Continuous Lateral Rotation Therapy Research Articles

Efficacy of Continuous Lateral Rotation Therapy in Mechanically Ventilated Critically Ill Adults on Clinical Outcomes.

Background: This PICO-guided systematic review assessed continuous lateral rotation therapy (CLRT) versus conventional position changes in mechanically ventilated critically ill adults, evaluating mortality, intensive care unit (ICU) and hospital stay duration as primary outcomes, and respiratory function, mechanical ventilation duration, pulmonary complications, and adverse events, as secondary outcomes. Methods: A systematic review followed PRISMA criteria (PROSPERO CRD42022384258). Searches spanned databases: MEDLINE/PubMed, EMBASE, Scopus, ScienceDirect, Cochrane, CINAHL and Web of Science, without language or publication year restrictions. Inclusion criteria involved randomized (RCT) and quasi-randomized trials, comparing CLRT (intervention) with conventional position changes (control). Risk of bias and quality of evidence for RCTs were assessed using the Cochrane collaboration and GRADE tools. For the quasi-randomized trials, the ROBINS-I tool was used. Results: In 18 studies with 1.466 participants (intervention, n= 700, 47.7%; control, n= 766, 52.2%), CLRT was predominantly used for prophylactic purposes, with protocols varying from 10 to 24 hours/day. Meta-analysis (16 RCTs) favored CLRT for reduced mechanical ventilation duration (SMD -0.17 days, CI -0.29 to -0.04, p=0.008) and lower nosocomial pneumonia incidence (OR 0.39, CI 0.29 to 0.52, p<0.00001). CLRT showed no significant impact on mortality (OR 1.04, CI 0.80 to 1.34, p= 0.77), ICU stay (SMD -0.11 days, CI -0.25 to 0.02, p= 0.11), hospital stay (SMD -0.10 days, CI -0.31 to 0.11, p= 0.33) and incidence of pressure ulcers (OR 0.73, CI 0,34 to 1.60, p= 0.44). Conclusions: CLRT showed no significant difference in primary outcomes (mortality, ICU, and hospital stay duration) but revealed significant differences in secondary outcomes (consistently reduced nosocomial pneumonia, with a minor effect on MV duration), supported by moderate certainty. Very low certainty for other outcomes highlights the need for current studies in diverse clinical settings and protocols to assess CLRT effectiveness.

Critical Care Beds With Continuous Lateral Rotation Therapy to Prevent Ventilator-Associated Pneumonia and Hospital-Acquired Pressure Injury: A Cost-effectiveness Analysis.

Mechanical ventilation increases the risk of hospital-acquired conditions (HACs) such as ventilator-associated pneumonia (VAP) and pressure injury (PrI). Beds with continuous lateral rotation therapy (CLRT) are shown to reduce HAC incidence, but the value of switching to CLRT beds is presently unknown. We compared the cost-effectiveness of CLRT beds with standard care in intensive care units. A cost-effectiveness analysis from the healthcare sector and societal perspectives was conducted. A Markov model was constructed to predict health state transitions from time of ventilation through 28 days for the healthcare sector perspective and 1 year for the U.S. societal perspective. Value of information was calculated to determine whether parameter uncertainty warranted further research. Our analysis suggested that CLRT beds dominate standard care from both perspectives. From the healthcare sector perspective, expected cost for CLRT was U.S. $47,165/patient compared with a higher cost of U.S. $49,258/patient for standard care. The expected effectiveness of CLRT is 0.0418 quality-adjusted life years/patient compared with 0.0416 quality-adjusted life years/patient for standard care. Continuous lateral rotation therapy dominated standard care in approximately 93% of Monte Carlo simulations from both perspectives. Value of information analysis suggests that additional research is potentially cost-effective. Continuous lateral rotation therapy is highly cost-effective compared with standard care by preventing HACs that seriously harm patients in the intensive care unit.

