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Physiological Rationale and
Current Evidence for Therapeutic
Positioning of Critically Ill Patients
Karen L. Johnson, RN, PhD
Tim Meyenburg, RN, MS, CNL
ABSTRACT
Prolonged bed rest is common in critically ill
patients, and therapeutic positioning is
important to prevent further complications
and to improve patient outcomes. Nurses
use therapeutic positioning to prevent com-
plications of immobility. This article reviews
therapeutic positions including stationary
positions (supine, semirecumbent with head
of bed elevation, lateral, and prone) and
M ultiple factors relegate critically ill
patients to strict bed rest including
altered level of consciousness, drugs that pre-
vent mobility (paralytics, sedatives), trau-
matic injuries, and surgical complications
(open chest or abdominal cavities). However,
bed rest is associated with multiple compli-
cations that are well documented in the liter-
ature (Table 1). Because critical care nurses
are keenly aware of these complications,
they use clinical judgment in their daily prac-
tice to place bedridden patients in the most
optimal position to prevent these complica-
tions and to improve patient outcomes. The
purpose of this article was to review options
of therapeutic positioning in critically ill
patients. The physiological rationale and
current evidence for stationary and active
repositioning are described. In addition,
positioning of critically ill obese and elderly
patients is discussed.
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AACN Advanced Critical Care
Volume 20, Number 3, pp.228240
In the Public Domain
active repositioning (manual, continuous
lateral rotation, and kinetic therapy). The
physiological rationale and current evidence
for each position are described. Applicable
evidence-based practice guidelines are sum-
marized. Special considerations for thera-
peutic positioning of critically ill obese and
elderly patients are also discussed.
Keywords: critically ill, positioning
Stationary Positions
Supine Position
In the supine position, ventilation and perfu-
sion are greater in dependent areas of the lungs
than in the anterior areas. In healthy lungs,
adequate matching of ventilation and perfu-
sion (V/Q match) can be achieved in the supine
position. In diseased lungs, prolonged place-
ment in the supine position can alter the V/Q
match. For example, excess fluid associated
with pulmonary edema accumulates in the
dependent areas of the lungs and interferes
Karen L. Johnson is Director of Nursing, Research and
Evidence-Based Practice, University of Maryland Medical
Center, 22 S Greene St, 7 Gudelsky, Room C728, Baltimore, MD
21201. She is also Associate Professor, Trauma/Critical Care/
Emergency Nursing Masters Program, University of Maryland,
School of Nursing, Baltimore (kjohnson8@umm.edu).
Tim Meyenburg is Clinical Nurse II, Surgical ICU, University
of Maryland Medical Center, Baltimore.
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Table 1: Complications of Bed Rest
Pulmonary1,2
Atelectasis
Pneumonia
Hypoxemia
Cardiovascular
Venous thromboembolism3
Syncope because of diminished baroreceptor
activity
Skin integrity
Pressure ulcers5
with diffusion of gases across the alveolar-
capillary membranes. Perfusion, however,
remains constant in the dependent areas.
Therefore, there is a V/Q mismatch that results
in an intrapulmonary shunt.
The supine position results in anatomical
changes that alter ventilation and perfusion,
especially in patients with enlarged hearts. In
the supine position, the major part of the left
lower lobe and a significant part of the right
lower lobe are located beneath the heart.6
Enlarged hearts produce an increased pleural
pressure in the dependent areas and contribute
to alveolar collapse.6 Studies using isotope ven-
tilation-perfusion scans in patients with car-
diomegaly and no evidence of pulmonary
pathology have shown a 40% to 50% reduc-
tion in left lower lobe ventilation in a prolonged
supine position with no concomitant reduction
in regional perfusion.7,8 Patients with acute res-
piratory distress syndrome (ARDS) who are
mechanically ventilated while in the supine
position develop atelectasis in the dependent
areas of the lungs.9 Ventilation is impaired by
airway secretions, lung edema, and cardiac and
abdominal compression of the lungs while per-
fusion is maintained, and this results in intra-
pulmonary shunt and severe hypoxemia.10,11
Semirecumbent Position With
Head of Bed Elevation
Head of bed (HOB) elevation is an important
component of the semirecumbent position that
must be considered for patients who are receiv-
ing enteral nutrition to prevent aspiration of
gastric contents and ventilator-associated
pneumonia (VAP). Several studies using radio-
labeled enteral feeding solutions in mechani-
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POSITIONING
cally ventilated patients have reported that
aspiration of gastric contents occurs to a
greater degree when patients are in the supine
position than when they are in the semi-recum-
bent position with the HOB elevated to 30 to
45.1214 Drakulovic and colleagues15 conducted
a prospective, randomized clinical trial to com-
pare continuous HOB elevation of 45 to no
elevation in the early mechanical ventilation
period and found a significantly greater inci-
dence of VAP in patients who did not have
HOB elevation. More recently, this work was
extended by Grap and colleagues,16 who found
