• Choose a category
• All
• Classic-Fiction

Procedure

4 Position in side-lying on the unaffected side. Refer to the general principles of moving and positioning the patient in side-lying (see Procedure guideline 7.3). Ventilation and perfusion are both preferentially distributed to the dependent areas of lung.

Procedure guideline 7.8 Positioning the patient to maximize V/Q matching for widespread pathology in a self-ventilating patient

Equipment

Pillows/towels

Sliding sheets/ manual handling equipment if indicated following risk assessment in accordance to local manual handling policy

Bed extension for tall patients

Preprocedure

Action Rationale

1 Explain and discuss the procedure with the patient. To ensure that the patient understands the procedure and gives their valid consent (NMC 2008, C).

2 Wash hands thoroughly or use an alcohol-based handrub. To reduce the risk of contamination and cross-infection (Fraise and Bradley 2009, E).

3 Ensure that the bed is at the optimum height for handlers. If two handlers are required try to match handlers’ heights as far as possible. To minimize the risk of injury to the practitioner (Smith 2005, C).

Procedure

4 Position the patient in high sitting as discussed in the general principles of moving and positioning of the patient in sitting in bed or chair (see Procedure guidelines 7.2 and 7.5). The effects of shunting mean perfusion will best match ventilation in high supported sitting (Dean 1985, R4).

Problem-solving table 7.2 Prevention and resolution (Procedure guidelines 7.7 and 7.8)

Positioning to minimize the work of breathing

Anatomy and physiology

At rest, inspiration is an active process whereas expiration is passive. The main muscle involved in inspiration is the diaphragm (Figure 7.14). The diaphragm contracts, thereby increasing the volume of the thoracic cavity. Additionally, the external intercostals work by pulling the sternum and rib cage upwards and outwards, likened to a pump and bucket handle (Figure 7.15). When increased ventilation is required (e.g. with exercise or in disease), the accessory muscles (scalene and sternocleidomastoid) assist with this process.

Figure 7.14 The diaphragm as seen from the front. Note the openings in the vertebral portion for the inferior vena cava, oesophagus and aorta.

Figure 7.15 Movement of chest wall on inspiration. (a) The upper ribs move upwards and forwards, increasing the anteroposterior dimension of the thoracic cavity. As a result, the sternum also rises forwards (b) The lower ribs move like bucket handles, increasing the lateral dimension of the thorax.

Reproduced with permission from Aggarwal and Hunter (2007).

If this situation is prolonged, as in respiratory disease, the diaphragm activity reduces and the accessory muscles have to do a higher proportion of the work. This can be observed in a patient who adopts a posture of raised shoulders.

Although expiration should be passive in normal conditions, the internal intercostals and muscles of the abdominal wall (transversus abdominis, rectus abdominis and the internal and external obliques) are utilized in times of active expiration to push the diaphragm upwards, reducing the volume of the thoracic cavity and forcefully expelling air. This can be observed clinically when the abdominal wall visibly contracts and pulls in the lower part of the rib cage during expiration.

Evidence-based approaches

Principles of care

Many people suffering with long-term breathlessness adopt positions that will best facilitate their inspiratory muscles. The aim of any position is to restore a normal rate and depth of breathing in order to achieve efficient but adequate ventilation (see Box 7.2).

Box 7.2 Positioning to minimize the work of breathing

There are certain resting positions that can help reduce the work of breathing, as shown in Figure 7.16.

Figure 7.16 Positions to support breathing.

1 High side-lying (see Figure 7.16a).

2 Forward lean sitting (see Figure 7.16b).

3 Relaxed sitting (see Figure 7.16c).

4 Forward lean standing (see