the existing guideline were revised by indispensable for the clinical process. On
ognised that enabled principle and age-in- means of a nominal group process and the other hand, methods or therapeutic
dependent statements. Only studies con- recompiled with respect to early mobili- principles, for which a strong recommen-
ducted on humans were included. Papers sation. Roll call votes were not necessary dation would have to be expressed based
relating to animal experimentation were with regard to the preparation of the S2e; on the studies, may receive a low recom-
only evaluated if significant pathophysio- there were no potential influencing factors mendation grade due to their limited clin-
logical conclusions could be made regard- due to interests linked to industrial prod- ical importance. The reasons of such a de-
ing the functional principle of position- ucts or other matters. Literary research viating evaluation are mentioned in the
ing therapy. Articles from textbooks were and evaluation was prepared by the edito- text.
not used. Informational material from the rial team for the individual topics.
medical device industry was only used for Prone position in patients with
technical questions. Financing acute pulmonary disorders
Initially, the literature of the already
existing guideline was revised. Of the 287 Travel expenses within the scope consen- Definition of prone position
publications included in the analysis at the sus conferences and literary research were
time, only 170 articles were taken into con- financed through the German Anaesthe- The prone position implies the position-
sideration. A total of 117 articles (editori- siology Fund. Support was not provided ing of a patient by 180 from the supine
als, case reports and smaller studies) were from sponsors from the industry. position. An incomplete prone position
precluded after updating the data if new- means a position between approximately
er articles regarding the same subject mat- Evidence level and 135 and <180.
ter had been published. recommendation grading schema
Within the scope of research (May Rational of the prone position
2005May 2014), 7051 publications were The classification of the Oxford Centre
initially identified based on the search for Evidence-based Medicine (May 2001) The primary goal of the prone position in
terms. After viewing the abstracts, exclud- was the basis for the evidence level and patients with acute lung injury is to im-
ing duplicates and reviewing relevance, recommendation grading schema. It was prove pulmonary gas exchange. Addi-
952 publications were analysed at first. modified and adapted for use in Germa- tional goals are to prevent/reduce the lung
After reading the full texts, an addition- ny [226] (see .Tables2 and 3) damage and secretion mobilisation. This
al 653 studies were precluded due to lack- involves a significant therapeutic meth-
ing relevance or inadequate study design Explanation regarding od in addition to an optimised ventilation
(e.g. limited case numbers, probability for recommendations strategy [33, 62, 127, 163, 275] (evidence
bias statistical deficiencies) or lack of ref- level 1a).
erence (experimental animal studies, pae- Recommendations are classified based
diatric patients). In the analysis, 299 stud- on the best-available evidence and clini-

S4 | Der Anaesthesist Suppl 1 2015

Table 2 Evidence level schema device are not changed [1, 2, 8, 33, 36, 54,
Source of evidence Level 91, 96, 100, 105, 123, 125, 146, 167, 171, 175,
Methodologically suitable meta-analysis/analyses from RCTs 1a 177, 185, 204, 225, 245, 261, 266, 271, 273
Suitable RCT(s) with a small confidence interval 1b 275, 280, 288, 302, 307] (evidence level 1a).
Well-designed controlled trial(s) without randomisation 2a Not all patients experience an acute im-
Controlled cohort trial(s), RCT(s) of an unlimited method 2b provement of oxygenation in the prone
Uncontrolled cohort trial(s), case control trial(s) 3 position; the rate of nonresponsiveness
Expert opinion(s), editorial(s), case reports(s) 4 (absence of an increase in oxygenation
RCT randomised controlled trial. by >20% of the initial value for sever-
al hours after situation in the prone po-
sition) is not systematically studied. The
Table 3 Schema for grading recommendations underlying disease, the time of onset and
Evidence level Recommendation classification Recommendation grade the type of application (length of time in
1a, 1b Strong recommendation A prone position, positioning intervals) are
of primary importance of great significance for the effect (see be-
2a, 2b Moderate recommendation B low) [297]. Some patients experience in-
of secondary importance creased CO2 elimination during ventila-
3, 4 Low recommendation, minimal clinical impor- 0 tion in the prone position if the settings of
the ventilation device remain unchanged,
possibly as an expression of a recruitment
Physiological fundamentals: Regarding (b): The prone position [106, 124, 236] (evidence level 3).
effects of the prone position leads to a homogenisation of pulmonary
gas dispersion in healthy lungs [215] as Effect of the prone position
The significant physiological effects of the well as in the case of acute respiratory in- on the duration of ventilation,
prone position are: (a) changes of the re- sufficiency [102, 124, 204, 298] and pul- incidence of pneumonia, length
spiratory mechanics, (b) the reduction of monary perfusion [147, 216, 252] and thus of hospitalisation and mortality
the pleural pressure gradient [126, 127, improves the overall ventilation/perfusion
166, 183, 206, 227] and (c) the reduction of ratio [166, 203, 216, 225] (evidence level In two broad studies from multiple cen-
tidal hyperinflation [62] as well as the ven- 2b). In some ventilated patients with an tres, daily prone positioning (approxi-
tilation induced lung injury (stress and acute limitation of the pulmonary gas ex- mately 8h for 510 days) did not lead to
strain) [193]. They may lead to the ho- change, the prone position may cause an a significantly shorter ventilation peri-
mogenisation of pulmonary gas exchange increase of gas exchanging lung tissue (re- od or to a survival advantage in patients
[5, 102, 203], to a reduction of ventilation- cruitment) through a reduction of atelec- with modest to moderate ARDS (PaO2/
perfusion mismatch [102, 215], to an in- tatic areas of the lungs. The significance of FIO2<300mmHg) despite an increase
crease of lung volume involved in gas ex- this effect overall is still unclear [6, 62, 104, of oxygenation compared to patients
change in CT analyses due to a reduction 123] (evidence level 2b). who were not placed in the prone posi-
of marginally or non-ventilated areas (at- Regarding (c): Ventilation in the prone tion [105,126] (evidence level 2b). Like-
electasis) [104, 107] and to a reduction of position leads to a delay and reduction of wise, until then this did not reveal a short-
ventilation-associated lung injury [5, 45, ventilation-induced lung injury in animal er duration in intensive care or hospital
46, 194, 228, 278]. The assumption is made experimentation [45, 46, 293] as well as in treatment. In the most severe case of AR-
that an improvement of the drainage of patients with acute lung damage [62, 193] DS (PaO2/FIO2<88mmHg), however,
bronchoalveolar secretion is affected. compared to ventilation in the supine po- a post-hoc analysis [105] revealed a sur-
Regarding (a): In ventilated patients sition (evidence level 2b). It is assumed vival advantage through daily prone po-
with acute lung failure, the prone position that an increase of drainage of bronchoal- sitioning compared to patients, who were
leads to a reduction of thoracoabdominal veolar secretion is caused by the prone po- not placed in the prone position (evidence
compliance [227, 282]. Repositioning to sition, however there is no data to support level 2b). In one study, the occurrence of
the supine position leads to a general in- this hypothesis (evidence level 4). ventilator-associated pneumonia (VAP)
crease in compliance of the entire respira- was substantially lower in patients, who
tory system compared to the previous su- Effects of the prone position on were repeatedly placed in the prone po-
pine or prone position [227, 261]. This ef- the pulmonary gas exchange sition [124]. In one prospective observa-
fect becomes more distinctive the higher tional study [200], no reduction of VAP
the elastance of the thorax and diaphragm In patients with acute respiratory insuf- incidence could be demonstrated (evi-
(thoracoabdominal compliance) is at the ficiency and particularly in the stage of dence level 3).
beginning of the positioning method (ev- ARDS, ventilation in the prone position In more recent studies conducted by
idence level 2a). leads to an acute increase of arterial oxy- multiple centres, patients with ARDS in
genation if the settings of the ventilation an early stage of the disease spent approx-

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Guidelines and recommendations