that VAP was more likely to occur in patients
who spent more initial mechanical ventilation
time with HOB elevation of less than 30.
Because of these studies, multiple clinical
practice guidelines have stated that the semire-
cumbent position with HOB elevation of 30
to 45 should be used for critically ill patients
to prevent aspiration pneumonia and VAP.
These guidelines include those issued by the
American Association of Critical-Care Nurses
(AACN),17 the Centers for Disease Control
and Prevention,18 the Society of Critical Care
Medicine,19 the American Thoracic Society,20
and the Canadian Critical Care Society.21 In
addition to the benefits of HOB elevation, crit-
ical care nurses need to be aware of the con-
traindications of this position and to apply
appropriate judgment. Contraindications to
HOB elevation, as identified in the AACN
VAP Practice Alert Audit Tool,17 are summa-
rized in Table 2.
Table 2: Contraindications to HOB
Elevation in Critically Ill Patients
Cardiovascular
Low cardiac index
Hypotension
Neurological
Ischemic stroke
Traumatic brain injury
Processes of care
Procedure in progress in which HOB elevation
is inappropriate
Prone position
Medical order for no HOB elevation
Abbreviation: HOB, head of bed.
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JOHNSON AND MEYENBURG
It is important for critical care nurses to rec-
ognize that HOB elevation above 30 may
increase the risk of pressure ulcer formation.
In a study of 57 patients in a surgical intensive
care unit (ICU), patients placed in semi-
Fowlers position had higher sacral tissue
interface pressures when compared with those
placed in other positions, regardless of the
type of pressure redistribution surface
selected.22 These results have been confirmed
in a more recent study involving healthy vol-
unteers. Defloor23 evaluated tissue interface
pressures and found that pressures in the
sacral area were higher when the HOB was
elevated to 90 than when it was elevated to
60. He found that the lowest tissue interface
pressures occurred when patients were placed
in a semi-Fowlers position with the HOB ele-
vated up to 30 and the knees elevated to 30.
The Wound, Ostomy and Continence Nurses
Society recommends maintaining the HOB at
30 elevation for supine positions.24 There are
very few studies to support the use of a special-
ized mattress to reduce elevated sacral pres-
sures caused by HOB elevation, and the results
are inconclusive.25,26
The optimal semirecumbent HOB elevation
position that reduces the development of aspi-
ration pneumonia, VAP, and pressure ulcers is
not known. Until there is further evidence,
nurses must use their judgment on the HOB ele-
vation that is best for each individual patient.
That judgment should be guided by the level of
evidence to support the degree of HOB eleva-
tion. And to that end, as Grap and Munro27
point out, the level of evidence for the use of
lower HOB elevation to prevent sacral pressure
ulcers (1 controlled trial, at least 2 descriptive
case studies or expert opinion) is not as strong
as that for HOB elevation to prevent aspiration
pneumonia and VAP (clinical or epidemiologi-
cal studies or strong theoretical rationale).
Although there is evidence to support HOB
elevation for critically ill patients in the semi-
recumbent position, HOB elevation does not
appear to be routinely implemented among
intubated patients. In a pilot study in 1999,
Grap and colleagues28 found that in 347 meas-
urements of 52 critically ill medical patients,
the mean backrest elevation was 22.9 and
that patients were in the supine position 86%
of the time, despite the presence of enteral
feedings. In a subsequent study in 2003,
involving 506 observations of 170 patients in
several ICUs, the results were worse: Mean
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AACN Advanced Critical Care
backrest elevation was 19, 70% of the
patients were in the supine position, and intu-
bated patients had lower backrest elevations
than did nonintubated patients.29 One expla-
nation for nurses not complying with HOB
elevation may be the inability to accurately
estimate backrest elevation.27
To address these issues, AACN issued a
VAP Practice Alert in 2004.17 The Practice
Alert included a procedure to audit backrest
elevation, suggestions for audit frequency,
and a data collection tool. These efforts seem
to have had a positive effect. A recent survey
of 1200 critical care nurses who attended
the AACN National Teaching Institute as
well as other national educational programs
reported that they maintained the HOB
elevations 30 to 45 most of the time. More
than 85% of the respondents reported that
they maintain HOB elevations 30 to 45 for
their patients 86% of the time.30 The VAP
Practice Alert was recently revised to include
additional sources of evidence and the levels
of evidence to support the Practice Alert
Statements.
The VAP Practice Alert Audit Tool contains
methods to estimate HOB elevation (Figure 1).
Use the built-in angle measurement for HOB elevation if
available.
Use a simple protractor positioned on the horizontal
frame of the bed and the frame of the backrest at the
pivot point of the backrest.
Calculate the angle of the backrest elevation by mea-
suring the length of the backrest from the pivot area
(A on diagram below) to the top of the backrest (B). Then
measure from the top of the backrest (B) straight down to
the horizontal frame of the bed (C). Divide the distance
from B to C by the distance from A to B and take the arc
