Knee-Chest Position

Improves Pulmonary
Oxygenation in Elderly
Patients Undergoing Lower
Spinal Surgery with Spinal
J. Clin. Anesth. 3:361-366, 1991 Anesthesia
*Assistant Professor, Department of Anes-
thesiology and Critical Care Medicine, Hi-
roshima University Katsuyuki Moriwaki, MD, PhD,* Hiroshi Sasaki,
tStaff Anesthesiologist, Department of
MD,? Minoru Kubota, MD,+ Akimitsu Higaki,
Anesthesiology and Critical Care Medicine, MD,$ Tomoki Yoshida, MD,/1Osafumi Yuge, MD,
Hiroshima City Asa Hospital
PhD,# Michio Morio, MD, PhD**
*Instructor, Department of Anesthesiology
and Critical Care Medicine, Hiroshima Departments of Anesthesiology and Critical Care Medicine, Hiroshima University
University and Hiroshima City Asa Hospital, Hiroshima, Japan.

SResearch Fellow, Department of Anesthe-

siology and Critical Care Medicine, Hiro-
Study Objective: To define the effect of the knee-chest position on pulmonary
shima University
oxygenation in patients who underwent lower spinal operations under spinal
anesthesia.
[IResearch Fellow, Department of Internal
Medicine, Kyushu University Design: Clinical, prospective study.
Setting: Inpatient anesthesia and orthopedic surgery clinic at a municipal hospital.
#Associate Professor, Department of Anes- Patients: Fajiy-six patients (30 males and 26 females) who underwent lower spinal
thesiology and Critical Care Medicine, Hi- sur<gery under spinal anesthesia.
roshima University
Interventions: After administering hyperbaric tetracaine solution and fixing the
anesthesia level in the supine position for 15 minutes, patients were turned to the
**Professor and Chairman, Department of
Anesthesiology and Critical Care Medicine,
knee-chest position. They breathed room air normally.
Hiroshima University Measurements and Main Results: Arterial blood gas tensions were measured
in the supine position 15 minutes after administration of the tetracaine solution
Address reprint requests to Dr. Moriwaki and 15 minutes after turning patients to the knee-chest position. Patients were
at the Department of Anesthesiology and classified into six groups according to their age: patients in their teens and 2Os,
Critical Care Medicine, Hiroshima Univer-
?Os, 4Os, 5Os, 6Os, and 70s. In the supine position, the mean values of the alveolar
sity Hospital, l-2-3 Kasumi, Minami-ku, Hi-
artem’al oxygen tension difference (A-aDO& of patients in their 5Os, 6Os, and 70s
roshima, Japan 734.
were significantly higher than those of patients in their teens and 2Os, ~OS, and
Received for publication October 1, 1990; 40s. In the knee-chest position, these high values of A-aD0, in the older patient
revised manuscript accepted for publication groups decreased significantly, thereby eliminating any s&nificant dqference in
February 25, 1991. A-aD0, among all age groups. To determine the mechanism of the improvement
of pulmonary oxygenation in the elderly patients, the effect of the knee-chest position
0 1991 Butterworth-Heinemann
on lung volumes was studied in eight young volunteers.