PMD53 - Cost-Effectiveness and Return on Investment of Continuous Lateral Rotation Therapy to Prevent Ventilator-Associated Pneumonia and Pressure Injuries in the Critical Care Setting

PMD53 - Cost-Effectiveness and Return on Investment of Continuous Lateral Rotation Therapy to Prevent Ventilator-Associated Pneumonia and Pressure Injuries in the Critical Care Setting

PD76 The Value Of Continuous Lateral Rotation Therapy In The ICU

Introduction:Mechanical ventilation in the intensive care unit (ICU) increases the risk of hospital-acquired conditions (HACs) such as ventilator-associated pneumonia (VAP) and pressure injuries (PrI). Continuous lateral rotation therapy (CLRT) has been shown to reduce VAP and PrI incidence, but the value of switching to CLRT over standard care is presently unknown. We evaluate the cost-effectiveness of CLRT beds compared to standard care in ICUs and determine the return on investment (ROI) associated with its implementation.Methods:A Markov model was constructed to predict health state transitions from the time of ventilation through 28 days using the healthcare sector perspective. Daily transition probabilities were extrapolated from prospective clinical studies comparing CLRT with standard care. Costs were estimated in 2014 USD. Utility scores were extracted from the published literature. Cost per quality-adjusted life-years (QALYs) was calculated and sensitivity analyses were conducted. A secondary analysis from a societal perspective with a one-year time horizon included the costs of patient and caregiver lost productivity. ROI analysis was performed to estimate the net benefit and breakeven point of the investment. Value of Information analysis was performed to determine whether further research is warranted.Results:From both perspectives, CLRT was dominant. From the healthcare sector perspective, the expected cost for CLRT per patient was USD 47,165 compared to standard care at USD 49,258 per patient, showing that CLRT saves cost per patient. The expected effectiveness of CLRT per patient was 0.0418 QALYs compared to 0.0416 QALYs for standard care. CLRT was dominant in 99.94 percent of Monte Carlo simulations. CLRT also reached the break-even point after 5 months. Expected Value of Perfect Information was equal to 0.019, indicating little value of additional evidence at the current level of parameter uncertainty.Conclusions:CLRT is highly cost-effective compared to standard care by preventing ventilator-associated infections and PrIs in an ICU setting.

The Value Of Beds With Continuous Lateral Rotation Therapy To Prevent Ventilator-Associated Pneumonia And Pressure Injuries: A Cost-Effectiveness Analysis

Immobility of mechanically ventilated patients in the intensive care unit (ICU) increases the risk of pulmonary complications and hospital-acquired conditions (HACs) such as ventilator-associated pneumonia (VAP) and pressure injuries (PrI). Continuous lateral rotation therapy (CLRT) has been shown to reduce the incidence of VAP and PrI, but the economic value of switching to CLRT over standard care is presently unknown. The objective of this study is to evaluate the cost-effectiveness of CLRT specialty beds compared to standard care in ICUs and to determine the return on investment (ROI) associated with its implementation. A Markov model was constructed to predict health state transition from the time of ventilation through 28 days using the healthcare sector perspective. Daily transition probabilities were extrapolated from prospective clinical studies comparing CLRT with standard care. Costs were estimated in 2014 USD. Utility scores were extracted from the published literature. Cost per quality-adjusted life-years (QALYs) was calculated, and probabilistic sensitivity analyses (PSA) using 10,000 Monte Carlo simulations were conducted. ROI analysis was also performed to estimate the net benefit and breakeven point of the investment. CLRT was dominant over standard care. The expected cost for a CLRT per patient was $47,140 compared to standard care at $49,229 per patient, showing that CLRT saves cost per patient. The expected effectiveness of CLRT per patient was 0.0454 QALYs compared to 0.0451 QALYs for standard care. CLRT was dominant in 99.94% of the Monte Carlo simulations in the PSAs and 100% of the simulations in the univariate sensitivity analysis. CLRT also showed outstanding ROI reaching the breaking even point after 0.42 of a year. CLRT appears to be highly cost-effective compared to standard care by preventing ventilator-associated infections and PrIs in an ICU setting.