sine of that product. Angle of backrest  arc sine of
(A to B)/(B to C).
Example: The angle of backrest elevation for a backrest (A to B) which is
32 in, which is 16 in above the frame (B to C), is equal to the arc sine of
32/16  30 degrees.
Figure 1: Methods for Estimating HOB Elevation.
HOB indicates head of bed elevation. Reprinted
with permission from the American Association of
Critical-Care Nurses.115
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Stationary Lateral Positions
The decision to place critically ill patients in
the left or right lateral decubitus position is
based on relevant lung pathology and hemo-
dynamic stability. Studies have shown that
when patients with unilateral lung disease
(pneumonia, atelectasis) are placed with the
consolidated lung in the dependent position,
there is a mismatch of ventilation to perfusion
that results in hypoxemia.3136 Placement of the
diseased lung in the dependent lateral position
results in greater perfusion to a diseased poorly
ventilated lung and impairs gas exchange.
Therefore, patients with unilateral lung
pathology should be placed in a lateral posi-
tion with the good lung down. Even though
this is the golden rule for patients with unilat-
eral disease, there are contraindications to this
position in certain lung pathologies. For exam-
ple, in patients with pulmonary abscesses or
pulmonary hemorrhage, it is important to
keep the affected lung in the dependent posi-
tion so that drainage will not migrate toward
the healthy lung.37,38 In addition, patients with
interstitial emphysema should be placed with
the affected lung in the dependent position to
prevent hyperinflation.38
Although there is evidence to support lat-
eral positioning in patients with unilateral
pulmonary disease, less is known about the
effects of lateral positioning on oxygenation
in patients with bilateral pulmonary disease.
At 10 to 30 minutes after a lateral position
change, cardiac output and heart rate may
not be the same as in the supine position, but
these changes in most mechanically venti-
lated patients are not clinically significant.3943
Early evidence demonstrated that cardiovas-
cular changes can be highly individualized
and may be most prominent in patients with
low cardiac output and in patients who are
hypothermic and/or receiving vasoactive
medications.41 More recent evidence suggests
that lateral positioning of critically ill
patients who are hypoxemic or have low car-
diac output does not further endanger tissue
oxygenation.44
Prone Position
Research demonstrates that prone positioning
in critically ill patients with acute lung injury
and/or ARDS improves pulmonary gas
exchange45,46 and reduces the rate of VAP.47,48
The physiological mechanisms responsible for
improvement in pulmonary gas exchange have
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POSITIONING
not been fully elucidated. Possible mechanisms
may include better drainage of pulmonary
secretions,45 reopening of atelectactic units in
the dorsal regions of the lungs,49 and minimiz-
ing ventilator-induced lung injury.50 The opti-
mal response and beneficial effect of prone
positioning may occur during the early edema-
tous phase of ARDS when atelectasis and lung
edema predominate.51 Despite these improve-
ments in pulmonary gas exchange, 2 recent
studies reported no survival benefit for the use
of the prone position in ARDS.48,52 The ration-
ale for this lack of a survival benefit is not clear
but it should be noted that the average range of
tidal volume given to patients in these studies
was 9 mL/kg, which may have contributed to
ventilator-induced lung injury.53
Alsaghir and Martin54 recently conducted a
systematic review and meta-analysis to assess
the effect of the prone position, as compared to
the supine position, on improvement in oxy-
genation, number of days on the ventilator, VAP,
and mortality. They included 5 randomized con-
trolled trials (n  1316) comparing greater than
6 hours of prone position in adult patients with
ARDS. Prone positioning showed significant
and persistent improvement in PaO2/FIO2 in all
phases of ARDS (Table 3). However, significant
statistical heterogeneity of treatment effect was
found, meaning that the results were highly vari-
able across studies. Sources of clinical hetero-
geneity included when proning was initiated and
the duration of the prone position. Treatment
effect heterogeneity may mask substantial bene-
fit for some, little benefit for others, and harm
for a few.58 There were no significant differences
in number of days on mechanical ventilation or
the incidence of VAP (Table 3). Although no sig-
nificant difference in short-term or long-term
mortality was reported, a couple of studies
showed that prone position significantly
reduced mortality in patients with higher illness
severity (Table 4). Future randomized controlled
trials focusing on early initiation of the prone
position while controlling for time in the prone
position are warranted.
Currently there are no clinical practice
guidelines that recommend the use of prone
positioning to decrease VAP. However, recent
guidelines released by the Society of Critical
Care Medicine recommend prone positioning
in patients with ARDS who require potentially
injurious levels of FIO2 or have elevated plateau
pressures, who are not at high risk for adverse
consequences of positional changes, in facilities
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JOHNSON AND MEYENBURG AACN Advanced Critical Care