J. Clin. Anesth., vol. 3, September/October 1991 361

Conclusion: A ,sig-nifimnt irq!mwtnm/ of p~dmonar~ ox- (( XF) ~;IS ol)tainetl, ~etracaine with phen)~lephrin<~ L\;I\
ygenation um .sem in dderlv patients who undmurnt /oam illjrctecl. ‘I‘etracaine hx supplied ils a 0.5% SO~tlti~Jtl.
.spinal operution with .spi~nal hnesthesiu, -idlen thp1’were tumed wi1ic.h is hyperbaric compared with (SF. I’llen!-l-
to the knee-chest position. The knee-rhest position has a ben- ephrine 0.5 mg was added to 1 ml of the tetracaine
eficial effect on pulmonary oxyygenation in elderly patients solution. One to 2.5 ml of this solution was injected
who are girlen spiml onesthesin. according to the patient’s phvsical constitution and
age. ‘I‘he anesthesia level was ‘carefully controlled at
Keywords: Posture; pulmonary artery; geriatrics; about rhe tenth thoracic dermatome (Th 10) it1 the
anesthesia, spinal; surgery, spinal. supine position hv tilting the operating tahlr.
Fifteen minutes at’ter administration of the tetra-
caine solution, the patients were turned to .l‘arlo\,‘s
knee-chest position:’ (Fqq~211.o 2). Free abdominal move-
Introduction ment was secured. Patients were sedated with 2.5 to
10 mg of intravenous (IV) diazepam about 5 minutes
Spinal anesthesia has been successfully used during after being turned to the knee-chest position. Airway-
operations of the lower lumbar spine in patients in paterq, respiration, electrocardiogram (EKG). and
the knee-chest position. ‘Z We also have used spinal blood pressure (BP) were carefully monitored. Five
anesthesia successfully for such operations. During hur~dred to 1,000 ml of lactated Ringer’s solution was
anesthesia, we have seen several cases in which the infused for the first hour of anesthesia. Decreases in
arterial oxygen tension (PaO,) increased in the knee- BP were treated with ephedrine hydrochloride 5 111%
chest position compared with the supine position be- IV, incrementallv if necessary. Peak dermatome of
fore the patient was turned to the knee-chest position. sensory anesthesia was checked 15 minutes after
This phenomenon seemed more likely to occur in ~rclrnitlisti-atiorl of spinal anesthesia in the supine po-
older patients. The present study attempted to clarify sition and 15 minutes after turning patients to the
this phenomenon in patients undergoing lower spinal knee-chest position. Patients hreathed room air nor-
surgery with spinal anesthesia. To understand the mally throughout the surgery. Arterial Mood was ob-
mechanism of this improvement in oxygenation, we tained from the radial artery in the supine position
also studied the effect of the knee-chest position on 15 minutes after administration of the tetracaine so-
pulmonary lung volumes in healthy young volunteers. lution and 15 minutes after turning the patient to the
knee-chest position. The arterial blood gas tensions
were measured using a Corning 175 automatic pEI/
blood gas system ((1orning (ilass Works, (:orning, NY).
Materials and Methods
A-aD0, was calculated hy the following equation:

Changes in Arterial Blood Gas Tensions and A-aD0, = P_\O, - PaO,

A-aD0,

After obtaining informed consent from the patients

and the approval of the protocol from the Ethics Com-
mittee of the Hiroshima City Asa Hospital, we studied
56 patients (30 males and 26 females) undergoing
lower spinal surgery. Thirty-six patients were diag-
nosed with lumbar disc hernia, 12 with lumbar spinal
column stenosis, and the rest with lumbar spondylolis-
thesis and spondylosis. All the patients were classified
as ASA physical status I or II. Decompression and/or
fusion procedures were performed for lesions.
Patients were premeditated with atropine 0.3 to
0.5 mg and hydroxyzine 25 to 100 mg. Spinal anes-
thesia was performed with a standard midline lumbar
puncture using a 25-gauge needle inserted at the in-
terspace between the third and fourth vertebrae or
between the second and third vertebrae in the lateral Figure 1. Knee-chest position used for lower spinal oper-
position. Once the free flow of cerebral spinal fluid ations at Hiroshima City Asa Hospital.

362 J. Clin. Anesth., vol. 3, September/October 1991

 Knee-chest position improves pulmonary oxygenation: Moriwaki et al.

where PAO, is the alveolar oxygen tension. It is cal- Results

culated by the following equation:

