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Cardio-Respiratory Effects of Change of Body Position: The Circulatory System
Cardio-Respiratory Effects of Change of Body Position: The Circulatory System
Cardio-Respiratory Effects of Change of Body Position: The Circulatory System
Cardio-respiratory
effects of change of
body position Thomas J. Coonan BA MDCMDA(Tor) FRCP(C),
Charles E. Hope MBCHB FFARCSFRCP(C)
pulse rate increases (up to 30 per cent), and body elevated towards the vertical, with thighs
systemic vascular resistance increases (30-60 per flexed on the trunk, legs flexed on the thighs and
cent) due, primarily, to constriction of the arterial feet close to the level of the heart, is more usually
and arteriolar ckculation. 1,9 Surprisingly, the tone adopted. 13
in the capacitance part of the circulation does not The literature suggests that bandaging of the legs,
change significantly. 1 Intra-thoracic blood volume the adoption of the modified sitting position and the
decreases by about 300-500 ml ~,l~ and the left careful adjustment of fluid load will go a long way
atrial pressure decreases significantly. Right atrial to minimising any extreme response. However,
pressure also decreases but usually less than on the such findings as exist are often specific to a given
left side of the circulation. This is probably due to anaesthetic technique, and extrapolation Io other
the increase in pulmonary vascular resistance, techniques must be done with some reservation.
which cart double. 1,1~ Cardiac output decreases In fit patients anaesthetised with nitrous oxide,
(20-40 per cent) as does stroke volume (40-50 per paneuronium and intermittent fentanyl, the change
cen0. Since oxygen consumption does not change to the sitting position led to a decrease in cardiac
significantly, the reduced cardiac output causes the output ( - 1 2 per cent), and an increase in systemic
arterlo-venous difference in oxygen content to vascular resistance ( +50 per cent), while heart rate
increase in the erect position.I'll and mean arterial pressure did not change signifi-
The mean arterial pressure remains constant or cantly. ~5 It must be emphasized, however, that the
increases (up to 18 per cent) depending on whether haemodynamic changes which occurred when the
the subject actually stands or undergoes passive tilt. sitting position was assumed from the supine were
Systolic blood pressure remains relatively constant examined against a baseline of stable anaesthesia
and changes in mean arterial pressure are largely the and not against pre-induction control values. It is
result of alterations in diastolic pressure, t,9 noteworthy that similar changes occur with identi-
Renal blood flow decreases significantly in the cal postural changes in conscious healthy man.
erect position ( - 3 0 per cent), az Glomerular filtra- Albin et al., in a similar study using nitrous oxide
tion rate decreases and increases in ADH and and narcotics (not identified), reported the same
aldosterone secretion result in both water and haemodynamic alterations but of considerably
sodium retention. In very obese patients the reduc- greater magnitude. Cardiac output fell 20 per cent,
tion in renal blood flow is even greater ( - 7 6 per systemic vascular resistance increased 80 per cent
cent), particularly in the sitting position, probably and mean arterial pressure 38 per cent. ~6'17 These
due to an increase in intra-abdominal pressure. 12 data indicate significantly greater changes than are
Hepatic and splanehnic circulatory changes are less normally seen in the conscious standing subject and
than renal and transient. Cerebral blood flow raise serious doubts about the capacity of the
decreases ( - 2 0 per cent) in the erect position. compromised patient to compensate for the effects
As might be expected, the responses of the of the sitting position during anaesthesia. It is not
normal subject to positions intermediate between clear why the results of these two studies differed,
the recumbent and erect positions are in the same but it is possible that the anaesthetic techniques
direction but of a lesser degree. were significantly different.
These changes are not seen when the position is Two interesting facts emerge from these stud-
changed with the subject imrnersed in water. The ies:t~-17 first, patients did not demonstrate signifi-
presence of an identical external pressure gradient cant haemodynamie change until a head-up tilt
antagonises orthostasis. This is part of the rationale greater than 60 deg. was established, and second,
for the bandaging of legs, and the use of anti-gravity the haemodynamic effects of the sitting position
suits and anti-shriek trousers and similar devices in progressed for at least one hour after the patient was
anaesthesia and acute care medicine, t4 placed in this position.
