Verticalisation Therapy

Original Editor - Saud Alghamdi Top Contributors - Saud Alghamdi and Ewa Jaraczewska

Introduction

The power of positioning is a growing area in Physiotherapy. During the COVID-19 pandemic, prone positioning became a widely used physiotherapy led treatment option for ventilated patients with COVID-19 in the UK . For adult patients, prone positioning (PP) was recommended for 12 to 16 hours per day . Despite it’s reported benefits, PP is logistically difficult and according to a 2021 systematic review, the most common complication to PP was the development of pressure ulcers.

Recently, a new term and method has been introduced in the literature, Verticalisation therapy (VT). VT is defined as the placement of patients with their heads up 45 to 90 degrees without flexion at the hip joint. This article will discuss the use of VT in patients with Acute Respiratory Distress Syndrome (ARDS).

Implications of VT in patients with ARDS who are mechanically ventilated

In 2006, the idea of verticalization as a therapy protocol for patients with ARDS was first introduced as a hypothesis that would increases lung volume and improves gas exchange by reducing the pressure surrounding lung bases . Indeed, their hypothesis was correct, and the researchers reported significant improvements associated with VT .

Later in 2013, another study with a larger patient size was conducted in 5 French ICUs. 40 patients were included and divided into 3 main groups: mild, moderate and severe.  5 with mild ARDS, 30 with moderate ARDS and 5 with severe ARDS . The researchers report that the effect of VT on PaO2/FiO2 ratio was quick, concluding that VT resulted in a rapid and significant increase in lung volume and oxygenation . It is noteworthy to mention that this study did come with its limitations, most notably the degree of verticalisation as the authors did not perform true verticalisation (identified by the placement of patients with their heads up 45 to 90 degrees without flexion at the hip joint). Instead, patients were placed in a seated position accessible to specific ICU beds. Additionally, another notable limitation is that patients were put in a sequence of positions that were not randomised, therefore it is difficult to precisely distinguish the effects of the seated verticalisation position.

Implications of VT in patients with ARDS who are on VV-ECMO

There appears to be only one case study investigating the effects of VT in patients who are on VV-ECMO . One patient with severe ARDS was undergoing VV-ECMO. Implementation of VT resulted in extremely promising results as the authors reported that the patient was able to sustain an oxygen saturation above 90% for approximately 3 hours following each VT session . In this case study, VT was favoured over prone positioning due to the adverse events that are typically associated with prone positioning in patients on ECMO. Most notably, pressure ulcers and inadvertent decannulation .

Dosage of VT

Of the 3 discussed studies, only one reported the duration and dosage of VT for patients with ARDS. The authors based the dosage and duration on patient tolerance. Due to deconditioning and lower extremity weakness, VT sessions were limited to no more than 60 degrees of verticalisation. Additionally, the patient was unable to tolerate more than 30 minutes of verticalization therapy twice per day .

Indeed, more studies are needed to make recommendations. However, it appears that the dosage and duration maybe be completely dependent on the patient’s tolerance. Nonetheless, due to a lack of guidelines, health care professionals should proceed and prescribe VT with caution. Additionally, it is recommended that each VT session is closely monitored.