Table 4 Meta-analyses (20082014) regarding randomised trials prone position in ARDS pa- 23.6% in the group of those in the prone
tients. The specification ml/kg refers to ideal body weight (predicted body weight) position and 41% in the control group
Design/Goal Patients Result (p<0.001, Odds Ratio (OR)=0.44). The
Alsaghir and Mortality, 5 studies: No effect on Mortality occurrence of complications did not dif-
Martin [8] PaO2/FIO2, 1316 patients Sub-analysis: SAPS-II fer between the groups, although the con-
Duration of ventilation, 50: mortality trol group patients demonstrated a sub-
VAP incidence PaO2/FIO2
stantially higher occurrence of cardiac ar-
No effect on the duration of
ventilation or VAP incidence rhythmias (evidence level 1a).
Sud et al.[274] ICU+28-day mortality, 13 studies: No effect on mortality
PaO2/FIO2, duration of 1559 patients PaO2/FIO2
ventilation, VAP, compli- No effect on VAP
cations In patients with ARDS (PaO2/
Abroug et al.[2] 28-day mortality, 6 studies: Broad variation in study design FIO2<150) and a lung-protective
PaO2/FIO2, 1372 patients No effect on mortality
VAP incidence, PaO2/FIO2
ventilation strategy, the early appli-
ICU duration, No increased complication rate cation of a prolonged prone position
Complications No significant VAP reduction leads to a substantial decrease in mor-
Kopterides et al. Mortality, 4 studies: No effect on mortality tality compared to the supine posi-
[163] duration of ventilation, 1271 patients Increased complication rate in tion (evidence level 1a). It is not clear,
complications the prone position whether or not repeated prone posi-
Sud et al.[273] Hospital mortality: 10 studies: 1867 Hospital mortality significantly tioning is suitable for decreasing the
PaO2/FIO2 patients reduced in patients with PaO2/ incidence of nosocomial pneumonia
100 FIO2<100 prone position at
versus the onset
(evidence level 4).
(prone position at the 1 Patients with ARDS and an im-
onset) versus supine pairment of arterial oxygenation
(PaO2/FIO2<150) should be placed
Abroug et al.[1] ICU and hospital mor- 7 studies: Inhomogeneity of patients and in the prone position (evidence level
tality, 1675 patients study design
complications No effect on overall mortality
1a, recommendation grade A).
Reduction of ICU mortality in
4 studies
No increased complication rate Time and duration of
Beitler et al. [33] 60-day mortality with 7 studies with No reduction of mortality for
the prone position
stratification: 2119 patients the entire group, but a signifi-
Tidal volume cant reduction for the low tidal The positive effect of the prone position
8ml/kg versus 8ml/ volume group (8ml/kg) on the gas exchange may occur immedi-
kg ately (30min) or with a delay of up to
Sud et al.[272] Mortality in patients in 11 studies: Significant reduction of mortal- 24h after repositioning [36, 100, 169, 188,
the prone position and 2341 patients. ity through the prone position
242] (evidence level 2b). A shorter anam-
lung protective ventila- Including 6 stud- in patients with a lung protec-
tion ies: tive ventilation strategy nesis of the ARDS was associated with
1016 patients a more positive effect of the prone posi-
ventilated for the tion on oxygenation and outcome [125,
protection of the 126] (evidence level 1b). The extent of ini-
lungs tial improvement of oxygenation does not
ARDS acute respiratory distress syndrome, VAP ventilator-associated pneumonia, ICU intensive care unit. permit a prognosis for a long-term effect
(e.g. after 12h) [242]. Likewise, there is no
imately 20h a day in the prone position. A In one multicentre study with a pro- typical morphology in thoracic CT for the
trend appeared involving a shorter period spective randomised design [127], 237 pa- prognosis of success in the prone position
of ventilation and a higher rate of surviv- tients with moderate or severe ARDS were [221] (evidence level 3b).
al (evidence level 2b), however, the stud- placed in the position soon (<48h) fol- Multiple intervals of an intermittent
ies revealed design flaws or a heteroge- lowing the occurrence of the disease (16h prone position and supine position re-
neous patient group [91, 185, 280]. These or more daily for approximately 7 days), vealed a sustainable effect for the im-
studies were compiled and interpreted in while the patients from the control group provement of the pulmonary gas ex-
meta-analyses; an overview of the meta- were treated in the supine position. All pa- change (in the supine position) compared
analyses from 20082014 can be found in tients were ventilated lung protective and to a method conducted once [100, 105,
.Table4. received muscle relaxants at an early stage 125] (evidence level 2b). In comparison to
of the ARDS. Ninety-day mortality was continuous axial rotation, treating ARDS

S6 | Der Anaesthesist Suppl 1 2015

patients with prone positioning leads to a difference in inspiration and expiration). 6 Prior to the application of prone
more rapid and distinctive increase of ox- Moreover, ventilation in the prone posi- positioning, the patient should be
ygenation, although a difference between tion implies physiological protection/re- stabilised haemodynamically and the
the patient groups is no longer demon- duction of ventilation-associated lung in- volume status should be balanced. The
strable after 72h [266] (evidence level 2b). jury [102, 107,124, 127, 170, 193] (evidence use of catecholamines is not a contra-
level 2b). indication against the prone position
2 A prone positioning interval of (evidence level 2b, recommendation
at least 16h should be targeted. The 4 The same principles of an opti- grade B).
prone position should be considered mised ventilation strategy apply for
at an early stage and implemented im- ventilation in the prone position as
mediately after indication (evidence for the supine position, including the In patients demonstrating no abdomi-
level 2b, recommendation grade B). lung-protective limitation of tidal vol- nal disease, a minimal, though substantial
ume, the prevention of derecruitment increase of intra-abdominal pressure with-
3 Prone positioning should be con-
and the integration of spontaneous out intra-abdominal compartment syn-
cluded in the case of persistent im-
respiratory rates (evidence level 2b, drome occurred as a result of prone posi-
provement of oxygenation in the su-
recommendation grade A). tioning during a period of up to 2h [99,
pine position (4 h after supine po-
134, 135] (evidence level 2b). Likewise, no
sitioning: PaO 2/FIO 2150 with a 5 An evaluation and adjustment of impact on splanchnic perfusion was dem-
PEEP10cm H2O and FIO20.6) or the ventilation mode in the context of onstrated [157, 187]. There are no study re-
if multiple positioning attempts re- a lung-protective strategy should be sults for patients with acute abdominal dis-
mained unsuccessful (evidence level conducted after each change of posi- eases and increase of pressure. There have
3, recommendation grade B). tion (evidence level 3, recommenda- been just as few previous reports that the
tion grade B). type of abdominal positioning (padded vs
Synergy effects of the prone hanging) or the duration of positioning
position with additional measures Effect of the prone position has an influence on intra-abdominal pres-
on other organ systems sure or perfusion ratios [58, 61, 134, 205],
The improvement of oxygenation in the although this type of support of the thorax
prone position is reinforced through the Prone positioning per se is not a meth- and pelvis worsened the compliance of the
application of PEEP, particularly in the od that promotes hypotension or cardi- thoracic wall and increased pleural pres-
case of diffuse ARDS [62, 101] (evidence ac instability [134, 146, 149, 193, 299] (ev- sure (evidence level 2b). Patients with ab-
level 2b). Intermittent recruitment ma- idence level 1b). In a broad study, prone dominal obesity developed hypoxic hepa-
noeuvres lead to a more sustainable ef- positioningas opposed to supine posi- titis during prolonged periods in the prone
fect on oxygenation while in the prone tioninglead to an improvement of hae- position (on average 40h) at a significant-
position as opposed to the supine posi- modynamics (increase of cardiac out- ly higher rate than patients without a simi-
tion [102,227] (evidence level 2b). The in- put or median arterial pressure) and to lar configuration (22 vs 2%, p=0.015) [309]
tegration of spontaneous respiratory rates a reduction of cardiovascular complica- (evidence level 2b).
while in the prone position, for example tions [125], however, a balanced volume
through the application of biphasic posi- status was necessary for this effect [149]
For patients with acute abdominal
tive pressure ventilation with spontaneous (evidence level 2b). In patients without a
diseases, no recommendation can cur-
respiration (airway pressure release ven- pre-existing limitation of the renal func-
rently be provided with respect to the
tilation [APRV]), increased the effect of tion, prone positioning did not lead to a
type and duration of a prone position
positioning methods compared to ventila- reduction of kidney function [134] (evi-
due to the lack of studies (evidence
tion in a predominantly controlled mode dence level 2b). Positioning on mattress
level 4, recommendation grade 0)
[295] (evidence level 2b). The inhalation systems controlled by compressed air re-
of nitric oxide for the improvement of the duced a positioning-related increase of in- 7 CAVE: In patients with abdomi-
ventilations/perfusion ratio [39, 111, 114, tra-abdominal pressure compared to con- nal obesity, kidney and liver function
145, 186, 220, 243] likewise demonstrat- ventional mattress systems [58, 198] (evi- should be monitored closely in the
ed synergetic effects on oxygenation (evi- dence level 2b). Patients with abdominal event of prolonged prone positioning
dence level 2b). obesity (CT definition: sagittal abdominal (expert consensus).
Ventilation in the prone position pres- diameter 26cm) developed kidney fail-
ents a sensible therapeutic perspective ure (83 vs 35%, p<0.01) [309] at a signifi- Prone positioning and
in order to implement a lung-protective cantly higher rate during prolonged prone acute cerebral lesion
strategy by adapting various ventilation positioning (on average 40h) compared
settings parameters (reduction of the tid- to patients without a similar configuration Prone positioning may cause an increase
al volume, reduction of FIO2, the inspira- (evidence level 2b). of intracranial pressure and (in the case
tory peak pressure, as well as the pressure of unchanged haemodynamics) a reduc-

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Guidelines and recommendations