Table 3: Results of Meta-analysis on Effects of Prone Positioning on PaO2/FIO2, Days on

Mechanical Ventilation, and Incidence of Ventilator-Associated Pneumoniaa

Number Weighted Mean

Outcome Variables of Studies n Difference 95% CI References

PaO2/FIO2 (12 h2 d) 4 866 51.5 6.9596.05 48, 5557

PaO2/FIO2 (4 d) 3 754 43.87 13.8673.88 48, 56, 57

PaO2/FIO2 (10 d) 4 833 24.89 15.334.48 48, 52, 56, 57

Days on mechanical 2 831 .42 d 1.56 to 0.72 48, 56

ventilation

Incidence of VAP 3 967 0.78% 0.401.51 48, 56, 57

Abbreviations: CI, confidence interval; n, sample size; PaO2/FIO2, ratio of partial pressure of oxygen in arterial blood to the fraction of inspired
oxygen; VAP, ventilator-associated pneumonia.
a
Data are from Alsaghir and Martin.54

that have experience with such practices.19
Adverse consequences include dislodgement of
the artificial airway and enteral feeding tubes,
loss of venous access, development of facial
edema and pressure ulcers, and difficulties
with cardiopulmonary resuscitation. Potential
contraindications to the use of the prone posi-
tion, as summarized by Ball and colleagues,59
are listed in Table 5.
For critical care units that use prone posi-
tioning, evidence-based guidelines for bedside
nurses should be in place. These guidelines
should include indications and contraindica-
tions, preprone assessment and safety prac-
tices, strategies for placing the patient in the
prone position, assessment guidelines for mon-
itoring patient response to the prone position,
and limb positioning while in the prone posi-
tion. The reader is referred to several pub-
lished clinical practice guidelines on the use of
prone positioning in critically ill patients.5961
Active Repositioning
Healthy individuals change positions, even dur-
ing sleep, approximately every 12 minutes.62 A
variety of sensory cues prompt a change in body
position. These sensory cues prevent detrimen-
tal effects of prolonged periods of immobility.
Individuals who have neurological or sensori-
motor impairments must rely on others to repo-
sition them to prevent hazards of immobility.
Manual Repositioning
Repositioning is conceptualized as turning the
patient from side to side when lying in bed or
on a similar surface.6365 Within this context,
the patient is placed in a side-lying position
with the pelvis rotated approximately 30
from the supine position.65 The current stan-
dard of care is to reposition patients every
2 hours. This standard is based on 2 studies
conducted in the early 1960s in healthy indi-
viduals.66,67 Repositioning every 2 hours is the
nursing standard for all immobilized critically
ill patients as documented in nursing text-
books68,69 and national guidelines.70 A survey of
ICU physicians revealed that 83% of respon-
dents agreed that the standard of ICU care is
to turn patients every 2 hours.71 However, a
prospective longitudinal observational study

Table 4: Results of Meta-analysis on Effects of Prone Positioning on Mortalitya

Outcome Variables Number of Studies n Odds Ratio 95% CI References

ICU mortality 3 466 0.79 0.451.39 52, 55, 57

28- to 30-day mortality 3 1231 0.95 0.711.28 48, 52, 57

90-day mortality 4 1271 0.99 0.771.27 48, 52, 56, 57

Mortality with SAPS II 50 2 113 0.29 0.120.70 52, 57

Abbreviations: CI, confidence interval; ICU, intensive care unit; n, sample size; SAPS, Simplified Acute Physiology Score.
a 54
Data are From Alsaghir and Martin.

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Table 5: Potential Contraindications to

conducted at 3 ICUs in 2 states demonstrated
Prone Positioning
this standard was not met.71 In this same study,
74 patients were observed for an average of
Cardiovascular 7.7 hours. Ninety-seven percent of the patients
Hemodynamic instability did not receive the minimum standard of body
repositioning every 2 hours. About half (47%)
Mean arterial pressure  60 mm Hg or systolic
blood pressure  90 mm Hg, regardless of of the observed patients were in the supine
fluid resuscitation or inotropes position for 4 to 8 hours, and 23% of the
patients were not repositioned for more than 8
Recent cardiopulmonary arrest
hours. A more recent study in 40 ICUs in the
Short-term bleeding United Kingdom revealed similar findings:
Ventricular assist devices Patients were in the supine position for 46%
of the observations, with an average time of
Intra-aortic balloon pump
4.85 hours between turns.72 If repositioning
Recent cardiothoracic surgery/unstable mediastinum every 2 hours is the standard of care, these
Trauma results prompt the question, why is the stan-
dard not being met?
Head injury There has been limited investigation into
Spinal cord precautions/injury the reasons why patients are not repositioned.
Multiple trauma
Nurses in long-term care facilities were sur-
veyed and said the chief reasons for not rou-
External pelvic fixation or pelvic fractures tinely repositioning patients were lack of
Rib fractures specific assignment to the task and a lack of
time and staff.73 Although there have been no
Traction
studies published that explain why critically
Neurological ill patients are not repositioned every 2 hours,
Increased intracranial pressure lack of time and staff are the most likely
explanations. Additional factors may include
Seizures
patient intolerance, hemodynamic instability,
Head and neck and pain. Evidence exists to support that
Increased intraocular pressure repositioning critically ill patients is painful.
In AACNs Thunder Project II, a study of
Maxillofacial surgery 6201 critically ill patients revealed that turn-
New tracheostomy (24 h) ing was the most painful routine procedure
Respiratory
performed for adults.74 A smaller, but more
recent, study found similar results as critically
Asthma ill patients reported turning to be the most
Open chest painful routine procedure they experienced.75
This study and others highlight the problem:
Abdominal
Not all patients receive preemptive pain relief
Recent abdominal surgery before repositioning.76,77
Recent stoma formation Strategies to remind staff of the need to turn,
such as playing music over the intercom when
Open abdomen
patients are to be turned and posting signs on
Large abdomen doors alerting staff of patient pressure ulcer
Musculoskeletal risk, have been implemented with some short-
term success.78 The reality is that rigid turning
Kyphoscoliosis schedules in the ICU are difficult to maintain
Advanced osteoarthritis because of treatments, therapies, diagnostic
Rheumatoid arthritis
tests, procedures, and nursing care that require
the patient to be in a supine position.
Others Although the initial question may be to ask
Pregnancy (second/third trimester) why the standard of every 2-hour turning is
not met, perhaps the real question should be,
Weight  135 kg
does repositioning every 2 hours impact

