Continuous Lateral Rotation Therapy: An Early Option For Mobilizing Patients

Continuous Lateral Rotation Therapy:
An Early Option for Mobilizing Patients

Created in Conjunction With
Kathleen M. Vollman, MSN, RN, CCNS, FCCM, FAAN
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©2013 Hill-Rom Services, Inc. ALL RIGHTS RESERVED
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The Impact of a Stationary
Supine Position on the
Pulmonary System
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The Effects of Immobility/Supine Position on
Respiratory Function
• Decreased movement of secretion1

– Impaired ability to clear tracheobronchial
secretions
– Normal mechanism dysfunctional in supine
position
• Increased dependent edema2

– Fluid accumulation in the dependent regions
– Compression atelectasis
• Decreased respiratory motion3

– Abdomen influence on diaphragm motion
– Atelectasis
1. Vollman KM. Crit Care Nurse. 2010;30:S3-S5.

2. Fortney SM, et al. Physiology of Bedrest (Vol 2). New York: Oxford University Press. 1996.
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3. Greenleaf JE, Kozlowski S. Exerc Sport Sci Rev. 1982;10:84-119.
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Compression Forces of the Heart in the
Supine Position
• In the supine position,

17% of the lung tissue
volume rests under the
compression forces of
the heart
– 11% of the left lower
lobe tissue volume
– 6% of the right lower
lobe tissue volume
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Malbouisson LM, et al. Am J Respir Crit Care Med. 2000;161:2005-2012.
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What is needed to do?
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Continuous Lateral Rotation Therapy
• CLRT mechanism of action
– A gentle side-to-side, full-body motion of the patient in which one
lung is placed above the other
– This motion allows for gravitational flow and mobilization of
pulmonary secretions, as well as enhance gas exchange
• What impact does it have on gas exchange?

– Increased oxygen
– Decreased CO2
– Improved blood flow
– Decreased atelectasis
• What happens inside the airways when patients are turned?
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Cross Section of a Chest in the Supine Position
Lung Sternum
Heart
Rib
Bronchi
Pulmonary
Infiltrates
Spine
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Rotation of the Chest
90° 62°
45°
30°
Supine Position
• Pulmonary infiltrates
are unable to drain into
the bronchi
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90°
30°
30°
the bronchi
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90°
45°
45°
the bronchi
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90° 62°
62°
• Some amount of
drainage of pulmonary
infiltrates into the
bronchi
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90°
180°
can successfully drain
into the bronchi
180°
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Table-Based vs Cushion-Based Rotation
• Turning on the long axis • Rotates patient by

• Measured in degrees of angle/turn inflation/deflation of air cushions
– 124° (62° per side) in 3.5 minutes • Longitudinal, full-body rotation
• Unstable spine patients • Measured in percent of air bladder
inflation
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Key Differences
Table-Based Rotation Cushion-Based Rotation

• Ideally suited for patients with • Usually does not require transfer to
unstable heads, necks, and spines a different surface, allowing it to be
(neuro and trauma patients)1 initiated more readily
• Uses a firm mattress essential for • More user-friendly for clinicians1
maintenance of spine alignment1 • Beds may include additional
– Can potentially put skin integrity features such as assist modes for
at risk
patient positioning1
• Can be set by degree of angle
desired
– Requires 2 fixed planes to
accurately determine angle
– Table-based products can
achieve this as both the surface
and the frame are moving at
the same angle
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1. Basham KA, et al. Respir Care Clin N Am. 1997;3:109-134.
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Evidence for the Use of CLRT
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Research on Rotational Therapy
Study Year Rotation Results

