Continuous lateral rotation therapy in preventing pulmonary complications in mechanically ventilated patients: an evidence-based guideline

Abstract

Immobility is one of the factors associated with the accumulation of respiratory secretion in mechanically ventilated patients. Placing patients in a semi-recumbent position between 30° and 45° and frequent manual turning in every two hours are the standard ventilator nursing care practice adopted worldwide. However, the prevalence of pulmonary complications remains high. The use of continuous lateral rotation therapy (CLRT) to improve drainage of secretion within the lung and the lower airways was proposed and has been investigated in numerous studies.

The purposes of this dissertation are (1) to perform a comprehensive systematic review for a critical appraisal of the current evidence on the use of CLRT to prevent pulmonary complications in mechanically ventilated patients, (2) to develop an evidence-based guideline and to assess the implementation potential, and (3) to develop an implementation and evaluation plan for translating the guideline to an adult intensive care unit (ICU) of a teaching hospital in Hong Kong.

In order to identify studies that compared CLRT with the standard care, four electronic databases, including CINAHL Plus, Medline, British Nursing Index and PubMed, were searched. 94 studies were identified and eight of them met the inclusion criteria. These studies included one randomized controlled trial (RCT), two non-randomized controlled clinical trials, one pretest-posttest clinical trial and four retrospective cohort studies. The quality of these reviewed studies was assessed by using the appraisal instruments of the Scottish Intercollegiate Guidelines Network. Four of the reviewed studies were graded as high quality. No major adverse patient outcome was reported. Instead, beneficial patient outcomes that reached statistical significance were consistently reported in the CLRT group. There were reductions in ventilator-associated pneumonia (VAP), atelectasis, duration of mechanical ventilation and length of stay. However, its effect on health care cost and mortality was inconclusive.

The implementation potential, in terms of the transferability, feasibility, and the cost-benefit ratio, was considered as high in the target setting. Based on the synthesized finding, a CLRT guideline is developed and is proposed to translate into practice. The implementation plan includes a communication plan with stakeholders and a pilot test. The guideline will be revised after the trial run of the proposed innovation for one and a half months. A full-scale controlled trial using a quasi-experimental design will be conducted. The primary outcome is to evaluate whether there is a reduction in the prevalence of VAP after the use of CLRT. According to previous studies, the use of CLRT can lead to a 49% reduction in VAP. The proposed innovation will be considered as clinical effective when similar observation is obtained.