It must be emphasized that the sitting position is
The sitting position in anaesthesia equivalent to a degree of tilt greater than 60 deg. In
It is nowadays rare that the full sitting position, with an oft-quoted study, Stoelting et aL concluded that
a vertical spine and dependent legs, is used in the circulatory changes during sodium nitroprusside
anaesthesia, The modified sitting position, with the administration for prolonged controlled hypoten-
Cnonan & Hope: CARDIO-RESPIRATDRY EFFECTS OF CHANGE OF BODY POSITION 427
sion in the semi-sitting position were similar to the and the results seem to have been skewed by the
haernodynamic changes observed during SNP ad- response of one patient. Nevertheless, the implica-
ministration in the supine position. Js Unfortunate- tions of these findings for intensive care and
ly, this study is simply not comparable with those anaesthesia are important.
carried out in the sitting position, as the head was In summary, while clinical experience indicates
elevated only to 30-45 deg. Reports of this study do that the subject with adequate circulatory reserves
not always clearly identify that the true modified can tolerate the sitting position well, care should be
sitting position was n o t u s e d . 13'j9 taken in utilising this position in patients without
The effects of anaesthesia in the sitting position circulatory reserve. If the sitting position has to be
on o~gan systems other than the brain have not been used in such patients, the fullest possible monitor-
documented, and even cerebral blood flow has not ing, including measurement of pulmonary arterial
received extensive attention. In a study of patients and pulmonary arterial wedge pressures and cardiac
undergoing chemotherapy for cerebral turnouts, output, should be instituted.
Tindall showed a decrease of carotid blood flow Ideally, cerebral blood flow should be assessed in
( - 14 per cent) in the sitting position. 20 There were patients with either marginal cardiovascular reserve
many interacting variables: the patients were hyper- or elevated ICP, with the use of cortical evoked
ventilated to a PaCO2 of 22 torr, ha]othane was used potentials or cerebral function monitoring, when
for the anaesthetic and cerebral autoregulation was the sitting position is being considered.
probably disturbed by the CNS pathology. Never- The response of the normal person to assuming
theless, the carotid blood flow did decrease to a the erect position has been discussed. If this
degree similar to that demonstrated in awake response is inadequate, hypotension can ensue, and
patients. This decrease was also proportional to the may develop rapidly after an initial period of partial
decrease in mean arterial pressure at the level of the compensation. Bradycardia, perhaps due to the
mid-cerebrum This must have involved an increase activation of Bezold-Jarisch reflexes produced by
in cerebro-vascular resistance because the hydro- strong ventricular contxaction against an inade-
static effect would have been equally distributed to quately filled ventricle can be seem This bradycardia
the intracranial arterial, venous and CSF compart- is responsive to atropine; however, cardiac output
ments. The cerebral peffusion pressure should may not change as a result of this therapy. This type
theoretically have remained constant. of cardiovascular collapse has been extensively
It would appear reasonable, on the basis of studied and seems to be related to a reduction in
available evidence, to ntilise mean arterial pressure arteriolar resistance. 23'24 Despite profound hypo-
at the level of the Circle of Willis as an index of tension, the cardiac output may be maintained. This
cerebral blood flow in anaesthetised sitting patients. is a highly dangerous situation as cerebral blood
This logic has been carded further and the arterial flow decreases despite the maintenance of cardiac
pressure at the Circle of Willis has been used to output.
monitor the induction of controlled hypotension for Certain patients have difficulty in compensating
difficult surgery of the posterior fossa in the sitting for the stress of the erect position (see Table I1).
position. 2~ This may or may not be valid. It has not Predictably, haemorrhage and dehydration are
to our knowledge been studied and, accordingly, poorly tolerated in this position. Chronic orthostatic
eannot be endorsed lightly. Particularly in patients stress seems necessary for the maintenance of an
with intracranial space occupying lesions, cerebral adequate blood volume; consequently, the chroni-
blond flow might not passively follow the mean cally bed-ridden patient with reduced blood volume
arterial pressure. will have difficulty in adjusting to the erect posi-
In this context, Shenkin et al. 22 demonstrated tion. 25In these patients electrolyte and fluid balance
that there was no alteration in cerebral blood flow in may be deranged. In addition there is a lag in the
normal subjects tilted head up to 20 deg., but that in response of peripheral vascular tone, ~ Increasing
patients with brain turnouts cerebral blood flow age alone might decrease the ability of man to
decreased ( - 2 0 percent). There was a concomitant compensate for orthostatic stress as a result of a
decrease in carotid artery pressure ( - 6 per cent). decreased sensitivity of the carotid sinus reflex, z6
There were only six patients in the tumour group Likewise, the chronically hypertensive patient with
428 CANADIAN ANAESTHETISTS' SOCIETY JOURNAL
foramen ovale, as even minute amounts of air can At present there appears to be no place for the
pass to the systemic cia'culation and preferentially Trendelenburg position in the management of shock
enter the cerebral circulation. The clinical incidence in man. There is considerable evidence to suggest
of such paradoxical embolus seems low but there that maintenance of the HIP at or close to the right
are at least three reports of its occurrence in atrium will optimise the cardiac filling pressures
association with air embolus in the sitting posi- and thus cardiac output. It is sufficient to elevate the
tion. ~'37 PEEP, IPPV and air embolism itself will legs in recumbent man to increase the venous return
increase the probability of an increase in fight to the heart and increase the cardiac output. The
venuicular and right atrial pressures. 37 In addition, length of the venous bed is thus effectively short-
moving from the supine to the erect position, causes ened, the bulk of the blood volume in the central
the right atrium to move from a position above to a compartment is maintained and the shift of the HIP
position below the left atrium. The pressure dif- away from the right atrial region is minimised.