Changes in Arterial Blood Gas Tensions and

PA@ = 150 - 1.25 X PaCO,
where 1.25 is a factor for the respiratory quotient,
assuming a respiratory quotient of 0.8, and PaCO, is
the arterial carbon dioxide tension.
The patients were divided into six groups accord-
ing to their age: patients in their teens and 20s 30s
4Os, 5Os, 6Os, and 70s. In each age-group, differences
in mean PaO, and A-aD0, were compared between
the supine and the knee-chest positions using Stu-
dent’s t-test for paired data. Differences in mean PaO,
and A-aD0, among age-groups were tested by anal-
ysis of variance and Bonferroni’s t-test. Differences
were considered statistically significant at p < 0.05.
Pulmonary Function Tests in Unanesthetized
Healthy Volunteers
Eight healthy volunteers, five males and three fe-
males, whose ages ranged from 2 1 to 33 years (mean
+ SD = 26.9 ? 4.0), were studied. Total lung ca-
pacity (TLC), functional residual capacity (FRC), and
closing capacity (CC) were measured in both the su-
pine and the knee-chest positions. FRC was measured
by the closed-circuit helium technique (helium dilu-
tion technique) with the use of a catharometer, and
CC was measured by a modified single-breath N, tech-
nique similar to that described by Anthonisen et al:’
All measurements were performed by a Morgan DC-
500 pulmonary function test system (P.K. Morgan Ltd,
Kent, UK). The data obtained from each position were
compared using Student’s paired t-test. A value of p
< 0.05 was considered statistically significant. Data
are expressed as means + SD.
A-aD0,
Patient characteristics, the peak dermatome of sen-
sory anesthesia, and the dose of tetracaine solution
for each group are shown in Table 1. Mean arterial
pressure (MAP) and heart rate (HR) in the supine
and knee-chest positions are shown in Table 2. The
mean and SD of PaCO,, PaO,, and A-aD0, in the su-
pine and the knee-chest positions are shown in Ta-
ble ?.
There was no significant difference in mean MAP
between the supine and knee-chest positions in any
age-group. There was no significant difference in HR
between these two positions in the first five groups,
but HR was significantly higher in the knee-chest than
in the supine position in patients in their 70s. The
mean values of MAP were significantly different
among age-groups in these two positions. The mean
values of HR were not significantly different among
age-groups in these two positions.
When patients were turned from the supine to the
knee-chest position, PaO, increased significantly and
A-aD0, decreased significantly in the three older
groups. In three younger groups, however, the mean
values of PaO, and A-aD0, were not significantly
different in these two positions. In the supine posi-
tion, the mean values of A-aD0, in the three older
groups were significantly higher than those in the
three younger groups. In the knee-chest position, there
was no significant difference in mean A-aD0, among
all age-groups.
After the patients were turned to the knee-chest
position, PaCO, was significantly increased in the pa-
tients in their teens and 20s 30s 5Os, and 60s. No

Table 1. Patient Demographics, Anesthesia Dosages, and Peak Dermatome of Sensory Anesthesia

Dose of
Peak Dermatome*
Number of Age Sex Weight Height Tetracaine
Age-group Patients (yr) (M/F) (kg) (cm) (mg) Supine Knee-Chest

Teens and 20s 8 19.4 ? 6.5 612 55.4 2 10.8 167.3 * 12.7 10.1 ? 2.5 Th7 Th7
30s 13 35.2 ? 3.4 518 66.8 +- 14.0 164.2 ? 7.3 10.1 2 1.9 Th7 Th8
40s 9 43.3 * 1.7 613 62.8 t 10.7 158.6 + 9.6 10.3 5 1.9 Th8 Th8
50s 12 55.6 ? 2.4 418 62.3 ? 11.5 159.9 * 8.1 10.4 * 0.9 Th7 Th7
60s 8 64.6 2 2.9 513 59.5 * 9.0 152.3 + 9.1 10.4 * 1.4 Th7 Th7
70s 6 74.0 * 2.8 412 55.7 * 10.4 152.3 ? 11.8 8.1 * 1.9 Th7 Th7

*Average peak dermatome of sensory anesthesia.

Note: Data are means ? SD.
Th7 = seventh thoracic dermatome; Th8 = eighth thoracic dermatome

J. Clin. Anesth., vol. 3, September/October 1991 363

Table 2. (Changes irt Mean Arterial PRSSUK (RIAP) and Heart Kacc iIlK)
______ _

Change in MAP (mmHg) Change in HR (beats/minute)

Significance Significance
Age-group Supine Knee-Chest (paired t-test) Supine Knee-Chest (paired t-test)

‘l‘eens and 20s 78.0 2 5.2 71.S + (i.7 NS 8.5.S -c “5.2 SC.0 + !I.!, KS
30s 82.1 2 7.6 Hi.5 k I I .O NS 72.9 k I-t.6 is..5 k II).0 KS
40s 73.1 2 10.3 80.3 + 7.4 NS 7S. 1 f 1.jA 7x.2 + 7.8 h’s
50s 90.1 + 12.9 85.3 k 9.4 h’s 7G.S k 2 I .x 21.5 ‘-+ 16.3 NS
60s 79.X ? 6.1 X4.0 + T.ti NS Xl.(i 2 10.9 x1.5 k IS.7 KS
70s 91.5 + 13.9 H9.5 k IX.2 h’s HO.” -t I4.i XC.2 2 17.5* fJ < I).().‘,

Significance F = 4.40 I; = 2.50 F = 0.M 1.’= 0.77

(ANOVA) (jj < 0.01) (p < 0.05) (NS) (NS)

*Difference between supine and knee-chest position.