tion of cerebral perfusion pressure in ative area prior to, during and after the po- Complications while in
the case of acute traumatic or non-trau- sitioning method, wherein the heads of a the prone position
matic cerebral lesions [34, 209, 241] (ev- patient group were additionally turned to
idence level 4). However, the improve- the right side at a 45 angle to the prone The following complications were de-
ment of the pulmonary gas exchange in- position [73]. While in the prone position, scribed while in the prone positions [28,
duced by the prone position may increase a moderate increase of the IOP occurred 30, 42, 43, 65, 105, 124, 144, 218, 272, 301]
cerebral oxygenation [283] (evidence lev- from 12 to 18mmHg (p<0.001) and upon facial oedema (2030%), pressure ul-
el 4). In healthy humans, systematic and turning the head to the side, the pressure cers around the face/cornea, pelvis, knee
cerebral haemodynamics were captured of the lower eye increased further. Two (approximately 20%) [234] intolerance
in the prone position during noninvasive additional studies from the operative ar- while in the prone position (= coughing,
positive pressure ventilation and a varia- ea confirmed these findings [88, 122] (evi- compaction, respiratory problems ap-
tion of the position of the head was con- dence level 2b). There is no data in this re- proximately 20%), cardiac dysrhythmias
ducted (centred, to the left and right side). gard for intensive care patients. (approximately 5%), necrosis of the ma-
The lateral rotation of the head leads to milla, pressure ulcers of the tibial crest (in-
a reduction of cerebral blood flow (Arte- Modifications of the prone position dividual reports), dislocations of the tra-
ria cerebri media) by approximately 10% cheal tube or venous/arterial lines (ap-
[137] (evidence level 2b). In addition to the complete prone po- proximately 12%) [105], nerve dam-
Sufficient studies were not conducted sition (180), the incomplete prone po- age (two case studies regarding brachi-
previously as to whether or not an adap- sition (135) is also applied because it is al plexus lesion [119]) (evidence level 2b).
tion of the ventilation settings (change of perceived as having fewer side effects for In this regard, it is necessary to consider
tidal volume and respiratory minute vol- patients and is easier to perform for the that complications also occur in the su-
ume = change of CO2 elimination = change nursing staff [30, 257]. With proper exe- pine position and a comparison of the in-
of cerebral perfusion) could have positive cution, there were no significant differ- cidences of position-related complications
effects on the damaged cerebrum while in ences between both positions in the inci- for the prone position has not previously
the prone position. Moreover, no study has dence of severe complications[30] (evi- been sufficiently studied. The retrospec-
been conducted regarding whether or not dence level 2b). tive analysis of the multicentre study by
the adapted analgosedation could prevent The incomplete prone position lead Guerin [116] revealed a higher incidence
the intracranial pressure increase in the to a substantial improvement of oxygen- of pressure points and skin ulcers in the
case of an acute cerebral lesion. ation in ARDS patients; however, this ef- prone position group (14.3/1000 ventila-
fect was not as distinctive as with the com- tion days) compared to the supine posi-
8 The indication for the prone posi- plete prone position. In patients with se- tion (7.7/1000 ventilation days, p=0.002)
tion with acute cerebral lesions may vere ARDS, a significant increase of arte- (evidence level 2b).
only be issued after individual con- rial oxygenation (defined as an improve- According to the results of a prospec-
sideration of benefit (improvement ment by more than 20%) while in a com- tive, randomised study, a lesser frequency
of oxygenation) and risk (intracrani- plete prone position occurred at a signif- of facial oedema was observed due to the
al pressure increase) (evidence level 3, icantly higher rate than while in the 135 modification of the prone position (135
recommendation grade 0). prone position[30] (evidence level 2b). position, incomplete prone position)
9 During the positioning method, In one prospective randomised study, the compared to the 180 position[30] (evi-
intracranial pressure should be con- combination of the prone position with dence level 2b). The safe execution of the
tinuously monitored (evidence lev- an elevation of the upper body lead to a prone position in patients with extracor-
el 2b, recommendation grade A). The significantly stronger effect on the oxy- poreal membrane oxygenation (ECMO)
head should be centred during this genation compared to the prone position was reported in a retrospective observa-
method and lateral rotation should alone [245] (evidence level 3). tional study [158] (evidence level 3).
be avoided (evidence level 3, recom-
mendation grade B). Expert consen- 10 The complete prone position Contraindications for
sus and S1 guideline Intracranial has a stronger effect on the oxygen- prone positioning
Pressure (AWMF registry no. 030/105, ation than the incomplete prone posi-
valid until 12/2015). tion and should be primarily applied Instability of the spine, severe, surgically
(evidence level 2b, recommendation untreated facial trauma, the acute cerebral
grade A). lesion with intracranial pressure increase,
Prone positioning and 11 The elevation of the upper body the critical cardiac rhythm disorder, acute
intraocular pressure while in the prone position may be shock syndrome and the open abdomen
sensible for preventing an impact on situation apply as contraindications for
In one prospective, randomised trial, in- other organs (intraocular pressure, prone positioning [304, 306].
traocular pressure (IOP) was measured in intracranial pressure) (evidence level
patients in the prone position in an oper- 3, recommendation grade 0).

S8 | Der Anaesthesist Suppl 1 2015

12 Compared to the supine position, most essential access points should prone position was greater than in
the prone position leads to a higher be secured by the person guiding the supine position [240]. In anoth-
incidence of pressure ulcers and re- the head of the patient. er trial, with adequate enteral feed-
spiratory problems, such that a posi- 3. The inspiratory fractional oxygen ing tube length, no increased resid-
tioning should be done particularly concentration (FIO2) should be set ual gastric volume or an increased
gentle and the airways should be pro- to 1.0. incidence of regurgitation was ob-
tected and monitored (evidence level 4. Enteral nutrition is interrupted; served in contrast to the supine po-
2, recommendation grade A). the stomach should be emptied sition [255] (evidence level 2b). On
through a tube. the condition of an application with
13 An open abdomen, spinal insta-
5. An adapted analgosedation (Rich- a low flow rate (30ml/h) and fre-
bility, increased intracranial pressure,
mond Agitation Sedation Scale quent reflux checks, no higher re-
critical cardiac rhythm disorders and
(RASS-Score) 2) is necessary for sidual volumes or other side effects
manifest shock are contraindications
the rotational manoeuvre to avoid were observed in one prospective
for the prone position. These contra-
coughing, compaction or regurgita- trial [294] (evidence level 2b), this
indications may be deviated from in
tion. Ventilation should be custom- approach is recommended in a sys-
individual cases after consideration
ised accordingly. After the position- tematic analysis [178].
for the benefits and risks and follow-
ing manoeuvre, the analgosedation 2. While in the prone position, enteral
ing consultation with the specialist
is reduced. nutrition is possible with a low flow
disciplines involved (expert consen-
B. Execution rate (30ml/h), however regu-
sus, recommendation grade 0).
lar reflux checks are suggested (ev-
During the rotating manoeuvre, monitor- idence level 2b, recommendation
Appendix I: Prone positioning: ing is necessary by means of continuous grade B).
recommendations for arterial blood pressure measurement. Var-
practical execution ious techniques are described for execut- Continuous lateral
ing the rotating process. It is recommend- rotation therapy
Prone positioning: ed to focus on one technique that all in-
practical execution volved are familiar with [13, 195] (evidence Definition of continual lateral
Each positioning processdepending on level 4, recommendation grade B for all rotation therapy (CLRT)
the body weight of the patient as well as previously described methods).
the invasiveness of the therapy (drainag- C. Follow-up CLRT involves the continuous rotation
es, catheters, extensions)is conducted 1. After the completed positioning of the patient around his longitudinal ax-
by three to five nurses and one physician manoeuvre, monitoring must be is in a motor-driven bed system. Depend-
[13, 17, 18, 42, 138, 190, 195, 207, 254, 260, completed. ing on the system, a maximum rotational
276, 303, 304]. 2. Ventilation must be adapted in the angle of 62 can be achieved on each side.
A. Preparational measures: context of a lung-protective strategy
1. Within the scope of prone position- and monitored after a brief stabili- Rational of CLRT
ing, the use of a special anti-decubi- sation phase (evidence level 3, rec-
tus mattress system is recommend- ommendation grade B). The goals of CLRT are to prevent pulmo-
ed to prevent/reduce pressure ul- 3. After the rotating manoeuvre, spe- nary complications (atelectasis, pneumo-
cers (evidence level 4, recommen- cial measures are taken to reduce nia, congestion of pulmonary secretion),
dation grade 0), particularly in pa- pressure around the head, around the reduction of pulmonary inflamma-
tients with an increased decubitus the pelvis and the knee. Always en- tion as a result of trauma or infection,
risk (high-dose catecholamine ther- sure careful padding particularly in as well as improving pulmonary gas ex-
apy, adiposity, cachexia, corticoste- areas prone to decubitus (recom- change in ventilated patients. The increase
roid therapy) (evidence level 3, rec- mendation grade A). The head and of oxygenation, the incidence of nosoco-
ommendation grade 0). arms should be additionally repo- mial pneumonia, as well as the duration
2. Catheters, drainages and artificial sitioned in short intervals while in of mechanical ventilation and intensive
airways are secured and, if neces- the prone position (recommenda- care stays or hospitalisation are classified
sary, extended. Prior to positioning, tion grade 0). as parameters for this. However, none of
it is necessary to check whether or D. Special aspects for executing prone these parameters are established as an ad-
not it is a difficult-airway-situation positioning: equate surrogate for survival and the qual-
in order to take potentially suitable 1. The application of enteral nutri- ity of survival. Indications for the use of
measures to ensure the airways (e.g. tion while in the prone position was CLRT comprise both prophylactic (pre-
preventative surgical tracheotomy, studies in multiple trials [240, 255, vention of complications) and therapeu-
providing intubation alternatives). 294]. In one prospective trial, the tic aspects (improvement of pulmonary
When performing the rotation, the residual gastric volume while in the functionality).

