Physiology of Body Positioning

Contents
• Definition of Therapeutic positioning
• Applied Physiology
Pressures
Pressure gradients
Pulmonary mechanics
• Ventilation (V)
• Perfusion(Q)
• V/Q Ratio
• Cardio Pulmonary Mechanics
• Physiological changes in different positions
Upright position
Supine
Side lying
Prone position
Trenlenburg Position
Definition
• Therapeutic body positioning is a primary
noninvasive physical therapy intervention that can
augment arterial oxygenation so that invasive,
mechanical, and pharmacological forms of
respiratory support can be postponed, reduced or
avoided.

• These positions aim at improving the oxygen

transport by altering the effects of gravity
Gravity & Normal physiological Function

• Gravity majorly affects the cardiopulmonary function as it acts on the

lungs, heart and peripheral circulation which help in establishing
normal oxygen transport.

• Gravitational effects & mobilisation alters the ventilation and

perfusion thereby optimising V/Q matching with physiological
demands.
Oxygen Transport
• Step 1- Air enters lung via
changes in pleural and
alveolar pressures.

• Step 2- The oxygen diffuses in

accordance with the pressure
gradients across the
respiratory membrane into
the blood.
• Step 3- In the blood oxygen is
carried via two mechanisms.
While most of the oxygen is
carried in combination with
haemoglobin; some of it is
carried in its dissolved form in
the blood.
• Step 4- oxygen diffuses into
the tissue membrane again
due to pressure gradients and
is utilized by the cell for its
metabolism. Other waste
products and carbon dioxide
are then released by the cell.
Applied Physiology
• Alveolar Pressure (P alv) :
o Pressure within alveoli
o Varies during breathing cycle
o Intrapulmonary pressure

• Intra Pleural Pressure (P pl) :

o Pressure within pleural space
o Varies at different levels
o Sub atmospheric
o Intra thoracic
Pressure Gradients
• Transpulmonary (PL)
o Palv – Ppl
o Pressure difference across the lung
o Created by elasticity of lungs and keeps the alveoli
patent
o Transmural pressure

• Transrespiratory
o Difference between pressures in alveoli & airway
opening.
o Responsible for flow of gas in & out of the lungs
 Pulmonary Mechanics
At rest alveolar pressure=atmospheric pressure

Spontaneous inspiration leads to enlargement of thoracic cavity

Negative intrapleural pressure becomes more negative(-5 to -8 cm H2O)

Transpulmonary pressure gradient widens & alveoli expands

Alveolar pressure becomes subatmospheric (-1cm H2O) & air is drawn into lungs

Inspiration continues till intra alveolar pressure rises

Expiration is passive & occurs because of elastic recoil of lungs

Ventilation
• Preferentially distributed to the area of best
compliance and least resistance.

• The weight of lung is supported by rib cage and

diaphragm therefore, a gradient in pleural pressure
exists,

• pleural pressure becomes less negative from the

apex to the base.

For more negative intrapleural pressure the volume is
more
Perfusion
• Determined by:
Alveolar pressure( PA )
Pulmonary Arterial pressure(Pa)
Venous pressure (Pv)

• Blood flow is gravity dependent

• Hydrostatic pressure differences within blood
vessels leads to differences in perfusion distribution
• Hydrostatic pressure differences creates base to
apex gradient
Zone of West
V/Q Ratio

• Normally alveolar ventilation- 4 L/min and Cardiac output- 5 L/min

• V/Q ratio for whole lung is average 0.8

• Regional differences in ventilation & perfusion result in relatively

greater ventilation at apex- making the Ratio high

• Perfusion is greater in bases making the ratio low

V/Q Mismatch
• 2 situations where V/Q mismatch occurs:

Shunt: blood enters the lungs without getting

ventilated
V/Q ratio is low (without getting ventilated)
Dead Space: ventilation is present but the alveoli
are poorly perfused
V/Q ratio is high
Closing Volume
• Closing volume is that volume on expiration where small airways in
the lungs begin to close .
• Expressed as percentage of vital capacity Normally 10%
• Increases with age & disease process that leads to loss of lung
elasticity
 Cardio Pulmonary Mechanics

• Increase in intrapleural pressure during inspiration is important for

bringing air into the lungs and for promoting venous return in right
heart(preload) by expanding the great veins.
Upright Position
 The upright position
• True physiological position

• Includes both upright sitting and standing positions.

• The energy demands of this position is high.

• To meet this energy demand oxygen transport is

optimized to the highest level.

• V/Q are the most uniform in this position.