Interface pressure redistribution on skin during continuous lateral rotation therapy: A feasibility study

BackgroundContinuous Lateral Rotation Therapy (CLRT) is a therapy used in ICUs for early mobilization of ventilated patients. CLRT is believed by some in health care to not be sufficient to allow for capillary re-perfusion, and may lead to tissue damage. ObjectivesTo determine if there are differences in skin interface pressures, skin integrity, or perceived discomfort across three positioning scenarios. MethodsA Hill-Rom Total Care SpOrt® bed was equipped with a pressure mapping device. Ten healthy volunteers were placed in each positioning scenario for 30 minutes; interface pressures were recorded. ResultsCLRT alone demonstrated statistically lower interface pressures on ischial tuberosities (p < 0.05) as compared to the scenarios with static wedge. Higher pressures were noted on the heels in CLRT alone (p < 0.05). One subject noted pain with CLRT. No erythema or breakdown noted. ConclusionsThis feasibility study supports the use of CLRT to decrease pressure on capillary beds and decrease patient discomfort.

Continuous lateral rotation therapy – a review

This article reviews the current evidence, benefits and drawbacks for the use of continuous lateral replacement therapy in the treatment and prevention of nosocomial infections in the ventilated patient. The acquisition of nosocomial infections and the development of pressure sores continue to be major issues in the care of the critically ill, ventilated patient. The use of continuous lateral rotation therapy (CLRT) as an adjunct in the prevention and treatment of pneumonia has increased in popularity in recent years. A number of institutions routinely advocate the use of CLRT in critically ill patients. While there is some data to suggest that CLRT may have an impact on prevention of and treatment for nosocomial infections acquired by ventilated patients, there still remains insufficient evidence to its inclusion as a fully validated treatment. Clearly, there is a requirement for more robust, in-depth research into the efficacy of this proposed treatment.

What is new in the prevention of ventilator-associated pneumonia?

Ventilator-associated pneumonia (VAP) remains a frequent and severe complication in endotracheally intubated patients. Strict adherence to preventive measures reduces the risk of VAP. The objective of this paper is to review what has come forward in recent years in the nonpharmacological prevention of VAP. It seems advantageous to implement care bundles rather than single prevention measures. A solid basis of knowledge seems necessary to facilitate implementation and maintain a high adherence level. Continuous educational efforts have a beneficial effect on attitude toward VAP. Intermittent subglottic secretions drainage, continuous lateral rotation therapy, and polyurethane cuffed endotracheal tubes decrease the risk of pneumonia. In an in-vitro setting, an endotracheal tube with a taper-shaped cuff appears to better prevent fluid leakage compared to cylindrical polyurethane or polyvinylchloride cuffed tubes. Cuff pressure control by means of an automatic device and multimodality chest physiotherapy need further investigation, as do some aspects of oral hygiene. New devices and strategies have been developed to prevent VAP. Some of these are promising but need further study. In addition, more attention is being given to factors that might facilitate the implementation process and the challenge of achieving high adherence rates.