233
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JOHNSON AND MEYENBURG
patient outcomes? The optimal interval for
turning acutely or critically ill patients is not
known. Only one study examined this issue.
Defloor and colleagues79 investigated the
effects of different turning intervals in a ran-
domized controlled trial involving patients in
11 long-term care facilities. They found that
turning patients every 4 hours combined with
the use of a specialized foam mattress signifi-
cantly reduced the incidence of pressure ulcers
compared with turning every 2 hours on stan-
dard hospital mattresses. It would be difficult
to advocate turning patients every 4 hours
rather than every 2 hours based on this 1 study
because there were several methodological
issues with this study including lack of alloca-
tion of interventions, inadequate blinding of
participants and data collectors, and lack of an
intent to treat analysis.
Rotation Therapy
Rotation therapy, including continuous lateral
rotation therapy (CLRT), involves the use of
specialized beds to mechanically turn the
patient from side to side. CLRT uses continuous
turning of a patient up to 40 on each side with
6 to 8 turns an hour. The bed frame rotates the
patient from side to side. Research demon-
strates that patients must be rotated at least 18
hours a day to achieve maximum benefit.8085
Four systematic reviews and meta-analyses
have shown that rotation therapy decreases
the relative risk of VAP but has no benefit on
reducing ICU length of stay or decreasing mor-
tality.81,86,87 Several methodological issues used
in these studies must be highlighted. Many
studies lack (or at least did not report) the use
of rigorous methods to ensure adherence to
manual turning routines in the control groups.
It is not apparent that manual turning was
strictly monitored or enforced.71 Given the
results of 2 studies that revealed critically ill
patients were not turned every 2 hours,71,72
rotation therapy studies may have been com-
paring specialty beds with a control group that
was not turned adequately. Therefore, the
reduction in VAP with the use of rotation ther-
apy may actually be due to being turned,
rather than the specialty bed itself. Future
studies need to include protocols that demon-
strate strict adherence to manual turning.
Despite the number of studies published on
rotation therapy, it remains unclear which
patients are the best candidates for this ther-
apy. This may be in part because few studies
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AACN Advanced Critical Care
have attempted to elucidate the underlying
physiological mechanisms by which rotation
therapy may decrease the development of VAP.
Bein and colleagues88 investigated the effects of
continuous rotational therapy on ventilation-
perfusion in 10 patients with ARDS. By using
the inert-gas elimination technique, they found
that 20 minutes of rotation improved gas
exchange by decreasing low ventilation to
perfusion lung units. They also found that
patients with more severe ARDS did not
improve oxygenation (PaO2/FIO2) with rotation
therapy than did patients with less severe dis-
ease. They speculated that these results were
due in part to the pathophysiological changes
with ARDS over time as the lung evolves from
a wet, heavy, atelectatic lung to a brittle
fibrotic lung. In the early stage of ARDS,
rotation therapy may be effective in altering
the distribution of ventilation and perfusion.
However, late ARDS pathophysiological changes
render position changes ineffective. Further
studies are needed to explain the physiological
basis of rotation therapy.
Current clinical practice guidelines by the
Centers for Disease Control and Prevention
make no recommendations for the use of rota-
tion therapy for the prevention of VAP in criti-
cally ill and immobilized patients.18 However,
more recent guidelines published by the Cana-
dian Critical Care Society recommend clini-
cians consider the use of kinetic beds to
prevent VAP.21
Positioning of the Critically
Ill Obese Patient
Obesity is defined as a body mass index (BMI;
weight [kg]/height [m2]) greater than or equal
to 30.89 According to recent data from the
Centers for Disease Control and Prevention,
more than 20% of American adults are obese
and the number is expected to increase.90 Con-
sequently, as the general population of obese
individuals has increased, so too has the popu-
lation of critically ill obese patients. Position-
ing these patients can be challenging.
Currently, most positioning interventions for
obese patients are only modifications of those
used for nonobese patients.91,92
A task force of the National Association of
Bariatric Nurses developed best practices for
safe handling of obese patients.93 These guide-
lines recommend the establishment of unit-
based multidisciplinary bariatric task forces to
identify high risk tasks and to outline solutions