Statistically significant reduction in incidence of
Nelson and Choi 1992 Table pneumonia, atelectasis, hours intubated, and ICU
LOS
Rotational therapy may decrease the incidence of
pneumonia
Studies included in the pneumonia meta-
Table and analysis: Kelley, et al. 1987; Gentilello, et al. 1988;
Goldhill, et al 2007
cushion Summer, et al. 1989; Demarest, et al. 1989; Fink, et
al. 1990; deBoisblanc, et al. 1993; Whiteman, et al.
1995; Traver, et al. 1995; Kirschenbaum, et al.
2002; Ahrens, et al. 2004
Prolonged pause time in lateral steep position
Schellongowski, et al 2007 –
should be avoided
Swadener-Culpepper, et al 2008 Cushion Early CLRT may reduce LOS and cost to treat
Staudinger, et al 2010 – CLRT significantly reduced VAP prevalence
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CLRT=continuous lateral rotation therapy; LOS=length of stay; VAP=ventilator-associated pneumonia.
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Meta-Analysis of Table-Based Rotation
Methodology:
• Reviewed 6 studies with 419 patients
– Randomized to 62° kinetic therapy vs manual turning
• Outcomes measured
– Pneumonia, embolus, pressure sores, acute respiratory distress
syndrome, atelectasis, mortality, hours intubated, ICU days, ICU
charges, hospital days
Results:
• A statistically significant reduction in the treatment group
– 50% reduction in incidence of pneumonia and 38% in atelectasis
– 35% reduction in hours intubated
– 24% reduction in ICU stay
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Choi SC, Nelson LD. J Crit Care. 1992;7:57-62.
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Systematic Review and Meta-Analysis of
Rotational Bed Therapy to Prevent and
Treat Respiratory Complications
Methods:
• Systematic review and meta-analysis of studies on
prophylaxis and/or treatment
• Prospective, randomized controlled trials
• Various types of beds were studied
– Table- and cushion-based therapies
• Kinetic (62°) and CLRT (40°, 30°, and 20°)
CLRT=continuous lateral rotation therapy.

Page 18DR, et al. Am J Crit Care. 2007;16:50-61.
Goldhill
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Review and Meta-Analysis of Rotational Bed Therapy
to Prevent and Treat Respiratory Complications:
Meta-Analysis of Pneumonia
Rotational therapy provides a benefit with respect to the

incidence of pneumonia
Page 19DR, et al. Am J Crit Care. 2007;16:50-61.
Goldhill
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Review and Meta-Analysis of Rotational Bed Therapy
to Prevent and Treat Respiratory Complications
Conclusions:
• Little evidence on which rotation parameter is most effective
• Effectiveness may not depend entirely on the angle of rotation, but
also on
– Frequency and duration of rotation
– Pause time
– Underlying disease
– Size and weight of patient
– Use of adjuncts such as vibration, percussion, or pulsation
• Some awake patients do not tolerate steep angle rotation
• May be best for patients with higher BMI, unconscious, or sedated
• Key recommendation: Rotational therapy may be useful for
preventing and treating respiratory complications in selected critically
ill patients receiving mechanical ventilation
Goldhill20DR, et al. Am J Crit Care. 2007;16:50-61.

Page
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Prolonged Pause Time in Deep Lateral Position:
Negative Impact on Pulmonary Mechanics
Methods:
• Prospective observational study
• 12 ICU patients with ALI/ARDS undergoing CLRT (62° angle)
• Measurement (gases and mechanics) taken during R, L, C rotation
and 30 minutes R, L, C
Results:
• No changes in gases, shunt, or cardiac index
• Lower compliance* and higher PaCO2** in steep lateral 30 minutes
pause position than supine
*P<0.0001.
**P<0.01.
ALI=acute lung injury; ARDS=acute respiratory distress syndrome; CLRT=continuous lateral rotation therapy
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Schellongowski P, et al. Intensive Care Med. 2007;33:625-631.
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Rotational Therapy Using
Cushion-Based Rotation
• The Medical Center of Central Georgia evaluated the impact of CLRT

• A CLRT protocol was implemented in patients who were identified as at risk for pulmonary
complications, and outcomes were compared with a historical comparison group
Cost to Treat, ICU

Hospital Reintubation
Vent Days ICU Days Thousands of Readmission
Days Rates, %
Dollars Rates, %
No CLRT 17.4 18.4 29.7 59.4 21 19
CLRT after
16.6 18.9 28.8 62.1 17 13
48 hours
CLRT within
12.4 13.1 23.4 45.2 4 4
48 hours
• When introduced early, CLRT may reduce critical care length of stay and cost to treat
• CLRT is an option for patient mobility

No CLRT: 75 patients; CLRT after 48 hours: 46 patients; CLRT within 48 hours: 50 patients.
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Swadener-Culpepper L, et al. Crit Care Nurs Q. 2008;31:270-279.
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CLRT to Prevent VAP: Controlling the Variables
• Methodology
– Prospective randomized controlled trial, 3 medical ICUs at a single center
– Eligible if ventilated <48 hours and free from pneumonia, ALI, or in ARDS
– 150 patients with 75 in each group
– 35 patients with CLRT allocated to undergo percussion before suctioning
– Measures to prevent VAP were standardized for both groups including HOB
• Results: CLRT vs control