• Lung volumes and capacities as well as functional residual capacities
(FRC) are maximum
• and Maximizing FRC is associated with reduced airway closure and
maximal arterial oxygenation
 Biomechanics

• The AP diameter of the chest wall is also the greatest.

• Compression of heart and lungs is minimum.

• The diaphragm is in the shortened position which increases the neural drive to breathe
when a person is in the upright position

• When upright, the diameter of the main airways increases slightly

• If the airways are obstructed, even small degrees of airway narrowing induced by
recumbency can increase airway resistance
 Pressures across the chest wall

• At FRC in an upright position: The intra pleural pressure at the bases is

-2.5 cm H2O and at the apices it is -10 cmH2O.

• So the alveoli are already in an expanded state in the upper areas.

• They have larger initial volume causing smaller changes in volume

during respiration.
• At the bases there is less negative intra-pleural
pressure.

• This causes higher compliance.

• Leads to lower initial volume.

• So volume changes during respiration are high in

the bases.
Ventilation
• The upright position increases all the volumes and capacities
especially functional residual capacity.

• The closing volume of the lung decreases in erect standing as

compared to supine lying or recumbency.

• Closing capacity of the airway is increased with age, smoking & lung
disease.
• Functional residual capacity is greater in standing
than in sitting and exceeds lying down by 50%.

• This maximizing effect on FRC is associated with

reduced airway closure and maximal arterial
oxygenation.

• Maximal expiratory pressure is also maximized during

standing, lesser in sitting and even lesser when
recumbent.

• Clinical implication: Coughing and other forced

expiratory maneuvers should be emphasized during
erect sitting.
 Perfusion(Q)

• Perfusion is more in dependent region of lungs.

• Bases is more perfused compare to apices.

(V/Q matching)

• Both V and Q increase from apex to base the

upright lung

• V increases disproportionately more than Q.

• As a result, the optimal area for V/Q matching is

in the mid zone where the ratio is about 1.0 and
V:Q ratio is high at the apex.

• V and Q are less matched in the upright position

Effect of voluntary muscle contraction on
Ventilation
• Distribution of volume is affected by compliance
of diaphragm

• Abdominal inspiration exaggerated the normal

apex-to-base gradient in Ventilation.

• Intercostal inspiration increased V to the

nondependent regions and resulted in a more
uniform distribution of V.
 Clinical implication- breathing at low lung volumes

• Whenever a person breathes at low lung volumes, the intra pleural

pressure ie. It becomes less negative at the bases and even more negative
at the apices.

• The apices become better ventilated than the bases since they are more
compliant.

• The bases become prone to airway closure as the positive intra pleural
pressure exceeds the airway pressure.
Clinical implication- mechanical ventilation
• Mechanical ventilation reverses the normal intra pleural pressure
gradient.

• Uppermost lung fields are preferentially ventilated.

• V/Q mismatch occurs.

• PPV further complicates by increasing intrathoracic pressure and

reducing venous return and cardiac output.
Hemodynamic Effects
• Central blood volume is shifted from the thoracic
compartment to the dependant venous
compartment.

• End diastolic volume and stroke volume are

decreased.

• Compensatory increase in heart rate.

• Cardiac output is correspondingly decreased.

• Net result = reduced myocardial work` `

• With assumption of upright position greater than
45 degrees Peripheral vascular resistance(PVR)
increases and blood flow decreases

Dependent fluid shift and potential blood

pressure drops(orthostatic hypotension)
• Net effect to heart is,
• Right atrial pressure - 5 mmHg
• SV - 40%
• Heart rate- 15-30
• Perfussion- 20%
• Blood pressure- 0-20%

[Canadian anaesthetists' society journal: Cardio-respiratory effects of change of

body positionThomas J. Coonan et al.]
 Tissue oxygenation
• During upright position, muscular and cutaneous
vasoconstriction, occur to ensure blood flow is
maintain to vital organs.

• Due to effect of gravity, regions below the level of

heart will have greater driving pressure, which
promotes diffusion, than those above the heart.
 Clinical significance
• Patients in whom the additional volume cannot be
pumped out by the left ventricle because of disease, there
is a significant reduction in vital capacity and pulmonary
compliance with resultant shortness of breath.

• In patients with congestive heart failure the pulmonary

circulation may already be overloaded, and there may be
reabsorption of edema fluid from previously dependent
parts of the body.
• Pulmonary congestion decreases when the patient assumes a more
erect position, and this is accompanied by an improvement in
symptoms.
SUPINE
The supine position
• Bed rest has been used indiscriminately since 150 years.