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Guidelines and recommendations

Comment: In one recommendation (59%) compared to the control group sure ratios possibly lead to increased
from the Paul Ehrlich Society (PEG) Nos- without CLRT (34%, p=0.028) (evidence drainage through the lymphatic system
ocomial Pneumonia: Prevention, Diagnos- level 1b). There are no comparative stud- of the lungs [10, 29] (evidence level 4).
tics, und Therapy [38], there is no recom- ies of CLRT with other positioning meth- b) The reduction of ventilation/perfu-
mendation for the use of CLRT within the ods for preventing VAP. sion mismatch [27] (evidence level 4).
scope of a bundle for the prevention of ven- c) In some trials, the incidence and ex-
tilator-associated pneumonia. The current tent of atelectasis were reduced with
recommendations of the Commission for 14 The early use of CLRT can be em- the early, that is preventative use of
Hospital Hygiene and Infection Prevention ployed in certain groups of ventilated CLRT from the start of ventilation.
(KRINKO) at the Robert Koch Institute patients as a supplement to preven- Few limitations of oxygenation oc-
[162] determined based on lacking consis- tion of ventilator-associated pneu- curred [4, 98, 160]. In other trials,
tency in the trials and meta-analyses that, monia, however, other methods (e.g. however, no significant effects were
Therapy with kinetic beds for the preven- adapted analgosedation, mobilisation demonstrated [51, 110, 277, 310] (ev-
tion of VAP (ventilator- associated pneu- concepts) should not be impacted by idence level 3). Particularly in poly-
monia) cannot be recommended at this this (evidence level 3, recommenda- traumatised patients with a pulmo-
time. As a restriction to this recommen- tion grade B). nary injury, early CLRT was able to
dation, it is necessary to adhere to the fact prevent the occurrence of ARDS or
that at the time of the publication from the The treatment period in intensive improve oxygenation [31, 86, 93, 202,
KRINKO, the prospective randomised pub- care was shorter in three out of eight ran- 223, 300] (evidence level 2b).
lications from Staudinger et al. [265] and domised trials compared to conventional- d) In trauma patients, CLRT reduced the
Simonis et al. [263] were not yet published. ly treated patients (evidence level 1b). The pulmonary inflammation reaction
The use of CLRT requires a targeted length of hospitalisation was shortened (reduction of pulmonary and system-
indication and safe handling in order to due to CLRT in a prospective randomised ic pro-inflammatory cytokines (TNF,
prevent undesired effects. After initiating trial [265] (evidence level 1a), though not IL-6) and lead to a less severe organ
this method, the persistence of the indica- in other trials with partially limited quali- function disorder up to the fifth day
tionas with other therapeutic methods ty [4, 60, 211, 291] (evidence level 3). post-trauma compared to patients
as wellshould be reviewed daily. treated in the supine position[31]
Physiological effects of CLRT (evidence level 2b).
Effects of CLRT on pneumonia e) In one trial, CLRT lead to the disso-
incidence, duration of CLRT was originally used in immobilised lution of atelectasis in ventilated pa-
ventilation and mortality patients for bedsore prophylaxis. Subse- tients [238]; a more recent publication
quently, the indication was broadened for could not verify this effect [51], how-
The present studies regarding the effect the treatment of patients with pulmonary ever both studies demonstrate meth-
of CLRT on the incidence of respiratory disorders. Improved oxygenation, the dis- odological weaknesses. Thus, no rec-
infections are limited by various criteria solution of atelectasis, improved ventila- ommendation is provided for treating
for the diagnosis of infections of the up- tion/perfusion ratios, increased secretion atelectasis with CLRT.
per and lower respiratory tracts as well as mobilisation, the reduction of pulmonary f) The improvement of oxygenation due
the lung parenchyma [70, 71, 120, 136, 184, inflammatory response following trauma to CLRT in patients with restricted re-
263, 265]. and a reduction of pulmonary fluid reten- spiratory function (ARDS) occurred
In two more recent prospective ran- tion was determined as effects. at a slower rate than in the prone posi-
domised trials [263, 265], a reduction of tion [266] (evidence level 2b).
the incidence of respiratory infection in- Effects of CLRT on the g) To date, there has been no proof of in-
cluding ventilator-associated pneumo- pulmonary function creased bronchopulmonary secretoly-
nia (VAP) was observed in ventilated pa- sis due to CLRT; however, a rotation-
tients compared to standard positioning CLRT improves the pulmonary gas ex- al angle of <30 was used in the only
(bedsore prophylaxis) (evidence level 1b). change in patients with acute respiratory study [77] (evidence level 4).
Furthermore, in the study by Stauding- insufficiency (evidence level 2b) [25, 222,
er et al. [265], the ventilation time (8 vs 223, 237, 238, 265, 267]. The following ef-
13 days, p=0.02) and the treatment time fects were confirmed starting at a rota- 15 CLRT should not be used in pa-
in intensive care (25 vs 39 days, p=0.01) tional angle of 40 on each side: tients with ARDS (PaO2/FIO2<150)
was significantly shorter in patients treat- a) The reduction of extravascular lung (recommendation grade A).
ed with CLRT; the mortality rate did not water (EVLW) in patients with im- In the case of contraindications to the
differ. The study by Simonis et al. on pa- paired oxygenation (ARDS)[32] (evi- prone position, the use of CLRT may
tients in cardiogenic shock [263] demon- dence level 2b). The mechanism is not be considered for improving oxygen-
stratedin addition to VAP reduction ultimately clear; continual movement ation (evidence level 3, recommenda-
a significantly higher 1-year survival rate and changes in intrapulmonary pres- tion grade 0).

S10 | Der Anaesthesist Suppl 1 2015

Time and duration of Complications and the manufacturer) are considered to be
CLRT: angular settings interactions of CLRT contraindications for CLRT.

In most studies, CLRT was conducted at The following complications were de- Appendix II: continuous lateral
beginning of intensive care treatment for scribed during CLRT: pressure ulcers, in- rotation therapy: recommendations
at least 72h. The use of CLRT within 2 tolerance (coughing, compactions, respira- for practical execution
days after development of a respiratory in- tory problems), cinetosis, catheter disloca-
sufficiency was linked to a significant re- tions, nerve damage [93, 184, 277]. In one Careful positioning requires special pro-
duction of intensive care therapy and hos- prospective observational trial on 20 hae- tective measures for pressure-sensitive ar-
pitalisation compared to a later initiation modynamically stable patients, no chang- eas (head/neck, auricles, pelvis, knee, bra-
of the method in two studies [98, 279] es of heart rate or blood pressure were reg- chial nerve, peroneal nerve) [94, 224] (ev-
(evidence level 3). One positive effect on istered during CLRT [12] (evidence level 3). idence level 4, recommendation grade B).
the gas exchange was able to be observed In the case of haemodynamically unstable Prior to starting the system each time,
up to a duration of 5 days after the onset patients, a drop in blood pressure in a steep a manual test rotation should be conduct-
of treatment [25, 224] (evidence level 4). lateral position (most often in the right lat- ed to check the proper positioning of the
The parameters or strategies according to eral position) is frequently observed [26] patient as well as adequate extension and
which CLRT should be concluded have (evidence level 2b). A direct comparison of attachment of all supply lines and drain-
not been studied (Weaning) [94]. the incidence of position-related complica- ages. CLRT should be started with small
In one study, it was determined that tions with other positioning methods is not rotational angles and then increased. To
longer periods of retention in the lateral possible due to a lack of data. achieve optimal rotational periods (18
position during CLRT do not improve the There is data from two trials regarding 20h/day), nursing and physician activi-
gas exchange and may even cause a dete- the use of CLRT in patients with acute ce- ties should be well coordinated with each
rioration in individual cases due to a re- rebral lesions [60, 287]. No increase of in- other (evidence level 4, recommendation
duction of pulmonary compliance [256 tracranial pressure during CLRT was stat- grade 0). In the case of an invasive, con-
(evidence level 2b). The positive effects ed in one trial [287] (evidence level 4). tinuous blood pressure measurement, the
on oxygenation and on pneumonia inci- In one retrospective trial, an increased pressure sensor must be fastened to the
dence (see below) were observed with one complication rate and duration of ventila- bed system at the level of the heart in the
exception [310] during CLRT with a rota- tion during CLRT was determined in pa- median axis in order prevent false mea-
tional angle >40. tients with spinal lesions, however the se- surements during the rotational process.
verity of neurological deficits in these pa- With a proper routine and preparation,
tients was greater [57] than in the conven- CLRT can also be safely used in combina-
16 If CLRT is used for treating oxy- tionally treated group (evidence level 4). tion with extracorporeal membrane oxy-
genation impairment, the indication genation [164] (evidence level 3, recom-
for continuation should be reviewed 18 The same criteria as with the mendation grade 0). In the case of dis-
daily based on the improvement of prone position apply for conduct- tinctive haemodynamic insufficiency in
oxygenation (as with the prone posi- ing CLRT in patients with acute ce- the lateral position, the angle of rotation
tion). rebral lesions. These patients should should be reduced to the respective side
be monitored by means of continu- (recommendation grade 0).
CLRT should be concluded upon sta-
bilisation of the gas exchange in the ous intracranial pressure measure-
ment (evidence level 3b, recommen- Lateral position for patients
supine position without rotation, or
dation grade 0) and may be situated with pulmonary disorders
if a continuous application showed
no success over a period of 48h to no in a moderately high upper body posi-
tion (inclined position of the bed sys- Definition of lateral position
more than 72h (evidence level 3, rec-
ommendation grade B). tem).
A position, in which the side of the body
19 It is necessary to individually
is supported and elevated up to an angle of
consider between potential damage
Ventilation setting during due to CLRT and the expected bene-
90, is referred to a lateral position.
CLRT and duration of CLRT fit in the case of severely injured pa-
tients (evidence level 4, recommenda-
Rational of the lateral position
tion grade 0).
17 For ventilation during CLRT, the In addition to relieving support areas (de-
principles of a lung-protective venti- cubitus prophylaxis), pulmonary compli-
lation strategy should apply (evidence Contraindications for CLRT cations are intended to be prevented and
level 2b, recommendation grade A). the pulmonary gas exchange improved.
An instable spine, acute shock syndrome This is the result of frequent reposition-
and a body weight >159kg (according to ing or special lateral positioning in the