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especially for repositioning patients in bed.
Caregivers must be knowledgeable about avail-
able technology to assist with positioning, how
to access it quickly, and the weight capacity of
beds and reclining chairs. The VISN 8 Web site
of the Department of Veterans Affairs has a
valuable resource available on its Web site,94
the Safe Bariatric Patient Handling Toolkit,
that contains assessment criteria, algorithms,
equipment lists, and a policy template. A task
that is challenging and places caregivers at high
risk for injury is repositioning an obese patient
up in bed for turning to the side. The use of
manufactured slings can greatly reduce these
risks and allow for repositioning the obese
patient while in bed. An algorithm on reposi-
tioning obese patients in bed (side to side, up in
bed) can be helpful for critical care nurses who
care for these patients (Figure 2).
Positioning Obese Patients to Promote
Adequate Oxygenation
In obese individuals, there are structural and
functional changes that impact ventilation. A
BMI greater than 30 kg/m2 is directly associ-
ated with reductions in all lung volumes, par-
ticularly in expiratory reserve volume and
functional reserve capacity.95 Adipose tissue
deposits in the abdomen, diaphragm, and
intercostal muscles can prevent proper chest
wall expansion and diaphragmatic excur-
sion.91 The airway may be narrowed from adi-
pose tissue deposits in the upper airway, which
can complicate airway management. These
structural changes may lead the obese patient
to experience a hypoventilation syndrome
with chronic hypoxia or obstructive sleep
apnea.91 Obese patients are at risk for more
ventilator days than are nonobese patients and
are more likely to aspirate gastric secretions
because of increased gastric secretions, upper
airway changes, and poor lung volumes.96
These patients are at greater risk for the devel-
opment of atelectasis and pneumonia from
shallow breathing patterns.92 Head of bed ele-
vation of at least 30 improves ventilatory
effort and tidal volume in patients with large
abdomens and reduces the incidence of aspira-
tion in mechanically ventilated patients.97
However, this HOB elevation is often associ-
ated with the patient sinking to the foot of
the bed (Figure 2). This requires additional
personnel to help reposition the patient to the
head of the bed. Useful strategies to counteract
this problem may include the use of an
Page 235
POSITIONING
adjustable footboard against which the patient
can push to move up in the bed, and an over-
bed trapeze that the patient can grasp to lever-
age into a higher position.98
Special care must be taken when placing the
obese patient with large pendulous abdomens
in a lateral position. If allowed to hang over
the side of the bed, they can have the effect of
pulling the patient off the bed via gravity.99
Care must also be taken, in both men and
women, to protect the breasts from compres-
sion injury.
The effects of the prone position in obese
patients have not been thoroughly examined.
The process of placing the obese patient in this
position presents challenges and safety risks for
the patient as well as members of the health care
team. Adequate numbers of staff and appropri-
ate equipment that can tolerate the weight shifts
of obese patients are required.98 A recent case
study of an obese patient with ARDS reported
that the prone position improved alveolar venti-
lation.100 Rossetti and colleagues101 in a study
conducted on ICU patients with ARDS found
that patients with increased body weight had
greater improvement in oxygenation than did
those with less weight. Further research is neces-
sary to strengthen and to support the use of the
prone position for obese patients.
There are specific mattress products that
offer CLRT for obese patients. These products
reduce friction and shear and provide for turn-
ing to maximize respiratory function.92,98 They
include air mattresses that have multiple air
chambers that inflate and deflate to laterally
rotate the patient. One example of this is the
Plexus TruTurn Elite Therapeutic Turning Mat-
tress (Gaymar Industries, Orchard Park, New
York). Nurses should be cognizant of avoiding
the use of the term big boy bed as this an
unnecessary assault on the patients dignity.94
Positioning Obese Patients
to Promote Skin Integrity
Obese patients are more susceptible to pres-
sure ulcers than are nonobese patients for a
variety of reasons including poorly vascular-
ized adipose tissue, additional mass and skin
surface area, limited mobility, improper equip-
ment, and inadequate staff members and staff
who lack training in caring for obese patients.
Standard hospital beds may not provide
enough pressure relief for the obese patient or
may be so narrow that the rails cause pressure
against arms, legs, and hips.102 Properly sized
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JOHNSON AND MEYENBURG AACN Advanced Critical Care