• The injudicious use of supine position for all medical conditions has
led to many documented medical problems since decades.
Biomechanical Changes
• Alters the chest wall configuration.
• Alters the normal anteroposterior position of the hemidiaphragms.
• Alters the intra thoracic pressure.
• Alters the intra abdominal pressure.
• Alters mechanics of cardiac function.
Diaphragmatic changes with supine lying
• Position and function of the diaphragm are
dependent on the body position.

• In spontaneously breathing, more excursion of

diaphragm occurs posteriorly.

• Anesthesia: without paralysis: 2 cm ascend.

• Paralysis: more ascend of the non- dependent

areas.
Effect of anesthesia
• Anesthesia and
paralysis results in
the lung and thorax
being expanded
passively.

• Dependent aspect of
diaphragm had
greater tidal
excursion in both
awake and
anesthetized
patients.
 Pulmonary mechanics:

• Increase in intra thoracic blood volume also

contribute to reduction in FRC & lung compliance
& increase airway resistance

• Increased pulmonary blood volume & airway

closure.

• Resistance within the respiratory system increases.

• Thus, the mechanical load breathe in supine

positioning increases to maintain minute
Ventilation
• Excess pulmonary secretions pool in the dependant areas.
• Cephaladly placed hemi diaphragms cause reduced FRC.
• Closure of dependant airways in supine position
• Reduced lung compliance
• Increased airway resistance
• Increased work of breathing.
Perfusion
• Secondary to closure of the dependant airways there is hypoxic
vasoconstriction.

• This leads to preferential perfusion of the non- dependant areas of

the lung.
V/Q matching
• Reduction in vertical gravitational gradient.
• Reduced FRC, Vital capacity, flow rate.
• Increased areas of dependant lung, closure of dependant airways.
• Improves central blood flow.
Changes in Cardiovascular System
• A central shift of the blood volume from the extremities to the central
circulation leads to increased venous return & increases cardiac output

• Preload and afterload of the right heart increase

• Disturbances with the autonomic nervous system functioning: greater

reduction in mean arterial pressure, greater dehydration
 Clinical significance:
• Anesthetized or paralysed patient diaphragm

ascends 2cm in chest.

• Less chest expansion during breathing.

• So frequent change in positioning is essential.

Side lying
The side- lying position
• Theoretically there are less deleterious effects than supine lying
position.

• The side-lying position is commonly used in the hospitalized patients

more often than supine.
Biomechanical Changes
• Increases the antero-posterior diameter at the expense of the
transverse diameter.
• Compression of viscera beneath the dependant diaphragm.
• Displacement of dependant diaphragm more caephaladly.
• Greater excursion during respiration on dependant side.
 Pulmonary mechanics
• The dependent lung is under-ventilated and over-
perfused

• non-dependent lung is over-ventilated and under-

perfused.

• FRC falls between that in upright and supine.

• Decreased compliance and increased
resistance and abdominal pressure increase
the work of breathing side lying compared to
the upright position and reversed with
comparing with supine position.

• Minute ventilation was lower than that in

sitting or supine.
 Ventilation and perfusion
Dependent lung Nondependent lung

• Inspiratory lung volume • More ventilation

compared to perfusion.
and FRC are reduced on
the dependant side. • FeV1 and FVC reduce
similarly in left and right
• Cephaled position of side lying.
diaphragm has greater
contribution to ventilation.

• Perfusion is more than

ventilation.
 V/Q matching
• Optimal V/Q matching occurs in the upper one-third of each lung in
the side lying position.

• Theoretically V/Q matching of side-lying is more than that in erect

sitting.

• Arterial oxygenation is greater in side-lying than in supine lying.

 Cardiovascular mechanics
• Right and left ventricular pressure increased in side lying
position.

• Increased end diastolic ventricular pressure on the

dependent side secondary to compression of the viscera
beneath the diaphragm and reduce lung compliance on
that side.

• Increase preload during left side lying as there is less

compliance of left ventricle during diastole.
 Clinical significance:

• Enhance the efficiency of oxygen transport, thus

useful in patient who are on oxygen therapy.

• Arterial blood gases are improved in patients

with unilateral lung disease when position with
good lung down and worsen with affected lung
down.
• When lung pathology is bilateral

Arterial blood gases are improved when patient lie

on right side compared with left side,
This is due to greater size of right lung and the
reduce compression of heart on the lung in this
position compared with left side lying.
Prone
Prone position
• Two major types:
1. Prone lying with abdomen restricted
2. Prone lying with abdomen free

• Prone abdomen- restricted refers to lying prone with the abdomen in

contact with bed.

