1 Physiology and Clinical Benefits of Kinetic Therapy and Prone Positioning Frank Sebat, MS, MD, FCCP Kritikus Foundation · Redding, California.

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Physiology and Clinical

Benefits of

Kinetic Therapy and

Prone Positioning

Frank Sebat, MS, MD, FCCPKritikus Foundation · Redding, California

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Positional Therapy

• Body movement and frequent posture changes are the norm

• The supine position is uncommon and deleterious

• Patients are nursed in the supine position

Will frequent positional changes > 40° rotationWill frequent positional changes > 40° rotationand proning improve patient outcomes?and proning improve patient outcomes?

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Immobility Is A Disease

• Skin breakdown

• Atelectasis

• Pneumonia

• Decreased gut motility

• Vascular stasis

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Standard of Practice for the Treatment of Immobility

• Turning q 2 hours by nursing

– Developed by Dr. Monroe in 1940’s to prevent skin breakdown

– Little evidence regarding pulmonary complications

– Compliance is difficult

– Inconsistency to the degree of rotation

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Mother Nature’s Answer to Positional Changing

Minimum Physiologic Requirement, Studied and Published by Dr. Francis Keane who developed

the first RotoRest

Minimal mobility requirement = 11.6

minutes

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Defined by the CDC

to be Continuous

Rotation > 40°

Kinetic Therapy

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Alternatives to Immobility in Critical Care

45°45°

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Alternatives to Immobility in Critical Care

62°

62°

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Alternatives to Immobility in Critical Care

248°

248°

A Proning Bed WithKinetic

Therapy

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A Proning Bed

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No Proven Outcomes In Rotation < 40°

Witerman, K, et al. Effects of Continuous Lateral Rotation Therapy on Pulmonary Complications in Liver Transplant Patients. American Journal of Critical Care, March 1995; 4:133-139.

N=69

Traver, GA, et al. Continuous Oscillation: Overcome in Critically Ill Patients, Poster presented at the 1993 ALA/ATS International Conference, San Francisco, California.

N=103

Macintyre, N., MD, et al. Automated Rotational Therapy for the Prevention of Respiratory Complications during Mechanical Ventilation. Respiratory Care, December 1999; Vol. 44, No. 12

N=104Macintyre, N., MD, et al. Automated Rotational Therapy for the Prevention of Respiratory Complications during Mechanical Ventilation. Respiratory Care, December 1999; Vol. 44, No. 12

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45° Combined Kinetic Therapy and Percussion Therapy on the Resolution of Atelectasis on Critically Ill Patients. • Recruitment of Segmental lobar or whole-lung

atelectasis with reduced need for bronoscopy. Raoof, Suhail, MD, FCCP; et al.. CHEST, 1999; 115; 1658-1666.

40-62°Kinetic Therapy in Critically Ill Patients; Combined ResultsMeta Analysis n= 419

• 24% reduction in ICU stay p < .02

• 35% reduction in hours intubated p < .04

• 50% reduction in ICU-acquired pneumonia p < .002

Choi, SC: Nelson. LD.. Journal of Critical Care, March 1992.

Benefit of Rotation > 40°

n=24test-17control-7

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• 23% reduction in pneumonia

• 24.5 days shorter median hospital length

of stay among survivors

• 42% reduction in median days of intubation

Fink, MP, MD; Helsmoortel, CM, RN, et al;, CHEST, Vol.97, 132-137

n=106Test-51Control-48Excluded-7

P=.006

P=.002

P=.05

Benefit of Rotation > 40°

The Efficacy of an Osculating Bed in the Prevention of Lower Respiratory Tract Infection in Critically Ill Victims of Blunt Trauma

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Physiology of Positional Therapy

• Pleural gradient

– Triangular shape of lung with more mass posterior than anterior

– Position of the diaphragm

– Position of the heart

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Physiology of Positional Therapy

• Mobilization of secretions

• V/Q matching

• Restriction of anterior chest (proning)

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Pleural Gradient

-10

0 + 1

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Proning -- Just Good Horse Sense

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Pleural Gradient

-10

-5

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Pleural Gradient

-10

+10 to +15

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Pleural Gradient

-5 to -10

-5

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Redding California’s Introduction to Kinetic Therapy 1992