Figure 2: Bariatric Reposition in Bed: Side to Side and Up in Bed. From the Safe Bariatric Patient Handling
Toolkit (www.visn8.med.va.gov/patientsafetycenter/safePTHandling/toolkitBariatrics.asp).

236
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V O L U M E 2 0 N U M B E R 3 J U LY S E P T E M B E R 2 0 0 9
equipment reduces the risk of pressure ulcers
through pressure reduction and promotion of
independence, decreases staff workload, and
increases satisfaction of the obese patient.103 Air
and foam matrix mattresses minimize friction
and shear and therefore reduce the development
of pressure ulcers.91,92,98,104,105 Appropriate bed
frames can be selected for safe mobilization and
positioning of the bedridden patient. Trapezes
are useful for patient positioning because they
allow patients to participate in their own care,
reduce the number of staff required for transfer,
and reduce the risk of friction and shear with
repositioning.102 A bariatric ceiling lift with a
seated sling can be used to transfer patients
from bed to chair if the patient cannot fully or
partially assist.
A multidisciplinary team effort is required
to determine which positioning interventions
are required for critically ill obese patients.
This team effort should be expanded to
encourage proper interventions to ensure
safety for the patient and caregivers.92,98,104 A
prospective, cross-sectional descriptive study
reported that at least 2 staff members were
needed to assist with positioning, and those
with a BMI greater than 40 kg/m2 were most
likely to need at least 4 staff for positioning.98
On the basis of these results, the investigators
recommend using BMI as a trigger for order-
ing rented or stored equipment to promote
timely arrival and intervention.
Positioning of the Critically
Ill Elderly Patient
The overall mortality rate for critically ill
patients older than 65 years is higher than
that for patients younger than 45 years
(36.8% vs 14.8%, respectively).106 Causes for
increased mortality include acute respiratory
failure, use of mechanical ventilation, and
development of complications.107 Pressure
ulcers can increase an elderly patients chances
of mortality in an ICU by 2 to 4 times.108
Regarding such staggering differences in mor-
tality statistics, these numbers are compelling,
particularly when they can be addressed, in
part, by patient positioning.
Positioning Elderly Patients to
Promote Adequate Oxygenation
There are structural and functional changes
that occur with aging that impact ventilation
and increase the risk of respiratory failure and
VAP including reduction in expiratory force,
Page 237
POSITIONING
diminished respiratory muscle strength, poor
mucociliary clearance, increased upper airway
colonization, swallow dysfunction, and dimin-
ished respiratory muscle strength. Elevation of
the HOB should be at least 30 to minimize the
incidence of VAP16 and to improve oxygena-
tion.109 In a study of healthy elderly patients,
Hardie and colleagues110 found that oxygena-
tion was better in the sitting position than in
the supine position; however, further studies in
critically ill patients showing the same results
are needed.
Positioning Elderly Patients
to Promote Skin Integrity
Critically ill elderly patients are at high risk for
the development of pressure ulcers.108,111 Fur-
thermore, and ironically, some research sug-
gests that obesity can reduce the incidence of
pressure ulcers in elderly populations when
compared with optimal weight patients and
underweight patients.112 The authors of the pre-
ceding study postulate that adipose tissue could
potentially provide a type of subcutaneous
cushion dispersing pressure over more tissue.
This research illustrates the point that it is
imperative to provide individualized care to the
elderly critical care patient when addressing
risks for pressure ulcer development. Evidence
exists to support the use of interventions for
general patient populations to address these
risks, such as patient turning in bed, CLRT,
and positioning on a specialty surface113,114;
however, research into the elderly populations
response to these interventions is lacking.
Age-related decreased peripheral perfusion
to the lower extremities in the elderly is a risk
factor for the development of pressure ulcers
on the heels of elderly patients on bed rest.
Cushioning devices, such as foam heel protec-
tors and pillows, are important in the preven-
tion of heel ulcers.
Summary
Nurses use clinical judgment based on physio-
logical and scientific evidence to position criti-
cally ill patients to prevent complications of
immobility and to achieve optimal patient out-
comes. Therapeutic positioning in stationary
positions is done to optimize ventilation and
perfusion and to promote effective pulmonary
gas exchange. In patients with unilateral dis-
ease, optimal gas exchange occurs when the
patient is placed with the good lung down.
Less physiological and scientific evidence exists
237
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JOHNSON AND MEYENBURG
for optimal positioning of patients with bilat-
eral disease. More research is needed. Strong
evidence exists that HOB elevation prevents
VAP. More research is needed to identify the
optimal degree of HOB elevation that
prevents VAP and development of pressure
ulcers. Although research has demonstrated
that prone positioning in patients with ARDS
improves pulmonary gas exchange, the exact
physiological mechanisms responsible for
improvement in pulmonary gas exchange have
not been elucidated. Even though prone posi-
tioning optimizes oxygenation, the use of
this position has not been shown to impact
mortality. The current standard of repositioning
patients is every 2 hours, yet there is little physi-
ological or scientific evidence to support this
standard. Furthermore, it appears that the stan-
dard is often not met. Research is needed to
provide evidence that turning frequency
impacts outcomes. Research has shown that
rotation therapy decreases VAP. However,
methodological issues arise because of lack of
rigorous methods to assess adherence to group
assignments in randomized controlled trials
comparing rotation therapy with conventional
turning methods. More research is needed to
understand physiological and scientific basis of
optimal positioning in select critically ill patient
populations, such as obese and elderly patients.
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hospitalized patients. J Gerontol A Biol Sci Med Sci.
2007;62(11):13101312.
113. Bliss MR. The rationale for sitting elderly patients in
hospital out of bed for long periods is medically unsub-
stantiated and detrimental to their recovery. Med
Hypotheses. 2004;62:471478.
114. Turpin PG, Pemberton V. Prevention of pressure ulcers
in patients being managed on CLRT: is supplemental
repositioning needed? J Wound Ostomy Continence
Nurs. 2006;33:381388.
115. American Association of Critical-Care Nurses. Practice
Alert: Audit of HOB Elevation in Intubated Patients.
http://www.aacn.org/WD/Practice/Docs/VAPAudit_HOB
_Elevation01-2008.pdf. Accessed June 30, 2009.
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AACN
ADVANCED CRITICAL CARE
Test writer: Denise Hayes, RN, MSN, CRNP
Contact hour: 1.0
Category: A, Synergy CERP A
Passing score: 9 correct (75%)
CE Test Instructions
To receive CE credit for this test (ID# ACC2032), mark your answers on the form below, complete the
enrollment information and submit it with the $10 processing fee (nonmembers only; payable in US funds)
to the American Association of Critical-Care Nurses (AACN). Answer forms must be postmarked by
September 1, 2011. Within 3 to 4 weeks of AACNs receiving your test form, you will receive an AACN
CE certificate.
The American Association of Critical-Care Nurses (AACN) is accredited as a provider of continuing nursing education by the
American Nurses Credentialing Centers Commission on Accreditation. AACN has been approved as a provider of continuing
education in nursing by the State Boards of Nursing of Alabama (#ABNP0062), California (#01036), and Louisiana (#ABN12).
AACN programming meets the standards for most other states requiring mandatory continuing education credit for relicensure.