ferential produced by this shift in position is low Cerebral blood flow has been shown to decrease
(2 mnaI-lg) but is certainly in the correct direction to by 14 per cent in the head-down position. 22 This
connibute to this potential problem in individuals at implies a more significant increase in venous
risk. pressure than in carotid artery pressure. In patients
with increased intracranial pressure the head down
Head-down positions position has not led to a decrease in cerebral blood
The head-down position (Trendelenburg and "var- flow. However, the period of observation was short
iations") is more complex than is apparent at first. It and the response to the head-down position might
might be expected that the intrathoraeic and intra- not have evolved fully. 22 We have not discovered
cardiac blood volume would increase and lead to an any report of a beneficial effect of the head-down
increased cardiac output. Tilts of up to 35 deg. position on cerebral blood flow.
head-down may lead to a slight increase in the right
atria] filling pressure and cardiac output in the The lateral and prone positions
normal individual. With greater degrees of tilt, and It is obvious that circulatory changes due to gravi-
certainly at 75 deg. head-down tilt, there is a tational effects on hydrostatic pressure are maximal
significant decrease in right atrial filling pressure along the long axis of the body. These gravitational
due to a drainage of blood from the heart in a effects are of lesser importance (except where
ceph~lad direction. This is due to shift of the HIP intra-polmonary gas exchange is considered) in the
with tilt. This shift is magnified by the use of venous lateral and prone positions. In these positions,
occlusion cuffs around the thighs. Sequestration of however, venous obstruction can be a major factor
blood in the veins distal to the venous occlusion cuffs and may have a considerable consequence. In
leads to a decrease in blood volume in the central addition, acute flexion and/or rotation of arterial
venous compartment and, as a result, a shift of the and venous channels can disturb blood flow.
HIP cephalad. Similarly, the head-down position Specific examples include the lateral positions with
has led to a reduction of right atrial filling pressure the use of "kidney-rests," extremes of neck flexion,
in man in hypotensive shock, as In animals (rats and extension and rotation which impede jugular
dogs), all forms of shock, including haemorrhagic venous drainage and vertebral arterial supply, and
shock, are made worse by the adoption of the acute truneal flexion in infants, 42 obese adults and
Trendelenburg position. 39"4~In man in normovol- females in advanced pregnancy. In this latter
aemic shock, the Trendelenburg position leads to a category, extreme hypoxia is not uncommon and, in
worsening of both hypotension and cardiac out- fact, cardiac arrest due to a presumed combination
put. 41 Where there is a decreased blood volume, the of hypoxia, vena caval obstruction and reduced
Trendelenburg position does not improve blood cardiac output has been reported.
pressure, although there may be a slight increase in Increased abdominal pressure leading to inferior
eardi~le output. Haemorrhagic shock has not been eaval obstruction has been associated with the prone
studied in man but it is possible that it may position. Abdominal compression may be caused
correspond to the low blood volume model of by either an exaggerated knee-chest position or
Taylor and Well 4 J inadequate or malplaced abdominal support.
430 CANADIAN ANAESTHETISTS' SOCIETY JOURNAL
TABLE Ili Respirator'/system.Effec~of change in body positionof consciousand anaesthetizedman, relatedto the
erect-consciousposition
Erect Supine
Erect anaesthetised Supine Lateral anaesthetised
conscious & paralyaed conscious conscious ¶lysed Prone
FRC Control J. 3% ,[ 24% $ Dependent ~,,14% ~, 12%
lung
~'Non-dependenl
lung
IC N/A ~ NJA
ERV NJA ,L NIA
VC N/A ~ , '~, ~, NtA
CC N/A ",-~, 1" (slight) ~, ]" (slight)
Changesindicatedas: 1' increase, ~. decrease, ~ unchanged.N/A - not applicable.