Dr. Johnson’s

ARDS Patient

on RotoRest

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• Apx. 1000 patients with ALI/ARDS treated with RotoRest with 62° rotation in the last 12 years

– Increase need of sedation

– Minimal to no hemodynamic instability

– RNs request RotoRest prior to physicians

– 14 Intensivists, 90 critical care beds in community all use RotoRest and now RotoProne for management of ALI/ARDS

Redding California’s Experience with Kinetic Therapy 1992-2004

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Results of Proning Studies

• A large number of small studies demonstrate:

– Improved P/F ratio

– Patient safety

– Requires 4-5 nurses and 1 physician

– Often used as a rescue method when other methods fail

– Convincing data lacking regarding morbidity and mortality

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Prone position as prevention of lung injury in comatose patients: a prospective, randomized, controlled study.

Beuret P, Carton MJ, Nourdine K, Kaaki M, Tramoni G, Ducreux JC: Intensive Care Med 2002; 28(5):564-569

51 Patients who required invasive mechanical ventilation because of coma with GCS < 9

• 25 Prone Group, 26 Supine Group

• Baseline Characteristics were similar

• VAP = 20% in PP vs. 38.4% in SP, p=.14

• Lung worsening in the PP = 12% vs. SP = 50%, P = .003

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Prone vs. Supine Position in ARDS Patients. Results of a Randomized Multicenter Trial[A094] [Poster: 920] J. Mancebo, G. Rialp, R. Fernndez, F. Gordo, R.K. Albert. Hospital de Sant Pau and the Spanish ARDS RCT on PP vs SP, Barcelona, Barcelona, Spain; Denver Health Medical Center, Denver, CO

Supine (n 58) Prone (n 75)

Age 54±17 55±17

SAPS II 38±15 43±15

PaO2 (mmHg) 128±95 108±66

FiO2 .77±.25 .83±.22

PaCO2 (mmHg) 43±11 45±9

Time Proned 0/24 hrs 20/24 hrs

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Prone vs. Supine Position in ARDS Patients Results of a Randomized Multicenter Trial

[A094] [Poster: 920] J. Mancebo, G. Rialp, R. Fernndez, F. Gordo, R.K. Albert. Hospital de Sant Pau and the Spanish ARDS RCT on PP vs SP, Barcelona, Barcelona, Spain; Denver Health Medical Center, Denver, CO

Supine (n 58) Prone (n 75)

RR (bpm) 19±4 20±4

PEEP (cmH2O) 12±2 12±2

VT (ml/kg) 8.1±1.4 8±1.7

Pplat (cmH2O) 32±4 33±5

ICU Mortality 58.6% 44.4%

Conclusion: A 14.2% absolute and a 25% relative reduction in mortality after adjusting for the difference in severity of illness p=.017

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Proning Pilot Study

• 19 patients randomized:– 2 hr Sup/ 2hr Pro……………..…..…12 hr prone

– 45 min Sup/ 3 hr 15 min Pro……….19.5 hr prone

• Purpose:– Feasibility– Safety– Segregation of responders

The utility of an automated proning and kinetic therapy-unit with intermediate versus long proning time and its effect on lung recruitment and ventilator days in patients with acute lung injury (ALI)

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Responds to Proning?

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Baseline Characteristics of Rotoprone Trial

Group 1

12 hours of proning

Group 2

19.5 hours of proning

p value

Patients 10 9

Age 61 57.8 .70

APS-Day 1 60.9 54.3 .52

APACHE III-Day1 72.7 64.7 .49

LIS 3.2 (10) 3.1 (9) .58

P/F Ratio 125.5 (10) 131.0 (9) .77

Compliance 33.7 (10) 35.3 (9) .77

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Results

Group 1

12 hours of proning

Group 2

19.5 hours of proningp value

Goal: Proning Time 50% 81.25%

Actual: Time proned 41.7% 63.5%

Hospital length of stay 36.2 29.1 .571

Mortality 40.0% (4) 22.2% (2) .631

Predicted mortality 36% 30%

1After accounting for difference in severity of illness

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Lung Injury ScoreLung Injury ScoreGroup 1: 12 Hr of proning / 24 hr / 2 hr intervalsGroup 2: 19:30 hrs proning / 24 hrs /:45 m supine vs. 3:15 hr prone