Note: Data are means % SD.
NS = no significant diffcl-ence between supine and knee-chest position: ANOVA = ;malyG ot vat-iance.

Table 3. Changes in Patient Arterial Blood YI’ensions (PaCO, and PaO,) and Arterial Oxygen ~Tension Dif’f’erences
(A-aDO,)

PaCO? (mmHg) PaO, (mmHg) A-aDOp (mmHg)

Age- Knee- Knee-

group Supine Chest Significance Supine Knee-Chest Significance Supine Chest Significance

Teens
and 20s 36.6 -’ 4.3 3Y.3 ? 3.(b p C 0.05 Y6.6 IT 6.4 95.3 f 4.7 NS 7.3 t 4.6 6.0 t 3.5 NS
30s 36.4 ? .5.3 3Y.2 2 3.4” p i 0.05 Y2.8 + 10.1 92.2 t 7.6 NS 1 I.5 5 Y.8 X.6 t 3.4 NS
40s 37.6 t 3.1 38.9 2 2.3 NS YO.4 +- 8.Y Y2.Y t 3.0 NS 12.3 I! 7.7 8.2 t .i.I NS
50s 36.7 2 3.5 40.0 t- 2.7” p < 0.005 80.0 + 11.3h 87.4 ? lO.l* p < 0.0.5 24.0 i 12.2” 13.2 ir 8.72 p < 0.05
60s 37.5 2 3.7 40.5 2 2.8‘1 p < 0.05 78.1 ? Y.6’, 88.0 +- 8.5~~ p < 0.0.5 24.7 t ll.lh 11.3 ? 8.3” p < 0.05
70s 36.6 I 3.6 40.7 ? 2.6 NS 82.9 2 6.9’1 Y2.5 ‘-’ 6.5~~ p < 0.00.5 2l.j ? 7.7” 3.6 f 2.2,g p < 0.05

Significance F = 0.13 F = 0.43 F = 5.Y4 F = 1.75 F = 5.52 E‘= 2.33

(ANOVA) (NS) (NS) (jI < 0.01) (NS) (/I < 0.01) (NS)

aDifference between supine and knee-chest position.

hDifference among age-groups.
Note: Data are means + SD.
PaCO? = arterial carbon dioxide tension: PaO, = arterial oxygen tension: NS = no significant difference; ANOVA = analysis of variance.

significant change in PaCO, was observed among pa- liters, and 1.76 2 0.72 liters, respectively. ‘1’LC and
tients in their 40s and 70s. FRC increased significantly (p < 0.05 and $I < 0.005,
respectively) when the subjects were turned to the
knee-chest position from the supine position. How-
Pulmonary Function Tests in Unanesthetized ever, the change in CC was not significant between
Healthy Volunteers these two positions.

The mean body height and weight of the volunteers Discussion

were 164.6 2 5.9 cm and 58.6 * 8.2 kg, respectively.
Changes in TLC, FRC, and CC from the supine po- The knee-chest position described by Tarlov” has two
sition to the knee-chest position in healthy volunteers principal advantages for lower spinal operations. One
are shown in Fi,q~e 2. TLC, FRC, and CC in the advantage is that this position causes no pressure on
supine position were 4.71 -+ 0.69 liters, 1.83 +- 0.29 the abdomen or chest, which decreases operative
liters, and 1.37 % 0.39 liters, respectively, and in the bleeding from the epidural veins.“,5 A second advan-
knee-chest position 5.23 t 0.84 liters, 2.72 t 0.74 tage of the knee-chest position is the widening of the

364 J. Clin. Anesth., vol. 3, September/October 1991

 Knee-chest position improves pulmonary oxygenation: Moriwaki et al.