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Guidelines and recommendations

case of unilateral lung damage. The sim- The haemodynamics are only slightly The effects of an intermittent lateral
plicity of the method is beneficial, which influenced by the lateral position of ven- position or CLRT up to a rotational
can be conducted at any time with mini- tilated patients; no significant changes of angle <40 on the pulmonary gas ex-
mal additional effort [14, 141]. cardiac output occurred [22, 285, 286] change have not been adequately ver-
(evidence level 4). A prophylactic effect of ified. In patients with ARDS, CLRT
Physiological effects and side the lateral position on the prevention of up to 40 does not demonstrate any
effects of the lateral position in postoperative pulmonary complications advantage compared to intermittent
patients without lung damage was not adequately studied. lateral positioning with respect to im-
proving oxygenation (evidence lev-
Effects on haemodynamics and gas ex- 20 During the ventilation of patients el 2b).
change were studied, wherein primarily without lung damage, a lateral posi- 21 Proper positioning and interpreta-
postoperative patients with healthy lungs tion exclusively for preventing pul- tion of invasively measured blood pres-
were studied [50, 212]. monary complications is not sensi- sure values should be particularly en-
Only minimal changes in ventilation ble (evidence level 2b, recommenda- sured in the lateral position (evidence
and haemodynamics were detected in tion grade B). level 3, recommendation grade B).
spontaneous respiration among individ-
uals with healthy lungs [50]. Blood pres-
sure tend to sink in the lateral position Indications and effects of the Unilateral lung damage
(left lateral position >right lateral posi- lateral position in patients In spontaneous breathing, the lateral po-
tion [148], evidence level 4). In the left lat- with lung damage sition improves oxygenation if the good
eral position, greater heterogeneity of ven- lung is down [23, 95, 284] (evidence lev-
tilation dispersion occurred compared to Bilateral lung damage el 4). However, in the case of a very high
the right lateral position [92] (evidence In the case of chronic obstructive pulmo- closing volume it may be better to posi-
level 4). The lateral position promoted nary disease (COPD), noninvasive ven- tion the bad lung down [59] (evidence lev-
the perfusion in the direction of the ven- tilation in the lateral position is possible. el 2b). Effects can be expected particularly
tral pulmonary sections in ventilated pa- However, it does not cause any addition- with pneumonia, although not with cen-
tients[27] (evidence level 3). The mea- al improvement of the gas exchange com- tral obstructions, such as carcinoma[53]
surement of haemodynamics in the lat- pared to the supine position [233] (ev- (evidence level 4).
eral position was vulnerable to artefacts, idence level 4). In two trials involving a In the case of mechanical ventilation
particularly when determining the refer- total of 22 ventilated patients with acute and lateral positioning with the good lung
ence point [12, 49] (evidence level 4). lung damage, the effects on oxygenation down, oxygenation improves [53, 59, 79,
In postoperatively ventilated patients due to the lateral position were variable 143, 235, 244] (evidence level 2b) through
without acute respiratory insufficiency, and not predictable compared to the su- homogenisation of ventilation/perfusion
the overall compliance of the respiratory pine position [210, 256] (evidence level 4). dispersion and reduction of the intrapul-
system in the lateral position is reduced CLRT with a minimal rotational angle monary shunt [115, 132] (evidence level 4).
compared to the supine position [282] 40 and the intermittent, 2h long lat- These improvements of the gas exchange
(evidence level 4). The phenomenon of eral position had the same effect on the are based on the same mechanisms as
atelectasis formation after the induction gas exchange, wherein higher secretion with the prone position, with which the
of anaesthesia and atelectasis treatment mobilisation was observed using CLRT bad lung is taken from the dependent po-
through PEEP occurred in the dependent [68] (evidence level 2b). In the right lat- sition. These effects can be expected for
lung in the lateral position just as in the eral position, there was more often a hae- gas exchange disorders due to pneumonia
supine position [161] (evidence level 4). modynamic compromise in ventilated pa- and atelectasis, but not due to pleural ef-
In postoperatively ventilated patients tients compared to the left lateral position fusion [50] (evidence level 4). Effects of
with healthy lungs and without acute re- caused by a more reduced right ventricu- the lateral position on the outcome with
spiratory insufficiency, without atelecta- lar filling [26, 76, 120] (evidence level 2b). respect to ventilation duration, pneumo-
sis and with a high tidal volume, the lateral These effects have not been studied in nia incidence or mortality have not been
position (4590) did not improve the pul- non-ventilated patients or ventilated pa- studied.
monary gas exchange compared to the su- tients without lung damage.
pine position [212, 285, 286] (evidence lev-
22 In the case of ventilation of pa-
el 2b). The moderate lateral position (45)
tients with unilateral lung damage, a
did not affect any clinical changes of the gas
lateral position of approximately 90
exchange, haemodynamics and tissue per-
is recommended with the good lung
fusion compared to the supine position [21,
down to improve the gas exchange
285, 286] (evidence level 4). The mixed ve-
(evidence level 2b, recommendation
nous oxygen saturation decreased mini-
grade B)
mally [108] (evidence level 4).

S12 | Der Anaesthesist Suppl 1 2015

Further studies regarding feasibility and
the effect of 45 position [19, 20, 37, 214,
231, 248, 249, 250] revealed that precise
compliance with the position in clinical
practice is normally not feasible and a tar-
get angle of 45 could not be achieved (ev-
idence level 2a). To improve practical im-
plementation, numerous technical appli-
Fig. 18Modifications of the elevated upper body position cations (angle measuring systems, train-
ings programmes for nursing staff) were
recommended and implemented, which
Backrest elevation position of diaphragm position) were considered (with substantial effort) contributed to the
to be gravitationally dependent [24]. increase of the precise execution [20, 37,
Definitions of elevated 182, 311, 314] (evidence level 2b).
upper body position Effects and impacts of backrest A systematic analysis and evaluation of
elevation on the lungs the three randomised trials regarding the
The elevated upper body position is im- impact of the backrest elevation on VAP
plemented in various ways in different Impacts on gastroesophageal incidence by means of the Delphi meth-
trialsthere is no universal definition. reflux and pulmonary aspiration od [213] did not reveal any clear evidence
Various positions are studied, which can The aspiration of secretion contaminated for the application of a 45 elevated up-
range between the classic sitting position with bacteria in the gastrointestinal tract per body position due to the heterogene-
with bent hip and knee joints on one hand and the pharynx is generally perceived as ity of the studies. Considering undesired
and tilting of the entire, flat-lying patient a risk factor and trigger for the develop- accompanying effects, this expert consen-
(called the anti-Trendelenburg position) ment of nosocomial and ventilator-associ- sus recommended that the elevated upper
on the other hand. This likewise includes ated pneumonia (VAP). Consequentially, body position (2045; more than 30if
the so-called reclined seated position, for measures that lead to decrease of gastroin- possible) be used as a preferred position
which there is no date regarding its ef- testinal reflux and a reduction of the oro- with reference to numerous limitations
fects on haemodynamics and lung func- pharyngeal secretion volume should ac- in ventilated patients (evidence level 2a).
tion. The semi-seated position refers to company a lower incidence of nosocomi- Despite the weakness of the Delphi rec-
a position, in whichwith bent hip and al pneumonia and VAP [7, 142, 213] (evi- ommendation, which is due to the weak-
extended or bent knee jointsthe upper dence level 3). ness of the analysed studies, the guideline
body and the head of the patient are ele- Studies are available that have been group supports this recommendation as it
vated by a certain degree as opposed to the conducted on patients with orotracheal appears practical for clinical use and re-
flat-lying lower extremities (see .Fig.1). intubation, who do not have known risk flects the limited evidence.
What all modifications of the elevated factors for gastroesophageal reflux. All
upper body share in common is that the patients were supplied with a nasogas- 23 The preferred principle position
upper body is positioned above the level tric tube; some were fed enterally. Stress for intubated patients is the backrest
of the trunk, wherein the angle is at least bleeding prophylaxis was conducted and elevation position of 2045, prefer-
30 [75]. the endotracheal cuff pressure was mon- ably 30, considering the limitations
itored (>25cm H2O). A 45 elevated up- (evidence level 3, recommendation
Effect mechanisms of the per body position in these patients lead to grade B).
backrest elevation a delay of gastroesophageal reflux and to
For patients with elevated intracrani-
a decrease, though not a complete preven-
al pressure, specific recommendations
As a goal of the clinical trials, the gravita- tion, of pulmonary aspiration of pharyn-
will be announced (see 2729).
tionally dependent effects of the elevated geal secretion compared to a flat supine
upper body position were studied. In this position [219, 290] (evidence level 2b).
regard, the prevention of passive regur- In two prospective randomised trials Impacts on pulmonary
gitation (pulmonary aspiration of gastric [78, 117], a substantial reduction of VAP gas exchange
contents) [63, 113] and the reduction of in- was observed through the application of a Even in those with healthy lungs, anaes-
tracerebral blood volume (reducing intra- 45 backrest elevation compared to the su- thesia and mechanical ventilation lead to
cranial pressure) were of primary focus. pine position (evidence level 2b), howev- a change of the regional ventilation with
The remaining described effects of the el- er, both of these studies were heavily crit- the development of atelectasis, particular-
evated upper body position on haemody- icised with respect to their design and the ly in the dorsal and diaphragm areas of the
namics (modified orthostatic reaction) method [213]. A small randomised pilot lungs. This effect is likely more distinctive
and the pulmonary gas exchange (change study observed a trend for reducing VAP in patients with increased intra-abdom-
with this position (evidence level 3) [154]. inal pressure (e.g. severe obesity, exten-