Continuous Lateral Rotation Therapy

Pulmonary complications remain common in critically ill patients and are especially prevalent in patients who are intubated and receiving mechanical ventilation. These complications include hypoxia, atelectasis, and hospital-acquired infections. The Institute for Healthcare Improvement has reported that ventilator-associated pneumonia is one of the most frequent causes of increased hospital morbidity and mortality. To prevent these complications of therapy, nurses have traditionally turned patients from side to side every 2 hours. However, this type of manual turning has not been reported to have a significant effect on pulmonary function. Continuous lateral rotation therapy (CLRT), an integral part of progressive mobility, came into use in the 1970s in an effort to reduce pulmonary complications of immobility. Lateral rotation therapies were delivered via continuous-motion bed frames that rotated the patient from side to side. Known by many different names, lateral rotation has been most commonly referred to as CLRT or kinetic therapy. Over the years, numerous studies have been performed to examine the effectiveness of CLRT. Many studies have shown improvement in various pulmonary outcome indicators when lateral rotation therapies were implemented. Mobilization of patients is widely accepted to reduce the impact of prolonged bed rest. However, during critical phases of acute illness, early mobilization of patients is difficult to accomplish. Therefore, the introduction of CLRT into patient care can provide an efficient way of providing early mobility to those critically ill patients whose condition or instability prevents implementation of other forms of mobility. Identification of patient populations who will benefit from CLRT is an important aspect of maximizing the benefits of therapy. McKay suggested that CLRTs achieve the best outcomes when implemented within 24 to 48 hours of meeting set criteria and are maintained for at least 18 hours per day. SwadenerCulpepper et al reported that CLRT patients in an early intervention group (implemented within 48 hours of meeting criteria) fared much better on the outcome criteria evaluated than did the late intervention group (CLRT implemented more than 48 hours after criteria were met). Therefore, early identification of patients who could benefit from therapy has the best potential for improving outcomes. Many criteria have been suggested in the identification of pulmonary patients who could benefit from CLRT. Methods that are quick and simply evaluated are most easily implemented in a busy critical care environment. One such method is the calculation of the PaO2/FIO2 ratio (P/F ratio). The P/F ratio reflects the effectiveness of oxygen transfer from the lung to hemoglobin. P/F ratios greater than 300 are considered to indicate minor pulmonary insufficiency, but ratios less than 300 are considered to indicate acute lung injury. Lower P/F ratios would indicate worsening of pulmonary function compared with higher ratios. Setting CLRT criteria at a P/F ratio of 300

Tips for Protecting Critically Ill Patients From Pressure Ulcers

Animportant focus in critical care units is maintaining circulatory, respiratory, and renal function. Care of critically ill patients also requires interventions that are designed to prevent pressure ulcers, an all-too-common complication of immobility, inadequate nutrition, and illnesses or medications that affect blood flow and perfusion. Pressure injuries may be avoidable when consistent attention is given to assessment, nutrition, and appropriate positioning within appropriate time frames. At least 10 published guidelines for the prevention and treatment of pressure ulcers can be found on the National Guidelines Clearinghouse Web site (www.guideline.gov). A planned repositioning schedule tailored to each individual patient is recommended in all pressure ulcer prevention guidelines. Recently, the National Pressure Ulcer Advisory Panel, in collaboration with the European Pressure Ulcer Advisory Panel, announced updated guidelines for prevention and treatment of pressure ulcers. Each guideline recommendation is supported by a rigorous review of the literature and a strength-of-evidence rating. The goals in progressive mobility programs, specifically prevention of complications associated with immobility, are aligned with recommended interventions for pressure ulcer prevention. Techniques for progressive mobility can be combined with repositioning techniques recommended for prevention of pressure ulcers.

Continuous lateral rotation therapy to prevent ventilator-associated pneumonia: The neglected effects of gravity on pathogenesis of ventilator-associated pneumonia

The author replies:Semirecumbent position has been shown to effectively prevent ventilator-associated pneumonia in a clinical setting (1), obviously by impeding aspiration of gastric contents (2).The aim of our study was to evaluate possible additive effects by continuous lateral rotation therapy. T

Continuous lateral rotation therapy to prevent ventilator-associated pneumonia: The neglected effects of gravity on pathogenesis of ventilator-associated pneumonia

Berra, Lorenzo MD; Cressoni, Massimo MD; Li Bassi, Gianluigi MD; Kolobow, Theodor MD; Panigada, Mauro MD; Zanella, Alberto MD The Gravity-VAP Network Author Information