Finally, the supine position in the pregnant its enclosed structures. This leads to a loss of lung
patient has been shown to produce inferior vena volume particularly where these compressive forces
cava obstruction. The pregnant patient should be are greatest. Pulmonary blood flow is also greatest
kept in the left lateral position if at all possible, and in these same areas. Clearly, gravity is important in
if she must he in the supine position, a left lateral tilt directing these compressive forces.
of 15 deg. must be utilised. FRC decreases progressively from the erect, to
the supine, to the lithotomy, to the head down and
The respiratory system finally to the lithotomy position head down. 43 The
Because of its effects on lung volume, distribution decrease in the FRC on passing from the erect to the
of inspired gases, pulmonary blood flow and ear- supine position averages 800 ml. In the lateral
diac output, body position has major implications in position there is a smaller total loss of FRC, but this
respiratory physiology. Positional changes in loss is not evenly distributed. FRC in the non-
respiratory function axe summarized in Table III. dependent lung increases; FRC in the dependent
lung decreases considerably. In the prone human
The Lung Volumes resting on his arms and legs, loss of FRC is
minimal.** hi the prone human well supported by
Functional Residual Capacity (FRC) mechanical devices, the decrease in FRC is less
When man remains at rest in the erect position, his than that in the supine or lateral positions. 4s Again,
lungs are subjected to minimal pressures. The gravitational forces play an important role.
thoracic cage and the diaphragm (subjected to the Diaphragmatic tone is important in minimising
gravitational pull of the weight of the abdominal the effect of the intra-abdominal pressure on the
contents) create a negative intrapleural pressure intrathoracic contents. Diaphragmatic paralysis
environment which is not uniform but more nega- leads to a further decrease in FRC ( - 15 per cent) in
tive at the apex than at the base. Because of this patients in the supine position. 43 Interestingly,
gradient, and because of the greater expansive Rehder et at. found a slight decrease in FRC in
elastic forces at the apex, the alveoli at the apex are anaesthetised and paralysed patients, even in the
kept at a greater volume than those at the base of the sitting position, as This is not explicable by trans-
lung. diaphragmatic pressure alone but may be due to a
When man lies down, the external forces acting slightly contracted resting position of the thoracic
on the lung change, in the supine position, the cavity brought about by paralysis of the intercostal
weight of the abdominal contents is transmitted muscles and those muscles suspending the thorax
through the diaphragm to the lung; in the lateral from the cervical and dorsal spine.
position, the more dependent lung is subjected not There is a 20 per cent loss of FRC after induction
only to a greater intra-ahdominal transmitted pres- of anaesthesia in the supine position. There is no
sure but also to the weight of the mediastinum and fully accepted explanation for this; hypotheses have
Coonan & Hope: C A R D I O - R E S P I R A T O R Y EFFECTS OF CHANGE OF BODY POSITION 431
included alterations in the tone of the diaphragm, change and in the same direction as the change in
the tone of the thoracic cage and the abdominal FRC, 35 not to change significantly with posture, ~3
musculature.43 FRC decreases most in the first few or even to increase on passing from the erect to the
minutes of anaesthesia. The effect of anaesthesia supine position, s6 These conflicting reports can
and paralysis upon loss of lung volume is approxi- probably be reconciled. Vital capacity is comprised
mately the same and is not additive. Accordingly, of the tidal volume, the expiratory reserve volume
the anaesthetised patient in the supine position does (ERV) and the inspiratory capacity. As FRC de-
not have a further decrease of FRC with muscle creases with postural change in the subject with
paralysis. Other factors which modify the loss of normal lungs, the ERV decreases significantly.