Der Anaesthesist Suppl 1 2015 | S13

Guidelines and recommendations

sive surgical procedures on the abdomen, 25 Within the scope of the difficult reaction through interactions with other
peritonitis) because the mobility of the di- weaning of mechanical ventilation parameters, such as ventilation pressure,
aphragm is limited and situated in crani- (without the presence of COPD), the sympathetic stimulation, haemodynamic
al orientation. Even with ARDS, the im- elevated upper body (45) should be function, volume status and level of seda-
paired lung function leads to ventilation used to reduce respiratory effort and tion is vast and thus not predictable [44,
disorders and the formation of atelectasis. to increase the comfort level of the pa- 83, 89, 155, 180, 251, 313] (evidence level 3).
We must assume that actions for prevent- tient (evidence level 2b, recommenda-
ing diaphragm dislocation reduce the for- tion grade B). 27 The application of an elevated up-
mation of atelectasis and thus contribute per body position of 1530 is sensi-
to an improvement of the gas exchange. ble in patients with increased intra-
In one prospective crossover trial in Backrest elevation in cranial pressure and may contribute
40 ARDS patients, the backrest eleva- the case of obesity to a reduction of intracerebral pres-
tion (2045) leads to an increase of ox- sure (evidence level 2b, recommenda-
ygenation in 32% of the patients studied In one prospective cohort study on 30 tion grade B)
(>20% compared to the flat supine posi- ventilated patients with obesity (BMI
28 A 45 backrest elevation cannot
tion) and to an increase of the lung vol- >35kg/m2), a significant reduction of ex-
be recommended without limitation
ume [72] (evidence level 2b). In a simi- piratory flow limitation (= improvement
in patients with suspicion of increased
lar crossover trial in 24 ventilated patients of the gas flow) and a reduction of auto
intracranial pressure due to the fact
with difficult weaning, the 45 position PEEP was revealed while in the sitting po-
that cerebral perfusion pressure can
lead to a significant reduction of respira- sition (>45) compared to the lying posi-
become critically degraded with an in-
tory effort. Patients found the comfort lev- tion. These effects were not demonstrable
creasingly elevated position (evidence
el in this position to be the highest; no im- in a control cohort (15 patients with BMI
level 2b, recommendation grade B).
pact on the reduction of the weaning pro- <30kg/m2) [173] (evidence level 2 b).
cess was observed [74] (evidence level 2b). 29 With respect to the treatment
In postoperative patients without AR- of patients with elevated intracranial
26 The flat supine position should be pressure, please refer to the S1 guide-
DS, the semi-seated or sitting position
avoided in patients with severe obesi- line intracranial pressure (AWMF reg-
lead to contradicting results with respect
ty (evidence level 4, expert consen- istry no. 030/105, valid until 12/2015):
to the gas exchange compared to the su-
sus). The backrest elevation position If possible, an elevated upper body po-
pine position. In patients who were not
(>45) may contribute to an improve- sition should be aimed for. The indi-
characterised in more detail with pre-ex-
ment of the respiratory mechanics in vidually optimised upper body posi-
isting pulmonary diseases, the sitting po-
ventilated patients with severe obesi- tion should be regularly evaluated with
sition had no effect on capillary blood gas-
ty (BMI >35kg/m2) (evidence level 2b, ICP and CPP controls in the 0 (not in
es as opposed to the flat position regard-
recommendation grade 3). Regarding the case of the risk of aspiration or with
less of age [212].
contraindications for the elevated up- ventilation), 15 and 30 position. Ve-
The effects of an intraoperative, semi-
per body positionsee 28 and 31 nous return flow should not be prevent-
seated position on the gas exchange are al-
so studied in neurosurgical patients [66]. ed by bending the head [11].
The small amount of available data re- Impacts on other organ system
vealed an improvement of oxygenation Impacts on respiratory effort
in these patients. However, due to the fact Intracerebral pressure (ICP) and Background: The most frequent postop-
that the intraoperative position was pri- cerebral perfusion pressure (CPP) erative complications after thoracic proce-
marily determined by the surgery, a tar- The elevated upper body position has dures are of a pulmonary nature caused by
geted, therapeutic application is not rele- been in treating ICP for a long time. Due partial respiratory insufficiency as well as
vant (evidence level 4). to gravitationally dependent shifting, the postoperative hypermetabolism with in-
cerebral blood and fluid volume are re- creased O2 consumption. Increased respi-
24 The elevated upper body position duced and ICP decreases. However, the ratory effort must be made by changing
(2045) may contribute to an im- semi-seated position may also lead to an the lung volume particularly in patients
provement of oxygenation and the re- impact on haemodynamics and thus to a with chronic obstructive pulmonary dis-
spiratory mechanics in patients with reduction of CPP. In patients with normal ease (COPD). Regarding the effects of the
ARDS (evidence level 2b, recommen- and elevated ICP, the elevated upper body position, however, differences can be ex-
dation grade B). position normally leads to a reduction of pected between patients with a chron-
ICP depending on the angle [87]. An ac- ic gas exchange disorder and those with
companying reduction of CPP can be ob- acute exacerbation.
served more frequently with an elevat- In patients following a thoracotomy,
ed upper body position of 30 and great- the semi-seated position resulted in a re-
er. However, the breadth of the individual duction of energy consumption with-

S14 | Der Anaesthesist Suppl 1 2015

out impacting haemodynamic function In a prospective randomised cross- The elevated upper body position with
through a decrease of respiratory effort over study on 200 haemodynamical- bending of the hip may affect an in-
and oxygen consumption in the respira- ly stable ventilated patients with differ- crease in intra-abdominal pressure
tory muscles [41] (evidence level 3b). ent underlying disease [118], the position (diverted through the bladder) (evi-
In noninvasively assisted ventilated change of the upper body from 0 to 45 dence level 3).
COPD patients, the backrest elevation lead to a significant reduction of average
32 In patients with abdominal disease
did not produce any changes in the respi- arterial pressure and central venous oxy-
or severe obesity, the anti-Trendelen-
ratory volume, the respiratory pattern, re- gen saturation; this effect was less distinct
burg position without bending of the
spiratory effort or the gas exchange com- at 30. In a multivariate analysis, the fol-
hip should be preferred for the elevat-
pared to the supine position or the later- lowing independent factors were identi-
ed upper body position (evidence level
al position [233]. The sitting position in fied for the development of hypotension
3, recommendation grade B).
patients with clinically significant dynam- within the scope of the 45 position: con-
ic distension, a deterioration of the activ- trolled ventilation (compared to augment-
ity of the diaphragm may occur to the ex- ed spontaneous ventilation), analgoseda- Elevated upper body position
tent that ventilation may be more effec- tion, increased need for vasopressors, high and the occurrence of decubitus
tive in the supine position [81] (evidence PEEP and high Simplified Acute Physiol- ulcers in proximal tissue
level 4). Effects of the elevated upper body ogy Score (SAPS-II) score (evidence lev- In a prospective crossover study with a
position on the pulmonary gas exchange el 1b). variation of the upper body position (0
and respiratory mechanism in ARDS pa- 75) the pressure on proximal tissue (in
tients and in patients with difficult wean- Under certain conditions, the back- the sacral area) was measured in healthy
ing were described above. rest elevation (45) may induce signif- test persons [232]. A significant and crit-
icant hypotension. Controlled venti- ical increase (>32mmHg) was revealed
lation (compared to augmented spon- in the sacral area starting at an elevated
30 In spontaneously breathing or
taneous ventilation), continuous anal- upper body position of 45. A significant,
noninvasively assisted breathing pa-
gosedation, an increased need for va- but less distinct pressure increase was al-
tients with COPD, positioning can oc-
sopressors, a high PEEP and a high so measured in the 30 position (evidence
cur pursuant to the individual request
SAP-II score are considered to be risk level 3). There are no studies for ventilat-
of the patient because the effects of a
factors for this (evidence level 2b). ed or critically ill intensive care patients.
45 elevated upper body position on
respiratory effort have not been suffi- 31 The elevated upper body posi-
ciently documented (evidence level 4, tion of 45 is not recommended in the The elevated upper body position
recommendation grade 0). presence of this/these constellation(s). >30 with bending of the hip can lead
A maximum backrest elevation of 30 to a critical increase of the pressure on
should be conducted in these patients the skin in the sacral area.
Impacts on haemodynamics (evidence level 2b, recommendation 33 It is recommended with critical-
The semi-seated position may cause a re- grade B). ly ill intensive care patients to reduce
duction of cardiac output, blood pressure
bending of the hip while in the elevat-
and peripheral oxygen supply due to a de-
ed upper body position using the anti-
crease of venous return to the heart. Elevated upper body position
Trendelenburg position (evidence lev-
In patients with ARDS, the semi-seat- and intra-abdominal pressure
el 3, recommendation grade 0).
ed position or the anti-Trendelenburg po- Multiple studies [189, 247, 262, 296] de-
sition may cause the recognition of an ex- scribed an increase of intra-abdominal
isting volume deficit [140], which is treat- pressure (diverted through the bladder) Unsuitable positions in
able however through adequate volume within the scope of an increasing elevated intensive care patients
substitution. The right ventricular func- upper body position in cohort studies on
tion is not influenced by the elevated up- intensive care patients (37120 patients), Two positions, namely the supine position
per body position in the case of normo- wherein no critical values (>15mmHg) and the Trendelenburg position are par-
volaemia regardless of mechanical venti- were achieved at the 45 position (evi- ticularly unsuitable for long-term appli-
lation [312]. In contrast, a cardiac output dence level 3). No patients with an exist- cation in critically ill patients and should
decrease may occur in patients follow- ing abdominal disorder or verifiable intra- only be applied in special situations, for
ing abdominal procedures, which how- abdominal pressure increase were found example cardiopulmonary resuscitation,
ever may also be a recognition of persis- in these groups. An overview and evalu- volume deficit shock, insertion of central
tent existing volume deficit [128]. Patients ation of these studies [156] critically dealt venous catheters. However, the position-
after a myocardial infarction individually with the significance of measuring blad- ing wish of the patient must also be tak-
demonstrate very differing changes of the der pressure within the scope of the ele- en into consideration when positioning.
haemodynamics as a reaction to the semi- vated upper body position.
seated position (evidence level 3b).

