Verticalisation Therapy
Introduction[edit | edit source]
The power of positioning is a growing area in Physiotherapy. During the COVID-19 pandemic, prone positioning (PP) became a widely used physiotherapy-led treatment option for ventilated patients with COVID-19 in the UK. [1] For adult patients, PP was recommended for 12 to 16 hours per day. [1] Despite its reported benefits, PP is logistically difficult, and according to a 2021 systematic review, the most common complication of PP was the development of pressure ulcers.[2]
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.[3] This article will discuss the use of VT in patients with Acute Respiratory Distress Syndrome (ARDS) who are either mechanically ventilated or are on Venovenous Extracorporeal Membrane Oxygenation (VV-ECMO).
Implications of VT in Patients with ARDS Who are Mechanically Ventilated[edit | edit source]
In 2006, the idea of verticalization as a therapy protocol for patients with ARDS was first introduced as a hypothesis that would increase lung volume and improves gas exchange by reducing the pressure surrounding lung bases. [4] Indeed, their hypothesis was correct, and the researchers reported significant improvements associated with VT. [4]
Later, in 2013, another study with a larger patient size was conducted in 5 French Intensive Care Units (ICU). 40 patients were included and divided into 3 main groups: mild, moderate and severe. 5 had mild ARDS, 30 had moderate ARDS, and 5 had severe ARDS. [5] The researchers report that the effect of VT on the ratio of partial pressure of oxygen in arterial blood (PaO2) to the fraction of inspiratory oxygen concentration (FiO2) was quick, concluding that VT resulted in a rapid and significant increase in lung volume and oxygenation. [5] 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[edit | edit source]
There appears to be only one case study investigating the effects of VT in patients who are on VV-ECMO. [3] 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. [3] 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. [2]
Dosage of VT[edit | edit source]
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. [3]
Indeed, more studies are needed to make recommendations. However, it appears that the dosage and duration may be completely dependent on the patient’s tolerance. Nonetheless, due to a lack of guidelines, healthcare professionals should proceed and prescribe VT with caution. Additionally, it is recommended that each VT session be closely monitored.
Potential Complications[edit | edit source]
Only one study reported that their patient demonstrated a slight reduction in blood pressure and an increase in heart rate during VT sessions. However, no serious adverse events were reported. Additionally, the reduction in blood pressure was not significant and did not warrant any interventions for blood pressure management during VT sessions. [3]
Based on the current evidence, initiating VT should be accompanied by close monitoring of the patient’s blood pressure, heart rate, and general feeling.
Implications for Clinical Practice for Physiotherapists[edit | edit source]
The current body of literature on the efficacy of VT for patients with ARDS in ICUs is limited. The available evidence remains inconclusive due to an insufficient number of well-designed and rigorous studies. Indeed, future research with large sample sizes is warranted to establish a more definitive understanding of the treatment's effectiveness. However, it is noteworthy that the available studies, albeit limited in number, demonstrate that VT for patients with ARDS is a promising treatment option with highly encouraging early results.
Physiotherapists should consider implementing VT as an alternative to prone positioning to improve PaO2/FiO2 ratios and lung volumes in patients with ARDS. The use of VT rather than prone positioning is particularly advantageous in patients on VV-ECMO due to the high risk of decannulation that prone positioning presents with. [3] [2]
Resources[edit | edit source]
References[edit | edit source]
- ↑ 1.0 1.1 Thomas P, Baldwin C, Bissett B, Boden I, Gosselink R, Granger CL, Hodgson C, Jones AY, Kho ME, Moses R, Ntoumenopoulos G, Parry SM, Patman S, van der Lee L. Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice recommendations. J Physiother. 2020 Apr;66(2):73-82.
- ↑ 2.0 2.1 2.2 Giani M, Rezoagli E, Guervilly C, Rilinger J, Duburcq T, Petit M, Textoris L, Garcia B, Wengenmayer T, Grasselli G, Pesenti A, Combes A, Foti G, Schmidt M; EuroPronECMO Investigators. Prone positioning during venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a pooled individual patient data analysis. Crit Care. 2022 Jan 6;26(1):8.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Shayan S, DeLeon AM, McGregor R, Mader T, Garino M, Mehta C. Verticalization Therapy for Acute Respiratory Distress Syndrome Patients Receiving Veno-Venous Extracorporeal Membrane Oxygenation. Cureus. 2023 Jun 7;15(6):e40094.
- ↑ 4.0 4.1 Richard JC, Maggiore SM, Mancebo J, Lemaire F, Jonson B, Brochard L. Effects of vertical positioning on gas exchange and lung volumes in acute respiratory distress syndrome. Intensive Care Med. 2006 Oct;32(10):1623-6.
- ↑ 5.0 5.1 Dellamonica J, Lerolle N, Sargentini C, Hubert S, Beduneau G, Di Marco F, Mercat A, Diehl JL, Richard JC, Bernardin G, Brochard L. Effect of different seated positions on lung volume and oxygenation in acute respiratory distress syndrome. Intensive Care Med. 2013 Jun;39(6):1121-7.
