critical care Continuous Lateral Rotational Therapy and Nosocomial Pneumonia* Steven A. Sahn, M.D., F.C.C.P.t
(Chest 1991; 99:1263-67) ~LRT = ~ontinuous lateral rotational therapy; ICP = mtr~cramal pressure; ISS= injury severity score; LRTI =lower
resptratory tract infection; SICU =surgical ICU
Healthy man spends most of a day in a variable degree of motion. Even while asleep, he moves about every quarter of an hour. This nocturnal postural change has been termed by Keane the "minimal physiological mobility requirement."• Although daily sleep and bed rest are critical to a normally functioning brain and musculoskeletal system, prolonged immobility can adversely affect not only these systems but also the lungs; the cardiovascular, gastrointestinal and genitourinary systems; and the skin. 2 •3
rotational therapy relate to the eflects of gravity on ventilation and pulmonary blood flow, 12-11 mobilization of secretions, 15 • 16 reduction in venous stasis'l.l 7 and prevention of skin and subcutaneous tissue breakdown.3.IH Surgeons have suspected fi>r yt>ars that mobilizing patients rapidly following surgery reduces the risk of pulmonary complications. 19 Logically, patients who cannot be mobilized from the bed soon after critical illness or surgery are more susceptible to developing pulmonary disease. This review will focus on the consequences of immobilization on the respiratory system and the documented and hypothetical eflects of CLRT on the prevention of LRTis. The optimal utilization and potential complications of CLRT also will he addressed.
HISTORICAL PERSPECTIVE
Thirty years ago, the potential hazards of immobilization were noted by the US Public Health Service.4 In 1967, the first form of rotational therapy fi>r immobile patients was devised by Keane. 5 He hypothesized that frequent automatic turning could be tolerated by the alert patient and could prevent pulmonary complications by promoting improved mobilization of secretions. EFFECTS OF htMOBILIZATION
·In the recumbent position, tidal volume diminishes6 and during sleep, mucociliary transport is decreased; 7 ·H both can result in varying degrees of atelectasis. If immobilization is prolonged, pneumonia is a common sequela of atelectasis and leads to increased patient morbidity, mortality and economic burden.s- 11 Other effects of immobilization on extrapulmonary sites can result in lung sequelae, such as venous thrombosis with pulmonary embolization, skin breakdown and urinary stasis leading to sepsis. The major benefits of *Fmm the Division of Pulmonarv and Critical Care Medicine ' Medical University of South Carolina, Charleston. tPmfessor of Medicine and Diredor, Division of Pulmonarv and Critical Care Medicine. · Reprint requests: Dr Sahn, Pulrrwnary/Critical Can•, 171 A~hlt•y Avenue, Charleston, SC 2942.5
NosocoMIAL PNf
(Chest 1991; 99:1263-67) ~LRT = ~ontinuous lateral rotational therapy; ICP = mtr~cramal pressure; ISS= injury severity score; LRTI =lower
resptratory tract infection; SICU =surgical ICU
Healthy man spends most of a day in a variable degree of motion. Even while asleep, he moves about every quarter of an hour. This nocturnal postural change has been termed by Keane the "minimal physiological mobility requirement."• Although daily sleep and bed rest are critical to a normally functioning brain and musculoskeletal system, prolonged immobility can adversely affect not only these systems but also the lungs; the cardiovascular, gastrointestinal and genitourinary systems; and the skin. 2 •3
rotational therapy relate to the eflects of gravity on ventilation and pulmonary blood flow, 12-11 mobilization of secretions, 15 • 16 reduction in venous stasis'l.l 7 and prevention of skin and subcutaneous tissue breakdown.3.IH Surgeons have suspected fi>r yt>ars that mobilizing patients rapidly following surgery reduces the risk of pulmonary complications. 19 Logically, patients who cannot be mobilized from the bed soon after critical illness or surgery are more susceptible to developing pulmonary disease. This review will focus on the consequences of immobilization on the respiratory system and the documented and hypothetical eflects of CLRT on the prevention of LRTis. The optimal utilization and potential complications of CLRT also will he addressed.
HISTORICAL PERSPECTIVE
Thirty years ago, the potential hazards of immobilization were noted by the US Public Health Service.4 In 1967, the first form of rotational therapy fi>r immobile patients was devised by Keane. 5 He hypothesized that frequent automatic turning could be tolerated by the alert patient and could prevent pulmonary complications by promoting improved mobilization of secretions. EFFECTS OF htMOBILIZATION
·In the recumbent position, tidal volume diminishes6 and during sleep, mucociliary transport is decreased; 7 ·H both can result in varying degrees of atelectasis. If immobilization is prolonged, pneumonia is a common sequela of atelectasis and leads to increased patient morbidity, mortality and economic burden.s- 11 Other effects of immobilization on extrapulmonary sites can result in lung sequelae, such as venous thrombosis with pulmonary embolization, skin breakdown and urinary stasis leading to sepsis. The major benefits of *Fmm the Division of Pulmonarv and Critical Care Medicine ' Medical University of South Carolina, Charleston. tPmfessor of Medicine and Diredor, Division of Pulmonarv and Critical Care Medicine. · Reprint requests: Dr Sahn, Pulrrwnary/Critical Can•, 171 A~hlt•y Avenue, Charleston, SC 2942.5
NosocoMIAL PNf
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