FRC on induction of anaesthesia include increasing This does not occur, however, in subjects with little
age, body build and presence of a tracheal tube. 47 ERV even in the erect position. These would
Small airways ( < [ ram) close at low lung vol- include quadraplegic patients, obese patients,
umes as a result of the physical forces which induce patients under high spinal or epidural analgesia, and
closure in all spherical configurations.48 The tend- patients with severe chronic obstructive lung disease
ency to closure is opposed largely by the inherent who are unable to perform a forced airway ma-
elaslicity of pulmonary tissue. A measurable vol- noeuvre without gas trapping.
ume, the closing capacity, exists below which Inspiratory capacity, on the other hand, increases
airway closure commences in the dependent areas as the resting position of the diaphragm is elevated
of the lung. This volume increases with age and on passing from the erect to the supine position, or
with many forms of pulmonary pathology. Closing from the erect to the erect-forward position. This
capacity has been reported as being both affected49 may be due to an increase in resting muscle tension
and unaffected by postural change. ~'s~ The closing or to alterations in the geometric configuration of
capacity is generally thought not to be affected by the diaphragm. In patients with increased pulmon-
anaesthesia5t although some disagreement can be ary respiratory resistance and hyperinflation, the
found in the literature, s~ In any case, the effect of mechanical advantage of the diaphragm is worse in
posture and anaesthesia on closing capacity is very the erect position and much improved in the supine
much less than the effect on FRC. or forward-bending positionY Whether vital
FRC, in effect the resting lung volume, is capacity increases, decreases or stays the same with
important in relation to the c]osing capacity. Air- posture depends on which alters the most, the
way closure has been shown to occur during tidal expiratory reserve volume or the inspiratory
breathing in normal subjects at about age 65 in the capacity.
erect position, and at age 45 in the supine position,sz
A further reduction in FRC occurs in the head down The distribution of inspired gases
and lithotomy positions, causing airway closure to The regional distribution of the inspired gas is
occ~tr during tidal breathing at an even younger determined by the regional lung compliance, chest
age. s3 The further decrease in FRC following in- wall and diaphragmatic compliance, diaphragmatic
duction of anaesthesia will compound this tendency mechanics and the flow rate of the inspired gas.
to closure, and airway closure and gas trapping Change in posture affects most of these deter-
have been documented in anaesthetised patients in minants, ss,sg
the supine position. 5'* It has been shown that the Because of the gradient of pleural pressure,
intrapulmonary shunt varies with both position and alveoli in the dependent regions of the lung are, at
age. At age 50, the shunt in the supine position is ten FRC, at a lower volume than those in the apex. A
per cent and in the erect position four per cent. At lower resting volume places dependent alveoli on a
age 70, these values increase to 15 and five per cent more compliant position of the alveolar pressure
respectively. 49 volume curve and inspired gas is then preferentially
distributed to the lower lung regions. This occurs in
Vital capacity healthy lungs in young subjects in all body posi-
There are conflicting reports on the effect of change tions, a~ If, on the other hand, dependent airways are
of posture on the vital capacity. Vital capacity has closed at the onset of inspiration, gas is redistrib-
beer, found to change significantly with postur',d uted to non-dependent regions.
432 CANADIAN ANAESTHETISTS' SOCIETY JOURNAL
1
A SEATED SUPINE
~ HIP Zone 2
' CAPACITY
SUPINE
perfusion mismatch in the supine position and may rest, and in the presence of pharmacological agents,
be better off erect. This tendency to closure is these compensmory responses may be attenuated.
accentuated in patients in the third category who Under anaesthesia, the degree of compromise
have airway closure in part of their tidal ventilation which will occur will be determined in part by the
in the erect position. When they move to a supine baseline against which the anaesthesia is induced.
position, airway closure will increase. Atelectasis Consideration of all of these factors is thus impor-
may result if soluble gases such as nitrous oxide and tant in anticipating or predicting the effects of
oxygen are used. changes in body position during anaesthesia,
Patients in the fourth and final category will have
airway closure throughout their entire tidal ventila- References
tion even in the erect position. These patients are I Goner OH, Thron HL. Postural changes in the cir-
severely compromised and may be better when culation. Ch, 67, 2409-2439. In: Handbook of
placed supine where the increased tendency to Physiology. Sect. 2, Vol. 3, Eds. Hamilton WF,
closure is balanced by increased cardiac output, a Dew P, American Physiologica] Society, Wash-
more evenly distributed pulmonary blood flow and ington DC, 1965.
more efficient diaphragmatic functiom 69 2 Cannon WB. The Wisdom of the Body, W.W.