– VAP: 11% vs 23% P=0.048
– Ventilation duration: 8 ± 5 days vs 14 ± 23 days, P=0.02
– LOS: 25 ± 22 vs 39 ± 45 days, P=0.01
– Mortality: no difference
ALI=acute lung injury; ARDS=acute respiratory distress syndrome; CLRT=continuous lateral rotation therapy;
VAP=ventilator-associated pneumonia.
HOB=Head
Page 23 of bed
Staudinger T, et al. Crit Care Med. 2010;38:486-490.
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CLRT Protocol:
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Moving Those Who Cannot Move Themselves:
Which Patients Should Receive CLRT?
• Target high-risk patient populations

– Pulmonary-hemodynamic instability with manual turning
– FiO2 50% or more
– Positive end-expiratory pressure (PEEP) 8 or more
– Existing pulmonary complications
– FiO2 increases by 20% (20 points) or PEEP >3 cm H2O from baseline within 2
calendar days
• Which patients should NOT receive CLRT?

– Those with unstable spines
– Those with long bone fractures or patients requiring traction
– Those with unstable intracranial pressure
– Marked agitation without therapeutic management
– Those with severe, uncontrolled diarrhea and patients that weight more than 300lbs

Swadener-Culpepper L, et al. Crit Care Nurs Q. 2008;31:270-279.
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Basham KA, et al. Respir Care Clin N Am. 1997;3:109-134.
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CLRT Quick
Reference Guide
CLRT Protocol for

Hemodynamically
Stable Patients
CLRT=continuous
Page 26 lateral rotation therapy.
* This tool is provided for education and discussion only. Each facility is responsibility for the development, adoption and implementation of its own protocols. Follow protocols and rules adopted by your facility.
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CLRT Quick
Reference Guide
CLRT Protocol for

Hemodynamically
Unstable Patients
CLRT=continuous
Page 27 lateral rotation therapy.
* This tool is provided for education and discussion only. Each facility is responsibility for the development, adoption and implementation of its own protocols. Follow protocols and rules adopted by your facility.
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CLRT Strategies for Success
• Early CLRT intervention
• The therapy must be driven by a protocol and changes in settings are
nursing orders
• Monitor initial rotation cycle to ensure one lung is above the other
• Automation of rotation requires insertion of usual assessment practices
• Minimum of 18 hours per day and 6 cycles per hour
• If done incorrectly, can cause skin injury
– Shorter pause times
– Assessment to ensure one lung above the other
– Every-2-hours assessment of the lungs and skin
• Yearly competency-based education to ensure proper use of the therapy
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CLRT Success Story at Union Hospital:
The Challenge
Union Hospital, Union NJ

• Utilization of the CLRT policy was inconsistent
– Long lag times in implementation of therapy
– No standard protocol
• Issues regarding use of CLRT

– Many nurses did not understand the pulmonary benefits of turning
– Purchasing was concerned that no appreciable savings were being
noted, as data were not consistently monitored

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A Comparison of Continuous Lateral Rotation and Manual Turning: A Process Improvement Initiative. A Hill-Rom white paper. 2001.
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The Solution
• Policy and procedure for CLRT was redesigned with a

focus on early intervention
• Staff were educated on CLRT

– New CLRT protocol
– How to maintain proper rotation
– How to collect therapy statistics
• A quality outcomes study was initiated

– 46 patients in the critical care unit were enrolled in the study
• 23 on a CLRT bed
• 23 on a standard bed with manual turning

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A Better Outcome
Union Hospital Total Charges
$6,000,000
Avg = $221,160
Cost, US Dollars
$5,000,000
$4,000,000
Avg = $121,662
$3,000,000
$2,000,000 CLRT Bed
Charges=1.1% Total
$1,000,000 Charges
$0
CLRT (n=23) Non-CLRT (n=23)
• Patients in the CLRT group had
– 26% decrease in the number of days on a ventilator
– 22% decrease in critical care unit LOS and 18% decrease in hospital LOS
– 45% decrease in hospital total charges
CLRT=continuous lateral rotation therapy; LOS=length of stay.

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Thank you!
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References
Basham KA, et al. To everything turn, turn, turn…An overview of continuous lateral rotational therapy. Respir Care Clin N Am. 1997;3:109-134.
Choi SC, Nelson LD. Kinetic therapy in critically ill patients: combined results based on meta-analysis. J Crit Care. 1992;7:57-62.
Device-associated module: ventilator-associated event protocol. NHSN website. http://www.cdc.gov/nhsn/PDFs/pscManual/10-VAE_FINAL.pdf.