Age and posture are among the major factors de-

termining PaO,. This finding is seen in the relation-
ship between CC and FRC. CC is less than FRC in
n=8 young adults but increases with age to become equal
* * PCO.05 to FRC at a mean age of 44 years in the supine position
* * P <0.005
and 66 years in the upright position. Shunting of blood
through areas of the lung with closed airways, which
TLC
is supposed to occur when FRC is less than CC, has
been considered one of the important causes of de-
** creased PaO, with increasing age and change of
position.”
:..;
FRC
---Icc
NS A significant increase of FRC in the prone position
was reported by Moreno and Lyons.’ They reported
no significant change in TLC when subjects were
turned from the supine to the prone position and
0 1
S KC S KC S KC showed no data on the change in CC. We showed a
significant increase in FRC and TLC but no change
in CC in young, healthy, unanesthetized subjects when
they were turned from the supine position to the knee-
Figure 2. Pulmonary function tests in unanesthetized chest position. Provided that the effect of the knee-
healthy volunteers. Total lung capacity (TLC) and func- chest position on lung volumes is the same in both
tional residual capacity (FRC) increased significantly when the young and the old, we speculate that the improve-
subjects were placed in the knee-chest position. The dif-
ment of pulmonary oxygenation in the knee-chest po-
ference in the means of closing capacity (CC) between the
sition seen in our older patients may be attributed to
supine and knee-chest positions was not significant (NS) (S
= supine position; KC = knee-chest position). the increase in FRC more than the increase in CC.
Rehder et ~1.~determined that it has not been clearly
established that the relationship between CC and FRC
lumbar space because flexion of the spine eliminates may underlie the change in pulmonary gas exchange
normal lumbar lordosis.3 Despite these well-recog- seen during anesthesia. We believe, however, that the
nized advantages in surgical procedures, little is known relationship between FRC and CC is one of the im-
about pulmonary physiology in the knee-chest position. portant underlying mechanisms of change in pul-
The current study focused on the relationship be- monary oxygenation.
tween age and improvement in pulmonary oxygen- In the current study, we did not study whether
ation in the knee-chest position under spinal spinal anesthesia itself had any effect on pulmonary
anesthesia. A-aD0, decreased significantly when pa- function in the knee-chest position. Decreased venous
tients over 50 years old were turned from the supine return by spinal anesthesia may cause a change in
to the knee-chest position, but no significant change pulmonary circulation and thus may influence pul-
was observed in younger patients. In the supine po- monary oxygenation in this position. Some reports”.‘”
sition, mean A-aD0, values in the three older groups suggest that the improvement in pulmonary oxygen-
were significantly higher than those in the three ation is due to changes in pulmonary circulation. Wie-
younger groups. After the patients were turned to the ner et al.” reported that the gravitational regional
knee-chest position, however, mean A-aD0, values distribution of the perfusion gradient was markedly
in the older patient groups decreased, thereby elim- reduced in the prone position in dogs with and with-
inating any significant difference in A-aD0, among out oleic acid-induced lung injury. They speculated
all the groups. Thus, it is believed that pulmonary that this change in gravitational regional distribution
oxygenation was improved when the older patients of the perfusion gradient is the mechanism of the
were turned to the knee-chest position under spinal prone position-induced improvement in oxygena-
anesthesia. tion. Kamal et al.‘” reported that intrapulmonary
PaCO, increased significantly in patients in their shunting decreased when cardiac output and mean
teens and 20s 30s 5Os, and 60s when they were turned pulmonary artery pressure decreased in lung-injured
to the knee-chest position. Diazepam was adminis- swine. These reports suggest the importance of pul-
tered after changing position, and we speculate that monary circulation in pulmonary oxygenation. Ac-
the increase in PaCO, may have been a result of the cording to the latter study,‘O the improvement of
depressant effect of diazepam on respiration. pulmonary oxygenation in elderly patients in the

J. Clin. Anesth., vol. 3, September/October 1991 365

Original Contrit/lltLolL~

present study may have been due to a reduction of tiotl presumably provides bettel- puhnonar) oxygrt~-
the intrapulmonary shunt caused by blood pooling in ation than does rhe supine position. Further stud\ i>
a sympathectomized leg in the dependent position required to confirm I his effect under gw~el-al
and a decrease in pulmonary blood flow. anesthesia.
Because we did not study postural changes in the I ri conclusion, a significant increase in pulnionar)
intrapulmonary shunt or in the ventilation-perfusion oxygenation was seen in older patients who under-
ratios, we cannot determine the precise mechanism(s) went lower spinal operations with spinal anesthesia
of the improvement in pulmonary oxygenation seen when they were turned from the supine to the knee-
in older patients in the knee-chest position. Further chest position. ‘l‘hese results suggest that the knee-
study is necessary to confirm the underlying mecha- chest position has a beneficial effect on pulmonary
nism of this phenomenon. oxygenation in older patients who undergo spinal
General anesthesia is more common for lower spinal anesthesia.
operations in the knee-chest position.’ Little has been
reported, however, on the influence of the knee-chest
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366 J. Clin. Anesth., vol. 3, September/October 1991