Posture must be chosen according to the particu- Norton & Co. Inc., 1939.
lar needs of specific patients. The prone position 3 Butch GE. Digital Plethysmography. New York;
may be of advantage in severely compromised Grurte & Stranon. 1954.
patients as FRC is better maintained in this position. 4 Butch GE. Method for recording simultaneously
Furthermore, during controlled ventilation, in- the time course of digital rate and of digital volume
spired gas may be delivered specifically to the of inflow, outflow and the difference between
dorsal lung fields 45 In subjects with severe unilat- inflow and outflow during a single pulse cycle in
eral lung disease the lateral position with the good man. J Appl Physiol 1954; 7: 99.
lung down will optimise ventilation perfusion 5 Hope CE. Personal observations.
matching. 7oFinally, the supine or the erect-forward 6 Wagner E. Fortgesetzte Untersuchungen nber den
position will optimise diaphragmatic function in the Einfluss der Schwerc auf den Kreislauf. Arch Ges
asthmatic Y Physiol 1886; 39: 371.
The therapeutic use of any respiratory manoeuvre 7 Sonkodi $, Agabiti-Rosei E, Fraser R et al,
can only be considered after full consideration of all Response of the reain-angiotensin-aldostemnesys-
of the variables. For example, the effect of PEEP on tem to upright fining and to intravenous frusem-
cardiac output and the distribution of pulmonary ide: effect of prior metoprolol and propranolol. Br J
blood flow may over-ride any gain derived from the Clin PharmaC 1982; 13: 341-50.
recruitment of lung volume. Likewise, it has been 8 Williams GH, Cain JP, Dluty RG et al. Studies on
shown that placing patients upright in the recovery the control of plasma aldostemne concentration
room may lead to a deterioration in arterial blood in normal man. 1. Response to posture, acute and
oxygenation, ~l perhaps due to a decrease in cardiac chronic volume depletion and sodium loading. J
output. Clin Invest 1972; 51 : 173 l.
9 WardRJ, Danziger F, Bonica ZI et al. Cardio-
Conclusion vascular effects of change of posture. Aerospace
The erect "active" position is man's normal or Med 1966; 37: 257.
"physiological" state. Gravitational stresses, acting 10 Fournier P, Mensch-Dechene J, Ranson-Bitker
directly on the arterial and venous circulations, and B, Valladares W, Lockhart A. Effect of sitting up on
indirectly through diaphragmatic mechanics and pulmonary blood pressure, flow, and volume in
intra-abdominal transmitted pressures on the lung, man. J Appl Physiol 1979; 46: 36-40.
are important in determining the net cardiorespira- l I Bevegard S, Hofmgren A, Jonsson B. The effect
tory response to change in body position. of body position on the circulation at rest and during
In normal active man, homeostatic compensatory exercise, with special reference to the influence
responses maintain physiological normal ranges. In on the stroke volume. Acta Physio! Seand 1960; 49:
disease states, after immobility or prolonged bed 279-98.
Coonan & Hope: CARDIO-RESPIRATORY EFFECTS OF CHANGE OF B O D Y P O S I T I O N 435
12 Rhodes JM, Graham-Brown RAC, Sarkany 1. 26 Wade JG, Larson PC, Hickey RF, Ehrenfeld WK,
Reversible renal failure in an obese patient: hazard Severinghaus JW. Effect of carotid endarterectomy
o~"sitting with feet continuously elevated. Lancet on carotid chemoreceptor and baroreceptor function
1979; 2: 96. in man. N Engl J Med 1970; 282: 823-9.
13 Martin JT. The head-elevated positions. In: Posi- 27 Tarazi RC, Frohlich El), Dustan tiP. Plasma
tioning in anesthesia and surgery. Ed. Martin JT. volume in men with essential hypertension. N Engl J
1st Ed., Boston, WB Saunders Company, 1978. Med 1968; 278: 762-5.
14 Gauer OH. Die hydrostatische witkung yon bedern 28 Eckberg DL, Abbaud FM, Mark AL. Modulation of
auf den kreislatff, Deut Med J 1955; 6: 462. carotid baroreflex responsiveness in man: effects
15 Datrymple DG. Cardiorespiratory effects of the sit- of posture and propranolol. J Appl Physiol 1976; 41:
ti:ag position in neurosurgery. Br J Anaesth 1979; 383-7.
51: 1079-82. 29 Brisrow SD, Honour AS, Pickering GW, Sleight P,
16 Albin MS, Janetta P J, Maroon JC, Tung A, Mil. Smith HS. Diminished baroreflex sensitivity in
len JE. Anaesthesia in the sitting position. In: high blood pressure. Circulation 1969; 39: 48-54.