CE Test Form

Physiological Rationale and Current Evidence Test ID#: ACC2032

FORM EXPIRES
for Therapeutic Positioning of Critically Ill Patients September 1, 2011
Fee: $10.00 (no fee for
Mark your answers clearly in the appropriate box. There is only one correct answer
members of AACN)
per question. You may photocopy this form.
A B C D A B C D A B C D
1. 5. 9.
2. 6. 10.
3. 7. 11.
4. 8. 12.

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Mail To: AACN
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Aliso Viejo, CA 92656 Or take test online at
www.aacn.org>Continuing Education

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CE Test Questions

Physiological Rationale and Current Evidence

for Therapeutic Positioning of Critically Ill Patients
Objectives:
Upon completion of this article, the reader will be able to:
1. Understand the role of therapeutic repositioning in preventing complications and improving critically ill patient out-
comes.
2. Describe the physiological rationale for stationary and active repositioning.
3. Recognize special considerations for therapeutic repositioning of critically ill obese and elderly patients.

1. What complication of bed rest is caused by diminished 8. According to Alsaghir and Martin, what is an effect of
baroreceptor activity? prone positioning?
a. Hypoxemia a. Decreased number of mechanical ventilation days
b. Venous thromboembolism b. Decreased VAP incidence
c. Syncope c. Improved PaO2/FIO2
d. Atelectasis d. Decreased mortality
2. How does prolonged placement in the supine position 9. Which is a potential contraindication to prone
affect patients with diseased lungs? positioning?
a. They have a normal ventilation/perfusion ratio. a. New tracheostomy (24 h)
b. They develop alveolar dead space. b. Weight of 130 kg
c. They have a high ventilation/perfusion ratio. c. Systolic blood pressure of 100 mm Hg
d. They develop an intrapulmonary shunt. d. Mean arterial pressure of 70 mm Hg
3. What head of bed (HOB) elevation do multiple clinical 10. In AACNs Thunder Project II, what was the most
practice guidelines recommend for critically ill painful routine procedure performed in adults?
patients in the semirecumbent position? a. Endotracheal tube suctioning
a. 10 to 25 degrees b. Arterial blood gases
b. 30 to 45 degrees c. Turning
c. 50 to 65 degrees d. Venipuncture
d. 75 to 90 degrees 11. In addition to expiratory reserve volume, what lung
4. Which is a contraindication to HOB elevation? volume is primarily reduced in patients with a body
a. Enteral nutrition mass index greater than 30 kg/m2?
b. Mechanical ventilation a. Functional reserve capacity
c. Hypertension b. Forced vital capacity
d. Ischemic stroke c. Inspiratory reserve volume
5. What is a possible risk of HOB elevation above d. Residual volume
30 degrees? 12. What structural and functional change of aging
a. Low sacral tissue interface pressures increases the risk of respiratory failure and VAP?
b. Pressure ulcers a. Increased expiratory force
c. Aspiration pneumonia b. Swallow dysfunction
d. Ventilator-associated pneumonia (VAP) c. Decreased upper airway colonization
6. A patient with which diagnosis should be positioned d. Increased respiratory muscle strength
with the unaffected lung in the dependent position?
a. Pneumonia
b. Interstitial emphysema
c. Pulmonary abscess
d. Pulmonary hemorrhage
7. Which position improves pulmonary gas exchange in
patients with acute lung injury and/or acute respiratory
distress syndrome?
a. Supine
b. Semirecumbent with HOB elevation
c. Left lateral decubitus
d. Prone

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