Continuous lateral rotation therapy to prevent ventilator-associated pneumonia*

To investigate the impact of prophylactic continuous lateral rotation therapy on the prevalence of ventilator-associated pneumonia, duration of mechanical ventilation, length of stay, and mortality in critically ill medical patients. Prospective, randomized, clinical study. Three medical intensive care units of an university tertiary care hospital. Patients were randomized to continuous lateral rotation therapy or standard care if they were mechanically ventilated for <48 hrs and free from pneumonia. Primary study end point was development of ventilator-associated pneumonia. Ventilator-associated pneumonia was defined as infiltrate on the chest radiograph plus newly developed purulent tracheal secretion plus increasing signs of inflammation. The diagnosis had to be confirmed microbiologically and required the growth of a pathogen >10(4) colony-forming units/mL in bronchoalveolar lavage. Radiologists were blinded to randomization whereas clinical outcome assessors were not. Rotation therapy was performed continuously in a specially designed bed over an arc of 90 degrees. Additional measures to prevent ventilator-associated pneumonia were equally standardized in both groups including semirecumbent position. Ventilator-associated pneumonia frequency during the intensive care unit stay was 11% in the rotation group and 23% in the control group (p = .048), respectively. Duration of ventilation (8 +/- 5 vs. 14 +/- 23 days, p = .02) and length of stay (25 +/- 22 days vs. 39 +/- 45 days, p = .01) were significantly shorter in the rotation group. In a forward stepwise logistic regression model including the continuous lateral rotation therapy, gender, Lung Injury Score, and Simplified Acute Physiology Score II, continuous lateral rotation therapy just failed to reach statistical significance with respect to development of ventilator-associated pneumonia (p = .08). Intolerance to continuous lateral rotation therapy during the weaning phase was observed in 29 patients (39%). Mortality was comparable in both groups. Ventilator-associated pneumonia prevalence was significantly reduced by continuous lateral rotation therapy. Continuous lateral rotation therapy led to shorter ventilation time and length of stay. Continuous lateral rotation therapy should be considered in ventilated patients at risk for ventilator-associated pneumonia as a feasible method exerting additive effects to other preventive measures.

Continuous Lateral Rotation Therapy for Acute Hypoxemic Respiratory Failure

Previous studies have indicated a positive impact of continuous lateral rotational therapy on nosocomial pneumonia, but have shown mixed results in decreasing length of stay or ventilator days. The objective of the study was to determine if the use of a continuous lateral rotational therapy protocol would decrease mortality and morbidity, mean ventilator days, and/or intensive care unit and hospital length of stay in patients with a pulmonary diagnosis. The study also analyzed the effect of the lag time to the initiation of therapy. Prospectively enrolled subjects receiving continuous lateral rotational therapy based on predetermined indications were compared with retrospectively identified control subjects who met the same inclusion criteria from a similar time period in the previous year. Early initiation of continuous lateral rotational therapy resulted in significant decreases in ventilator days and intensive care unit length of stay. The therapeutic benefit of continuous lateral rotational therapy may be enhanced with early identification and treatment of appropriate patients.

The Impact of Continuous Lateral Rotation Therapy in Overall Clinical and Financial Outcomes of Critically Ill Patients

Significant pulmonary complications are prevalent in intubated and mechanically ventilated patients. This study was conducted to determine the impact of continuous lateral rotation therapy (CLRT) on patients considered to be at high risk for pulmonary complications. Overall study objectives included hospital length of stay, critical care length of stay, ventilator days, and cost to treat. Patients at risk for pulmonary complications as defined by Pao2/Fio2 ratio < 300, Fio2 > 50% for more than 1 hour, positive end-expiratory pressure > or = 8, or a Predicus score of > or = 5 were compared with a historical comparison group that met the high-risk criteria given above and did not receive CLRT. Patients who received CLRT were separated into 2 groups, early CLRT group (began therapy within 48 hours, n = 49) or late CLRT group (n = 46). The early CLRT group had a reduction in critical care LOS, (P = .04) as compared with the non-CLRT group. Total hospital costs were reduced (P = .01) in the early intervention group compared to the late intervention group, as well as ICU LOS (P = .02). Nonsignificant trends were seen in reduced ventilator days and hospital LOS. Reintubation rates and readmissions to critical care were also lower in the early intervention group. Continuous lateral rotation therapy, when introduced early in course of treatment of high-risk patients, reduces critical care LOS and cost to treat.