Recent progress in anesthesiology and resuscitation. 30 Tarazi RC, Melsher HJ. Dustan HP. Frohlieh
Amsterdam. Excerpta Medica International Con- El). Plasma volume changes with upright tilt: stud-
gress Series No. 347, 1974. ies in hypertension and in syncope. J Appl Phys-
17 Afbin MS, Babinski M, Wolf S. Cardiovascular iol 1970; 28: 121-6.
response to the sitting position (Letter). Br J Anaesth 31 Ekelund L-G, Ektund B, Kaijser L Time course
1980; 52: 961-2. for the change in haemoglobin concentration with
18 Stoeltmg RK, Viegas O, CampbetI RL. Sodium change in posture. Acta reed seand 1971; 190:
nitroprusside-produced hypotension during anaes- 335-6.
thesia and operating in the head-up position. Anesth 32 Bicketmann AG, Ltppschurz EJ, Brunjes CF.
Analg 1977; 56: 391-4. Haemodynarnics of idiopathic orthostatie hypoten-
19 /Jam AM. Proper positioning of the patient. In: sion. Amer J Med 1961; 29: 26-38.
Anaesthetic considerations in the surgical repair of 33 Morrison SC, Kumana CR, Rudniek KV, Haynes B,
intracranial aneurysms. Ed Varkey GP. Interna- Jones NL. Selective and non-selective beta adreno-
tional Anesthesiology Clinics Vol. 20, No. 2. receptor blockade in hypertension. Responses to
Boston: Little, Brown & Co~, 1982. change in posture, cold and exercise. Circulation
20 TindaU GT, Craddock A, Greenfield JC. Effects of 1982; 65: 1171-7.
the sitting position on blood flow in the internal 34 Co@ R J, Franklin KW, Kluger J, Laragh JH.
carotid artery of man during general anesthesia. J Mechanisms governing the pastural response and
Nearosurg. 1967; 26: 383-9. baroreceptor abnormalities in chronic congestive
21 Curcic M. The practice at some other centres - Uni- heart failure: effects of acute and long term con-
versity Hospital, Zurich, Switzerland. In: Anaes- vetting-enzyme inhibition. Circulation 1982; 66:
thetic considerations in the surgical repair of intra- 135-42.
cranial aneurysms. Ed. Varkey GP. IAC Vol. 20, 35 Murata K, Yamane O, Suga H. Alterations of
No. 2. Boston: Little, Brown & Co., 1982. circulatory responses to upright tilt in cardiac
22 ShenMn HA, Scheuerman EB, Spitz EB, Groff RA. patients. Jpn Heart J 1981; 22: 551-60.
Effect of change of posture upon cerebral circula- 36 Perkins-Pearson NAK, Marshall WK, Bedford RF.
tinn of man. J Appl Physiol 1949; 2: 317-26. Atrial pressures in the seated position. Anesthesi-
23 R,'zshmerRF. Cardiovascular dynamics. 4th Ed. ology 1982; 57: 493-7.
Philadelphia; WB Saunders Company; 1976. 37 Gronert GA, Messick JM, Cucchiara RF, Michen-
24 Epstein SE, Stampfer M, Beiser GD. Role of the felderJD. Paradoxical air embolism from a patent
capacitance and resistance vessels in vasovagal syn- foremen ovale. Anesthesiology 1979; 50: 548-9.
cope. Circulation 1968; 37: 524-33. 38 Sibbald WJ, Paterson NAM, HoUiday RL, Baske.
25 Convertino V, Hung J, Goldwater D, DeBusk RF~ ville J. The Trendelburg position: haemodynamic
Cardiovascular responses to exercise in middle- effects in hypotensive and normotensive patients.
aged men after 10 days of bed rest. Circulation 1982; Crit Care Met 1979; 7: 218-24.
65: 134-40. 39 Well MH, Whigham H. Head-down (Trendelen-
436 CANADIAN ANAESTHETISTS' SOCIETY JOURNAL
burg) pr~sition for treatment of irreversible hemor- 53 Craig DB, Wahba WM, Don HF. Airway closure
rhagic shock. Ann Surg 1965; 162: 905-9. and lung volumes in surgical positions. Can Anaesth
40 Guntheroth WG, Abel FL, Multins GL. The effect Soc J 1971; 18: 92-8.
of Trendelenburg's position on blood pressure 54 Don HF, Wahba WM, Craig DB. Airway closure,
and carotid flow. Surg Gynecol Obstet 1964; 119: gas trapping and the functional residu-,d capacity
345-8. during anaesthesia. Anesthesiology 1972; 36:
41 Taylor,I, Well MH. Failure of the Trendelenburg 533-9.
position to improve circulation during clinical 55 Wade OL, Gilson JC. The effect of posture on
shock. Surg Gynecol Obstet 1967; 124: 1005-11). diaphragmatic movement and vital capacity in nor-
42 Spahr RC, MacDonald HM, Mueller-Heubach mal subjects with a note on spirometry as an aid
E. Knee-chest position and neonatal oxygenation in determining radiologic',d chest volumes. Thorax
and blood pressure. Amer J Dis Child 1981; 135: 1951; 6: 103-26.