Der Anaesthesist Suppl 1 2015 | S15

Guidelines and recommendations

Flat supine position Trendelenburg position If the application of the Trendelen-

burg position is absolutely necessary
Definition. The supine position refers to Definition. The Trendelenburg position for special medical or nursing mea-
a position, in which the patient lies flat is a variation of the flat supine position, in sures, it should be limited to a brief
and horizontally on his back. which the head is at the lowest position of period (evidence level 4, recommen-
If someone with a normal weight lies the body through the inclined positioning dation grade A).
in the flat supine position, an increased of the bed. It was used regularly starting in
36 The Trendelenburg position
venous return flow to the heart will oc- 1880 by the surgeon, Friedrich Trendelen-
should principally be avoided in obese
cur. Cardiac output, pulmonary blood burg (*1844, 1924), during urological and
patients (evidence level 3a, recom-
flow and arterial blood pressure increase, gynaecological procedures and remained
mendation grade A).
the functional residual capacity (FRC) de- widely popular in the following decades
creases, the diaphragm is compromised [196, 197].
by the abdomen and limited in its mobil- The Trendelenburg position is an ex- Early mobilisation
ity. Anaesthesia, analgosedation or mus- treme strain on the respiratory and car-
cle relaxants increase the undesired effects diovascular system of the critically ill pa- Definition of mobilisation
[239]. The reduced FRC will also lead to tient. Blood is channelled from the low-
the collapse of small respiratory tracts, to er parts of the body toward the heart and The term mobilisation describes mea-
the formation of atelectasis and to a limit- causes a right heart overload. The ab- sures involving the patient, which intro-
ed pulmonary gas exchange [69]. dominal organs andin the case of the duce and/or assist passive or active move-
The flat supine position can be dan- obesethe abdominal fat masses press ment exercises and which aim to promote
gerous particularly for obese patients. It the diaphragm upward and compromise and/or maintain mobility. In contrast, po-
can lead to acute heart failure, respirato- the lungs. The Trendelenburg position sitioning refers to the change of bodily po-
ry arrest and pronounced pulmonary gas leads to a variety of physiological/patho- sitions with the goal of influencing gravi-
exchange disorders [165, 172, 292, 315]. physiological changes: an increase in the ty-related effects [3, 121, 153, 176].
Death in the extremely obese due to the stroke volume of the heart, the pressure
flat supine position is referred to as obesi- on the central veins and pulmonary arter- Early mobilisation refers to the begin-
ty supine death syndrome [292]. ies, the resistance of the vascular system, ning of mobilisation within 72h after
Expiratory flow impediments, the de- the right and left ventricular end systol- admittance to intensive care.
velopment of an auto PEEP as well as a ic volume index, cardiac output and in-
collapse of small respiratory tracts oc- trathoracic blood volume as well as to re-
curred regularly in mechanically ventilat- duced cerebral blood flow, to reduced sys- Elements of mobilisation
ed obese patients in the flat supine posi- temic oxygenation and an increase of ar-
tion if an external ZEEP (zero endexpira- terial carbon dioxide partial pressure. The Methods for mobilisation are classified in
tory pressure) or too low of a PEEP level FRC decreases; atelectasis formation oc- three areas: passive mobilisation, assisted
was selected [174]. curs [129]. active mobilisation and active mobilisa-
If there is a combination of COPD and The Trendelenburg position is the tion [3, 9, 80, 84, 85, 130, 176, 153, 230, 258,
obesity, a tracheomalacia can only be ex- most hazardous position for the obese 259, 319]. These three areas can be struc-
pected in rare cases (3%) based on a dif- [191, 264]. It should not be applied in tured as follows:
ferential diagnosis, which becomes symp- spontaneously breathing, awake, obese Passive mobilisation:
tomatic in the flat supine position [133, patients. For anaesthesiological and in- 55Passive motions of all extremities in
165]. tensive care interventions (e.g. applying all physiological directions
a central venous catheter, etc.), the obese 55Passive cycling (bed pedal exerciser)
34 The flat supine position should patient should not be placed in the Tren- 55Passive vertical mobilisation (tilting
not be applied in critically ill patients delenburg position. table, standing frame)
due to the numerous unfavourable ef- 55Passive transfer to rehabilitation chair
fects on haemodynamics and pulmo- 35 The Trendelenburg position
nary gas exchange (evidence level 3, should not be applied in critically ill Assisted active mobilisation:
recommendation grade B). patients due to numerous unfavour- 55Active movement exercises in the su-
able effects on haemodynamics, pul- pine position with manual support
If the application of the flat supine po-
monary gas exchange and the respira- 55Independent mobilisation in bed (sit-
sition is absolutely necessary for spe-
tory system (evidence level 3, recom- ting down upright, turning)
cial medical or nursing measures, it
mendation grade B). 55Balance training
should be limited to the shortest pos-
55Assisted cycling
sible period (evidence level 4, recom-
mendation grade A).

S16 | Der Anaesthesist Suppl 1 2015

Active mobilisation: ty, quality of life and discharge from the tiple observational studies [15, 40, 56, 103,
55Sitting on the edge of the bed, tor- hospital. 121, 139, 152, 168, 181, 201, 317]. Bourdin
so control The following prospective randomised et al. [40] systematically compiled 275 in-
55Active mobilisation to the status trials are suitable for an analysis: Morris et terventions, for which 33% of ventilated
55Attempting to stand up, walking exer- al. [199] discovered a substantially short- patients were mobilised. Getting up out
cises while standing er treatment period in the intensive care of the chair (56% of actions) was linked
55Walking with and without walking unit and in the hospital as well as a trend to a substantial reduction in heart and re-
aids for shorter treatment costs in early mobil- spiratory rate; average arterial blood pres-
55Active cycling ised patients. In Burtin et al. [48], signifi- sure and arterial oxygen saturation (pulse
55Isotonic movement exercises with cantly higher muscle strength in the quad- oxymetry) remained unchanged. Contin-
walking aids riceps as well as a significantly higher state ued standing (25%) and walking (11%)
of functional independence (SF-36) after resulted in a heart and respiratory rate in-
Goals of mobilisation discharge was observed following early crease and a significant decrease of arteri-
mobilisation. Schweickert et al.[259] de- al oxygen saturation (evidence level 2b).
The general goals of mobilisation are to scribe a substantially longer walking dis- Kasotakis et al. [152] presented a surgical
promote and maintain mobility as well as tance after intensive care treatment, a sig- intensive care unit optimal mobility score,
to prevent and/or reduce the effects of im- nificantly higher Barthel index, a signifi- which captured the exclusion of serious
mobilisation. Immobilisation refers to the cantly higher state of functional indepen- organ function disorders and the suit-
idle position of the bodily parts or the en- dence (SF-36), a shorter ventilation peri- ability for mobilisation prior to mobilisa-
tire body for the purpose of treatment or od during intensive care treatment and a tion. In one prospective study, this score
for rest (bed rest). Undesired effects of im- trend toward greater probability of dis- proved to be better suitedcompared to
mobilisation are a general deconditioning, charge in the early mobilisation group other general scores (comorbidity index,
the development of a weakness, rapid fa- (allevidence level 2b). Other prospec- APACHE)to determine suitability for
tigue and atrophy of the muscular respira- tive randomised trials with limited qual- mobilisation (evidence level 3).
tory pumps and the skeletal muscles, the ity [35, 52, 55, 64, 82, 208] underscore
development of psycho-cognitive deficits other outcome findingsChen et al. [ 38 Regarding early mobilisation,
and delirium, the emergence of position- 55] detected a lower one-year mortality the following requirements should be
ing-related skin and soft tissue damage as rate among a very small group of patients present or established:
well as the reduction of haemodynamic in the early mobilisation group. Cuesy et 55Customised, score-controlled (e.g.
responsiveness [47, 179]. al. [64] observed a significant reduction RASS) symptom control of pain,
The specific goals of mobilisation con- of incidences of nosocomial pneumo- fear, agitation and delirium ac-
sist in improving/maintaining skeletal nia among stroke patients in the patient cording to the S3 guideline revi-
and respiratory muscle function, increas- group that experienced passive mobili- sion Analgosedation (German
ing haemodynamic responsiveness, im- sation at an early stage (turn-mob). Na- Society of Anesthesia and Inten-
proving central and peripheral perfusion va et al. [208] studied the effect of early sive Care)
and muscle metabolism, increasing cog- mobilisation in patients with COPD dur-
55Sufficient respiratory reserve
nitive competence and mental wellbeing, ing a six-minute walk. The patients of the
reducing incidence and duration of de- group with early mobilisation walked a 55Sufficient cardiovascular reserve
lirium, reducing positioning-related skin significantly longer distance. Bezbaruah The following serve as reference points
ulcers andcompared to patients, who et al. [35] recognised a substantially short- for this: average arterial blood pres-
were not mobilised earlyimproving the er ICU treatment duration in early mobil- sure >65 or <110 mm Hg, systolic
subsequent health-related quality of life isation patients in a small study (allev- blood pressure <200mmHg, heart
[3, 9, 121, 153, 176]. idence level 3). rate >40 or <130/min, arterial oxygen
saturation (pulse oxymetry) 88%, no
Effects of early mobilisation 37 In principle, early mobilisation higher-dosage vasopressor therapy.
on treatment success should be conducted in all patients If cardiopulmonary instability devel-
treated in intensive care, for whom ops during ongoing mobilisation, the
When recording and assessing the effects no exclusion criteria apply (evidence exercise unit should be discontinued
of early mobilisation on the outcome, level 2b, recommendation grade A). until stabilisation returns or conduct-
various relevant parameters are included. ed to an adapted extent (evidence level
These include bodily function outcomes, 2b, recommendation grade A).
peripheral muscle strength and function Patient-related requirements/
of the muscular respiratory pump, neu- suitability for mobilisation
rocognitive competence, ventilator-free
days, ICU stay, hospitalisation, mortali- Patient-related requirements and suitabil-
ity for mobilisation was reviewed in mul-