Impact of Kinetic Beds on the Incidence of Atelectasis in Mechanically Ventilated Patients

We investigated the impact of kinetic beds on the incidence of atelectasis in mechanically ventilated patients in an intensive care unit (ICU). All bronchoscopies performed for atelectasis on mechanically ventilated patients between July 2000 and June 2001 and between July 2002 and June 2003 were reviewed. On July 26, 2001, 50 kinetic beds, 20 continuous lateral rotation therapy modules, and 20 percussion and vibration modules were introduced to our institution. Of the 3399 ICU admissions between July 2000 and June 2001, 71 patients developed atelectasis while being mechanically ventilated. Of the 3065 ICU admissions between July 2002 and June 2003, 83 patients developed atelectasis while being mechanically ventilated. Of these, 48 (58%) patients had left-sided atelectasis, 30 (36%) had right-sided atelectasis, and 5 (6%) had bilateral atelectasis. There was no decrease in the incidence of atelectasis in mechanically ventilated patients at our institution after the introduction of kinetic beds and vibration, percussion, and rotation modules despite their widespread availability.

Prolonged lateral steep position impairs respiratory mechanics during continuous lateral rotation therapy in respiratory failure

To establish whether prolonged lateral steep position during continuous rotation therapy leads to improvement on pulmonary gas exchange, respiratory mechanics and hemodynamics. Prospective observational study. Intensive care unit of a university hospital. Twelve consecutive patients suffering from acute lung injury or adult respiratory distress syndrome undergoing continuous rotation therapy. Blood gas analysis, static lung compliance, blood pressure, cardiac index and pulmonary shunt fraction were measured in supine as well as in left and right lateral steep position at 62 degrees during continuous rotation therapy (phase I). Rotation was then stopped for 30 min with the patients in supine position, left and right lateral steep position, and the same measurements were performed every 10 min (phase II). Phase I and II revealed no significant changes in PaO(2)/FiO(2) ratio, mean arterial blood pressure, pulmonary shunt fraction, or cardiac index. Significantly lower static compliance was observed in lateral steep position than in supine position (p<0.001). Concomitantly, PaCO(2) was significantly lower in supine position than in left and right lateral steep position (p<0.01). Lateral steep positioning impairs the compliance of the respiratory system. Prolonged lateral steep position does not lead to benefits with respect to oxygenation or hemodynamics. Individual response to the different positions is unpredictable. The pauses in "extreme" positions should be as short as possible.

Prevention of Pressure Ulcers in Patients Being Managed on CLRT

To determine if there is a difference in interface pressures for patients using continuous lateral rotation therapy (CLRT) without pillow repositioning compared with interface pressures for the same patients on CLRT with pillow repositioning. Quasi-experimental. Six critically ill but stable patients (4 female and 2 male, aged 20 to 86 years) in medical, surgical, and trauma intensive care units in a large urban, tertiary care hospital in the southwestern United States were investigated. Tissue interface mapping was completed using Xsensor cushions or full-body mats. Tissue interface pressures were measured with and without pillow propping while on CLRT. No clinically relevant differences in interface pressure mapping were observed when CLRT with pillow repositioning was compared with CLRT alone. The results of this small pilot study suggest that positioning patients on pillows while on CLRT may not be necessary. Results also suggest that positioning with pillows may diminish pulmonary benefits of CLRT. Additional research is needed to confirm these hypotheses.

CONTINUOUS LATERAL ROTATION THERAPY FOR ACUTE LUNG INJURY: TIMING MATTERS

PURPOSE: Continuous Lateral Rotation Therapy has been shown to reduce nosocomial pneumonia, intensive care unit (ICU) length of stay (LOS) and the number of ventilator days. No study has addressed the effect of this therapy specifically on the course of acute lung injury (ALI) or the effect of timing of institution of Continuous Lateral Rotation Therapy (CLRT). This study was designed to determine whether use of a CLRT protocol would decrease morbidity and mortality, ventilator days and/or ICU LOS in ALI.

Should continuous lateral rotation therapy replace manual turning?

Learn the pulmonary complications of immobility in the critically ill, which are associated with significant morbidity and mortality.