Accessed 2/22/13.
Dudeck MA, et al. National Healthcare Safety Network (NHSN) report, data summary for 2010, device-associated module.
http://www.cdc.gov/nhsn/PDFs/dataStat/2010NHSNReport.pdf. Accessed 12/19/12.
Fleegler B, et al. Dimens Crit Care Nurs. Continuous lateral rotation therapy for acute hypoxemic respiratory failure: the effect of timing.
2009;28:283-287.
Fortney SM, et al. Physiology of Bedrest (Vol 2). New York: Oxford University Press. 1996.
Froese AB, Bryan AC. Effects of anesthesia and paralysis on diaphragmatic mechanics in man. Anesthesiology. 1974;41:242-255.
Goldhill DR, et al. Rotational bed therapy to prevent and treat respiratory complications: a review and meta-analysis. Am J Crit Care. 2007;16:50-
61.
Greenleaf JE, Kozlowski S. Physiological consequences of reduced physical activity during bed rest. Exerc Sport Sci Rev. 1982;10:84-119.
Kubo A, et al. Early ICU mobility for nurses. NTI Sunrise Session. 2011.
Malbouisson LM, et al. Role of the heart in the loss of aeration characterizing lower lobes in acute respiratory distress syndrome. CT Scan ARDS
Study Group. Am J Respir Crit Care Med. 2000;161:2005-2012.
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References (Cont.)
Restrepo MI, et al. Economic burden of ventilator-associated pneumonia based on total resource utilization. Infect Control Hosp Epidemiol.
2010;31:509-515.
Riggs L. As the bed turns: Clinical and cost management of lateral rotation. AACN/NTI presentation. 2005. St. Luke’s Hospital, Kansas City, MO.
Rosenthal VD, et al. International Nosocomial Infection Control Consortium (INICC) report, data summary of 36 countries, for 2004-2009. Am J
Infect Control. 2012;40:396-407.
Schallom L, et al. Effect of frequency of manual turning on pneumonia. Am J Crit Care. 2005;14:476-478.
Schellongowski P, et al. Prolonged lateral steep position impairs respiratory mechanics during continuous lateral rotation therapy in respiratory
failure. Intensive Care Med. 2007;33:625-631.
Staudinger T, et al. Continuous lateral rotation therapy to prevent ventilator-associated pneumonia. Crit Care Med. 2010;38:486-490.
Swadener-Culpepper L, et al. The impact of continuous lateral rotation therapy in overall clinical and financial outcomes of critically ill patients.
Crit Care Nurs Q. 2008;31:270-279.
Vollman KM. Prone positioning in the patient who has acute respiratory distress syndrome: the art and science. Crit Care Nurs Clin North Am.
2004;16:319-336.
Vollman KM. Introduction to progressive mobility. Crit Care Nurse. 2010;30:S3-S5.
Washington GT, Macnee ML. Evaluation of outcomes: the effects of continuous lateral rotational therapy. J Nurs Care Qual. 2005;20:273-282.
Winkelman C. Bed rest in health and critical illness: a body systems approach. AACN Adv Crit Care. 2009;20:254-266.
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Continuous Lateral Rotation Therapy:

An Early Option for Mobilizing Patients

• Decreased movement of secretion1

• Increased dependent edema2

• Decreased respiratory motion3

1. Vollman KM. Crit Care Nurse. 2010;30:S3-S5.

• In the supine position,

• What impact does it have on gas exchange?

• What happens inside the airways when patients are turned?

• Turning on the long axis • Rotates patient by

Table-Based Rotation Cushion-Based Rotation

Study Year Rotation Results

CLRT=continuous lateral rotation therapy.

Rotational therapy provides a benefit with respect to the

Goldhill20DR, et al. Am J Crit Care. 2007;16:50-61.

• The Medical Center of Central Georgia evaluated the impact of CLRT

Cost to Treat, ICU

CLRT=continuous lateral rotation therapy.

• Results: CLRT vs control

• Target high-risk patient populations

• Which patients should NOT receive CLRT?

CLRT=continuous lateral rotation therapy.

CLRT Protocol for

CLRT Protocol for

• Yearly competency-based education to ensure proper use of the therapy

Union Hospital, Union NJ

• Issues regarding use of CLRT

CLRT=continuous lateral rotation therapy.

• Policy and procedure for CLRT was redesigned with a

• Staff were educated on CLRT

• A quality outcomes study was initiated

CLRT=continuous lateral rotation therapy.

CLRT=continuous lateral rotation therapy; LOS=length of stay.

Device-associated module: ventilator-associated event protocol. NHSN website. http://www.cdc.gov/nhsn/PDFs/pscManual/10-VAE_FINAL.pdf.

Vollman KM. Introduction to progressive mobility. Crit Care Nurse. 2010;30:S3-S5.

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