Der Anaesthesist Suppl 1 2015 | S17

Guidelines and recommendations

Table 5 Components for an early mobilisation algorithm. The essential initial conditions of the patient, the aid to be used, the suitable proce-
dure and formulation of objectives are listed without clear allocation. The allocation is the result of available staff resources and aids of the respec-
tive intensive therapy unit. The stated actions are examples without claim of completeness. Further information can be found at the German Early
Mobilisation Network (
Patient Aid Method Goal
Limited vigilance (RASS 3) Passive motion Prophylaxis of joint contractions and muscle
Passive cycling loss
Increasing vigilance (RASS 3 to 1) Mobilisation chair Activated sitting in bed Prophylaxis of deconditioning and delirium
Tilting table Moving the extremities against gravity
Vertical mobilisation
Passive cycling
(Passive) transfer to mobilisation chair
Return of vigilance Mobilisation chair Active cycling Prophylaxis of deconditioning, delirium and
(RASS 0) (Active) transfer to mobilisation chair pulmonary function disorders
No serious haemodynamic instability Mobilisation chair Standing in front of the bed Prophylaxis of deconditioning, delirium and
Walking exercises while standing pulmonary function disorders
Walking aids Walking with and without walking aid Prophylaxis of deconditioning, delirium and
pulmonary function disorders
RASS Richmond Agitation Sedation Scale.

Criteria for checking the feasibility/ ing/extension of structures of the mechan- admittance to intensive care with a grad-
contraindications or cancellation ical respiratory tract, the infusion lines or ual increase. The actions were conducted
criteria for (early) mobilisation other drainages as well as the monitoring on average or at least 20min twice daily.
of vital parameters during the procedure.
Clearly defined exclusion criteria for ear- 42 Treatment should begin no later
ly mobilisation are not designated in the 40 The preparation of early mobil- than 72h after admittance to inten-
literature. However, the requirement for isation comprises the information of sive care and be conducted twice dai-
mobilisation should be evaluated for cer- the patient, the provisioning of suf- ly with a duration of at least 20min
tain acute situations in a symptom-adapt- ficient staff and the securing/exten- for the length of stay in intensive care.
ed manner. The following examples are sion of structures of the mechanical A gradual approach should be aimed
described in the literature [9, 97, 109, 150, respiratory tract, the infusion lines for starting with passive mobilisation
159, 218, 268, 269, 281, 289, 318]: or other drainages. During mobili- (.Table5). In this regard, the develop-
55increased intracranial pressure sation, the heart rate, blood pressure ment of an algorithm specific to a unit
55active bleeding and arterial oxygen saturation should or hospital is recommended (evidence
55acute myocardial ischaemia be continuously/closed recorded for level 3, recommendation grade B)
55agitated delirium the monitoring of the vital parame-
ters (evidence level 2b, recommenda-
tion grade A). Safety aspects/complications
39 The decision to conduct limited
41 In ventilated patients, the venti- and cancellation criteria within
forms of mobilisation (passive or ac-
lation parameters should be contin- the scope of mobilisation
tive with assistance) with the specified
relative contraindications should be uously featured (tidal volume, inspi-
ratory pressure, respiratory rate, re- The following complications are de-
considered in individual cases in light
spiratory minute volume; in the case scribed in individual cases within the
of the benefits and risks (evidence lev-
of invasively ventilated patients cap- scope of mobilisation: orthostatic dys-
el 2b, recommendation grade A).
nometry) (evidence level 3, recom- regulation, patient fall, disconnection of
mendation grade B) catheters/airway, cardiac dysrhythmias,
Preparation/monitoring respiratory fatigue/dyspnoea and agita-
tion/stress [103, 150, 268, 269]. In a sys-
The preparation for mobilisation and Duration and intensity tematic of overall four studies, no seri-
monitoring of the patient during the ac- of mobilisation ous complications were detected within
tion is described in various observational the scope of mobilisation, which involved
studies or randomised trials [15, 40, 103, In the prospective randomised studies further intervention other than the ter-
139, 152, 168, 181, 201, 317]. This includes [84, 85, 121, 130, 192, 270] deemed suitable mination of the action [150]. Mobilisation
the information of the patient, the provi- for the meta-analyses [3, 121, 176], early should be cancelled in the event of the fol-
sioning of sufficient staff and the secur- mobilisation was started within 72h after lowing signs of intolerance: SaO2<88%,

S18 | Der Anaesthesist Suppl 1 2015

Fig. 29Algorithm for po-
sitioning therapy in inten-
sive care. SP supine posi-
tion, PP prone position, ICP
intracranial pressure, CLRT
continuous lateral rotation
therapy, ARDS acute respi-
ratory distress syndrome,
PEEP positive end-expirato-
ry pressure

heart rate increase >20% or heart rate In consideration for patient-related 43 Cancellation of mobilisation is rec-
<40 or >130/min, newly occurring car- requirements and potential exclusion ommended in the event of the following
diac dysrhythmias, systolic blood pres- criteria as well as compliance with vital parameter changes: SaO2<88%,
sure >180mmHg or mean blood pres- preparation measures, early mobili- heart rate increase >20% or heart rate
sure <65mmHg or >110mmHg (evi- sation presents a safe and uncompli- <40 or >130/min, new cardiac dys-
dence level 2b). Overall, the occurrence cated method. rhythmias, systolic blood pressure
of undesired events provided with an in- >180mmHg or mean blood pressure
cidence of 1.14.4%. <65mmHg or >110mmHg (evidence
level 2b, recommendation grade A).

Der Anaesthesist Suppl 1 2015 | S19

Guidelines and recommendations

Structure/organisation/ tients benefited at which point from elec- 7. Alexiou VG, Ierodiakonou V, Dimopoulos G et
al (2009) Impact of patient position on the inci-
personnel/expense/protocol trical muscle stimulation while in inten- dence of ventilator-associated pneumonia: a me-
sive care [305]. ta-analysis of randomized controlled trials. J Crit
Early mobilisation represents an interdis- At the moment, no recommendation Care 24:515522
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the results of intensive care. The establish- in intensive care patients can be expressed tress syndrome: a meta-analysis. Crit Care Med
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pects was classified as beneficial in multi- 81
Corresponding address 10. Anzueto A, Peters JI, Seidner SR et al (1997) Ef-
ple publications [9, 16, 64, 67, 80, 84, 130,
fects of continuous bed rotation and prolonged
192, 230, 259, 319]. A standard of care is Prof. Dr. Th. Bein mechanical ventilation on healthy, adult ba-
recommended [230], which enables a Clinic for Anaesthesiology boons. Crit Care Med 25:15601564
tiered, customised increase of mobilisa- University Hospital Regensburg 11. Arbeitsgemeinschaft der Wissenschaftlichen
93042 Regensburg Medizinischen Fachgesellschaften (AWMF)
tion in four phases, particularly in ven- (2012)Leitlinie Intrakranieller Druck (ICP)
tilated patients [259] as well. Appropri- Entwicklungsstufe: S1, Stand: September 2012,
ate personnel and spatial requirements Gltig bis: Dezember 2015, AWMF-Registernum-
mer: 030/105
are integrated in this standard of care. In Compliance with 12. Aries MJH, Aslan A, Elting JWJ et al (2012) Intra-
a prospective observation study, the regu- ethical guidelines arterial blood pressure reading in intensive care
lar integration of aphysiotherapist in early unit patients in the lateral position. J Clin Nurs
mobilisation proved to have a better effect Conflicts of interests. Information regarding con-
13. Athota KP, Millar D, Branson RD, Tsuei BJ (2014) A
flicts of interests was requested with the AWMF form.
on outcome parameters compared to ear- Based on a self-assessment on the part of the partici-
practical approach to the use of prone therapy in
ly mobilisation without physiotherapeutic acute respiratory distress syndrome. Expert Rev
pants, there were no relevant conflicts of interest. A
Respir Med 8:453458
aid [131, 270] (evidence level 2b). discussion among the guideline group regarding the
14. Badia JR, Sala E, Rodriguez-Roisin R (1998) Posi-
evaluation of and dealing with conflicts of interest at
tional changes and drug interventions in acute
the onset of the initial guideline meeting found that
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44 A protocol-based approach is the systematic search for and evaluation of evidence
15. Bahadur K, Jones G, Ntoumenopoulos G (2008)
and the additionally structured coordination of
recommended for implementing ear- recommendations was considered adequate under
An observational study of sitting out of bed in
tracheostomised patients in the intensive care
ly mobilisation. Active mobilisation neutral moderation for avoiding risks for bias.
unit. Physiotherapy 94:300305
should be conducted by at least two 16. Balas MC (2000) Prone positioning of patients
qualified staff members; a physiother- Open Access This article is distributed under with acute respiratory distress syndrome: apply-
the terms of the Creative Commons Attribution 4.0 ing research to practice. Crit Care Nurse 20:2436
apist should be regularly integrated. International License ( 17. Balas M, Buckingham R, Braley T et al (2013) Ex-
Sufficient spatial requirements and licenses/by/4.0/), which permits unrestricted use, dis- tending the ABCDE bundle to the post-intensive
resources should be kept. tribution, and reproduction in any medium, provided care unit setting. J Gerontol Nurs 39:3951
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corporated into a set of measures, mons license, and indicate if changes were made. acute respiratory distress syndrome. Intensive
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Guidelines and recommendations

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