Lateral positioning for critically ill adult patients

We reviewed the evidence on the effects of turning critically ill adults from side to side while lying on a hospital bed. We found 24 studies.

Background

Nurses change the body position of critically ill patients as frequently as every two hours to prevent bed sores and other complications associated with immobility. Turning from side to side may also help loosen and drain secretions accumulated within the lungs. Routine lateral repositioning is a relatively safe standard practice. However, if a patient's blood pressure or oxygen level drops to a dangerously low reading during the position change, urgent medical attention is required. Most events resolve quickly, but for some patients these events may be slow to resolve and are potentially life-threatening. We wanted to discover whether routine lateral repositioning is better than other positioning strategies including less frequent turns, and whether a lateral position may cause more adverse events.

Search date

The evidence is current to May 2015.

Study characteristics

We included randomized studies of critically ill adults receiving treatment in intensive care units and in other critical care areas. We selected studies that included lateral positioning after a single turn or following repetitive turns. The duration of each body position was 10 minutes or longer. Comparisons included the other lateral position (opposite side), as well as supine (lying on your back), semi recumbent (lying on your back with your upper body elevated to a 45-degree angle) and prone (lying on your stomach) positions.

Results

We found 24 eligible studies. No studies reported on mortality. Two studies reported on pulmonary morbidity following cardiac surgery, but available data were insufficient for analysis. The other studies reported measures that we included to identify clinical adverse events. Most of these studies did not report results in a way that could be combined for review of evidence, and trial design was often dissimilar. We compared two studies of critically ill adults with unilateral lung disease (one 'bad lung' and one 'good lung'). Oxygen levels within the blood were lower for 'bad lung down' (side lying with the 'bad lung' lowermost). However, the sample was small, both studies were of poor quality and very low oxygen levels in the blood were not consistently found across studies. Therefore, results need to be viewed with caution.

Conclusion

We found no clear evidence on the effectiveness of routine lateral repositioning or the effects of a single turn for critically ill patients. Good quality studies are needed to find out whether routine lateral repositioning is still recommended for most critically ill patients, and whether one body position is best avoided for some.

Authors' conclusions: 

Review authors could provide no clinical practice recommendations based on the findings of included studies. Available research could not eliminate the uncertainty surrounding benefits and/or risks associated with lateral positioning of critically ill adult patients. Research gaps include the effectiveness of lateral positioning compared with semi recumbent positioning for mechanically ventilated patients, lateral positioning compared with prone positioning for acute respiratory distress syndrome (ARDS) and less frequent changes in body position. We recommend that future research be undertaken to address whether the routine practice of repositioning patients on their side benefits all, some or few critically ill patients.

Read the full abstract...
Background: 

Critically ill patients require regular body position changes to minimize the adverse effects of bed rest, inactivity and immobilization. However, uncertainty surrounds the effectiveness of lateral positioning for improving pulmonary gas exchange, aiding drainage of tracheobronchial secretions and preventing morbidity. In addition, it is unclear whether the perceived risk levied by respiratory and haemodynamic instability upon turning critically ill patients outweighs the respiratory benefits of side-to-side rotation. Thus, lack of certainty may contribute to variation in positioning practice and equivocal patient outcomes.

Objectives: 

To evaluate effects of the lateral position compared with other body positions on patient outcomes (mortality, morbidity and clinical adverse events) in critically ill adult patients. (Clinical adverse events include hypoxaemia, hypotension, low oxygen delivery and global indicators of impaired tissue oxygenation.) We examined single use of the lateral position (i.e. on the right or left side) and repeat use of the lateral position (i.e. lateral positioning) within a positioning schedule.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 5), MEDLINE (1950 to 23 May 2015), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 to 23 May 2015), the Allied and Complementary Medicine Database (AMED) (1984 to 23 May 2015), Latin American Caribbean Health Sciences Literature (LILACS) (1901 to 23 May 2015), Web of Science (1945 to 23 May 2015), Index to Theses in Great Britain and Ireland (1950 to 23 May 2015), Trove (2009 to 23 May 2015; previously Australasian Digital Theses Program (1997 to December 2008)) and Proquest Dissertations and Theses (2009 to 23 May 2015; previously Proquest Digital Dissertations (1980 to 23 May 2015)). We handsearched the reference lists of potentially relevant reports and two nursing journals.

Selection criteria: 

We included randomized and quasi-randomized trials examining effects of lateral positioning in critically ill adults. We included manual or automated turns but limited eligibility to studies that included duration of body position of 10 minutes or longer. We examined each lateral position versus at least one comparator (opposite lateral position and/or another body position) for single therapy effects, and the lateral positioning schedule (repeated lateral turning) versus other positioning schedules for repetitive therapy effects.

Data collection and analysis: 

We pre-specified methods to be used for data collection, risk of bias assessment and analysis. Two independent review authors carried out each stage of selection and data extraction and settled differences in opinion by consensus, or by third party adjudication when disagreements remained unresolved. We planned analysis of pair-wise comparisons under composite time intervals with the aim of considering recommendations based on meta-analyses of studies with low risk of bias.

Main results: 

We included 24 studies of critically ill adults. No study reported mortality as an outcome of interest. Two randomized controlled trials (RCTs) examined lateral positioning for pulmonary morbidity outcomes but provided insufficient information for meta-analysis. A total of 22 randomized trials examined effects of lateral positioning (four parallel-group and 18 cross-over designs) by measuring various continuous data outcomes commonly used to detect adverse cardiopulmonary events within critical care areas. However, parallel-group studies were not comparable, and cross-over studies provided limited data as the result of unit of analysis errors. Eight studies provided some data; most of these were single studies with small effects that were imprecise. We pooled partial pressure of arterial oxygen (PaO2) as a measure to detect hypoxaemia from two small studies of participants with unilateral lung disease (n = 19). The mean difference (MD) between lateral positions (bad lung down versus good lung down) was approximately 50 mmHg (MD -49.26 mmHg, 95% confidence interval (CI) -67.33 to -31.18; P value < 0.00001). Despite a lower mean PaO2 for bad lung down, hypoxaemia (mean PaO2 < 60 mmHg) was not consistently reported. Furthermore, pooled data had methodological shortcomings with unclear risk of bias. We had similar doubts regarding internal validity for other studies included in the review.

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