79-80. 56 Cameron GS, Scott JW, Jousse AT, Botterell Ell.
43 Nunn JF. Applied Respiratory Physiology. 2nd Diaphragmatic respiration in the quadraplegie
Ed. I.~ndon; Butterworths; 1977, patient and the effect of position on his vital capa-
44 Agosfini E, Mead J~ Statics of the respiratory city. Ann Surg 1955; 141: 451-6.
system. In: Handbook of Physiology, See 3, Res- 57 Druz WS, Sharp JT. Electrical and mechanical
piration, Vol. 1, F_As.Fenn WO, Rahn H. American activity of the diaphragm accompanying body posi-
Physiological Society, Washington, DC.; 1964; tion in severe chronic obstructive pulmonary dis
387-409. ease, Am Rev Respir Dis 1982; 125: 275-80.
45 Douglas WW, Rehder K, Beynen F, Sessler A, 58 Milic-EmiliJ. Regional distribution of inspired
Marsh M. Impaired oxygenation in patients with gas in the lung. J Appl Physiol 1966; 21: 749.
acute respiratory failure: the prone position. Am 59 WestJB. Respiratory Physiology - the essentials.
Rev Respir Dis 1977; 115: 559-66. Baltimore; The Williams and Wilkins Company;
46 Rehder K. Sessler AD, Rodarte JR. Regional intra- 1974.
pulmonary gas distribution in awake and anesthe- 60 Kaneko K, Milic-Emiti J, Dolovieh MB, Dawsan
tised paralysed man. J Appl Physiol 1977; 42: A, Bates DV. Regional distribution of ventilation
391-402. and peffusion as a function of body position. J
47 Hickey RF. Visiek W. Fairley HB, Fourcade HE. Appl Physiol 1966; 21: 767-77.
Effects of halothane anaesthesia on functional resid- 61 Rehder K, Sessler AD. Function of each lung in
ual capacity and alveolar-arterial oxygen tension spontaneously breathing man anesthetised with thio
difference. Anesthesiology 1973; 38: 20-42. pental-meperidine. Anesthesiology 1973; 38:
48 Burger EJ, Macklem P. Airway closure: demon- 320-7.
stration by breathing 100% oxygen at low lung vol- 62 Rehder K, Wenthe FM, Sessler AD. Function of
umes and by nitrogen washout. J Appl Physiol each lung during mechanical ventilation with ZEEP
1968; 25: 139. and with PEEP in man anesthetised with thiopental-
49 Don HF, Craig DB, Wahba WM, Couture JG. The meperidine. Anesthesiology 1973; 39: 597-606.
measurement of gas trapped in the lungs at func- 63 Froese AB, Bryan AC. Effects of anesthesia and
tional residual capacity and the effects of posture. paralysis on diaphragmatic mechanics in man. Anes-
Anesthesiology 1971; 35: 582-90. thesiology 1974; 41: 242-55.
50 Rehder K, Sessler AD, Marsh HM. General anes- 64 Roussos CS, Fixley M, Genest Jet aL Factors
thesia and the lung. Am Rev Respir Dis 1975; 112: influencing the distribution of inspired gas. Amer
541-63. Rev Respir Dis 1977; 116: 457-74.
51 Gilmaur I, Burnham M, Craig DB. Closing capa- 65 ChevroletJC, Martin JG, Flood R, Martin RR,
city measurement during general anesthesia. Anes- Engel Ltt. Topographical ventilation and perfusion
thesiology 1976; 45: 477-82. distribution during IPPB in the lateral posture.
52 LeBlanc P, Ruff F, Milic.Emili J. Effects of age Am Rev Respir Dis 1978; 118: 847-54.
and body position on "airway closure" on man. J 66 Hulands GH, Greene R, Cliff LD, Nunn JF. In-
Appl Physiol 1970; 28: 448-51. fluence of anaesthesia on the regional distribution of
Coonan & Hope: CARDIO-RESPlRATORY EFFECTS OF CHANGE OF BODY POSITION 437