Initial Day Day 3

Group 1

Group 2

2.8

2.3

3.2

3.1

2.0

2.5

3.0

3.5

4.0

P = 0.13

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P/F Ratio and Compliance

200-

100-

50-

25-

P/F Ratio and ComplianceGroup 1: 12 Hr of proning / 24 hr / 2 hr intervalsGroup 2: 19:30 hrs proning / 24 hrs /:45 m supine vs. 3:15 hr prone

166.7

188.5

125.5

131.0

Initial Day Day 3

Group 1

Group 2

P/F Ratio

31.6

41.0

33.7

35.3

Compliance

P=0.55

P=0.25

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Bed, Ventilator, ICU Days

Group 1: 12 Hr of proning / 24 hr / 2 hr intervalsGroup 2: 19:30 hrs proning / 24 hrs / :45 m supine vs. 3:15 hr prone1After accounting for difference in severity of illness

5.1

19.9

24.2 23.7

3.7

10.5

15.6

10.9

0

10

20

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Therapy Unit Days Ventilation Days ICU Length of Stay Ventilation Days of

Survivors

Group 1

Group 2

P value .251 .131 .191 .171

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Homo vs. Hetero ALI by CT Distribution

Homo1 Hetero2 p value

Patients CT Scans at Enrollment 5 14

APS-Day 1 43.8 62.8

APACHE III-day1 53.8 74.3 .11

Actual Mortality (%, n ) 60.0 (3)21.0

(3) .054*

Repeat CT Findings-Improved 3 of 3 9 of 9

* After accounting for difference in severity of illness1heterogeneous i.e., dorsal consolidation generally with ventral sparing2homogeneous i.e., diffused pan-lung infiltrates

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Adverse Events

• Facial edema 100%

• Right mid auxiliary line/chest skin breakdown (1 patient)

• Self Extubation (1 patient)

• Poorly functional groining CVVH catheter (1 patient)

• Scleral hemorrhage (2 patients)

• No hemodynamic or respiratory instability requiring discontinuation of proning

• Rapid mobilization of copious endotracheal secretions in patents with pneumonia

At EnrollmentAt 2 Days of Proning

Patient #1

At EnrollmentAt 2 Days of Proning

Patient #1

At EnrollmentAt 2 Days of Proning

Patient #1

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At EnrollmentAt 2 Days of Proning

Patient #2

41

At EnrollmentAt 2 Days of Proning

Patient #2

At EnrollmentAt 2 Days of Proning

Patient #3

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At EnrollmentAt 2 Days of Proning

Patient #4

44

At EnrollmentAt 2 Days of Proning

Patient #4

45

At EnrollmentAt 2 Days of Proning

Patient #4

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At EnrollmentAt 2 Days of Proning

Patient #4

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Before Bed Placement

48 hours After Bed Placement

17 y.o. w/ Tricuspid Endocarditis

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Before Bed Placement

48 hours After Bed Placement

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Before Bed Placement

48 hours After Bed Placement

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Before Bed Placement

48 hours After Bed Placement

Evaluation of Density Area in Dorsal Lung Region During

Prone Position Using Transesophageal Echocardiography

Tsubo T, Yatsu Y, Tanabe T, Okawa H, Ishihara H, Matsuki AUniversity of Hirosaki School of Medicine, Hirosaki, Aomori-ken, Japan

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AO, ascending aorta CW, chest wall DA, descending aorta

DE, density area ES, esophagus LA, left atrium

LV, left ventricle PE, pleural effusion

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Transesophageal Echocardiography Image During Prone Position

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Conclusion: Kinetic Therapy with > 40° Rotation

• Reduction in ventilator associated pneumonia and possibly hospital days

• Reduction in atelectasis and need for bronchoscopy

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Conclusion: Automated Proning

• Restriction of anterior chest with possible reduction in VILI

• Rapid mobilization of secretions

• Improvement in oxygenation /Rapid recruitment of posterior consolidation

• Accomplished with one nurse

• 20 hrs proning per day well tolerated and trended toward better outcomes compared to 12 /24 hrs

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Conclusion: Other Possible Benefits

• Reduction of sinusitis

• Reduced skin breakdown

• Increased output from abdominal drains