• Prone abdomen- free position the patient’s hip and chest are elevated
so that abdomen is free.
Biomechanical Changes
• Diameter of rib cage and abdomen are similar to those in the supine
position, except for decrease in the antero-posterior diameter of
abdomen.

• The heart and great vessels are displaced anteriorly

• The liver, spleen and kidney shift anteriorly and caudally.

Ventilation & Perfusion
• Increases arterial oxygenation (70-80%), tidal volume and lung
compliance.

• Enhances FRC- in prone abdomen free position.

• Reduces work of breathing

• Enhances diaphragmatic excursion to a greater degree

• Ventilation is distributed uniformly in the vertical direction.

• Prone abdomen- free position- Ventilation is greater in dependent

zone.
 Cardiovascular changes
• Abdominal compression increases inferior vena
caval obstruction.

• Compressive force acts on the heart chambers

more equally.
Trendelenburg Position
The Head Low Position
• Causes viscera to be displaced cephalad leading to limited excursion
of diaphragm leading to reduction in FRC

• Reduced WOB, upper chest breathing patterns, minute ventilation.

• Patients who have hyperinflated chest and
flattened diaphragm in which contraction of
diaphragm is insufficient, this position causes the
viscera to be displaced cephalad beneath the
diaphragm.

• Patient may experience relief from dyspnea,

reduced accessory muscles use.

• In case of respiratory muscle fatigue, additional

weight of the viscera may cause increased WOB.

• Also not advised for raised ICP.

Pediatric Position
• Infants and children are anatomically and
physiologically different from adults
• The upper lobes and the right middle lobe in
infants is a common site for airway collapse and
atelectasis.

• Positioning may help to:

1. Optimize lung function
2. Enhance bronchial secretion
Prone positioning
• Results for PaO2 and Sp02 show a small
significant beneficial effect of the prone
position.
• The meta-analysis supported a significant
increase in Sp02 in the prone position.
• Patients in the prone position needed less
aggressive ventilator parameters.
• Lower incidence of desaturation episodes in
the prone position

Infant position in neonates receiving mechanical ventilation

Balaguer A et al, Cochrane Database of Systematic Reviews
2013
 Prone positioning

• Prematures who had been weaned in prone position subsequently

had to be re-intubated significantly less than those that had been
weaned in supine.

• No differences in the duration of the process of weaning between the

prone and supine position.

Infant position in neonates receiving mechanical ventilation

Balaguer A et al, Cochrane Database of Systematic Reviews
2013
Side-lying position
• Lateral right position nor lateral left position have shown any
significant differences compared with supine position hemoglobin
oxygen saturation, oxygen pressure, or carbon dioxide pressure)

• Meta-analysis results- non-significant for left lateral and right lateral

comparison.

Infant position in neonates receiving mechanical ventilation

Balaguer A et al, Cochrane Database of Systematic Reviews
2013
Physiological effects of frequent changes in
body position
Physiological effects of frequent changes in body position depends on their effects
on-
• Respiratory mechanics

• Cardiac mechanics

• Airway closure

• Mucociliary transport

• Lymphatic drainage

• Altered neural activation of the diaphragm

Frequent body positions

• Stimulate the patient

• Increase arousal to more alert and wakeful state

• Leading to take deeper breaths and increase VA

• When coupled with mobilization stimulates vasodilation and

• Recruitment of pulmonary capillaries

• Improves homogeneity of distributions of VA and Q hence

augmenting VA/Q matching
Where, Functional Residual Capacity (FRC) is the amount of air
present in the lungs at the end of passive expiration
 Prescription of therapeutic body positions and body
position changes

• Prescription of body positioning is based on analysis

of factors that contribute to impaired oxygen
transport for each patient.

• It ranges from most to least physiological

• Incorporating active movement into the body

position change is optimal

• Body position is the next best physiological

approximation to a mobilized upright state
• Even mobilized patient benefits from therapeutic
body positioning between mobilization sessions
and during the night and rest period

• Body position should first be exploited when

coupled with movement followed by the erect
sitting positions with legs dependent
Mechanical Body Positioning:
• Mechanical turning beds such as the Rotobed® have significant benefits on
oxygen transport in severely ill patients.
• These beds are indicated for patients who are moderately hemodynamically
unstable and on neuromuscular blockers, and thus tolerate manual turns
poorly.
• Such turning frames are contraindicated, however, for patients who are less
ill.
• The benefit of these beds on oxygen transport in critically ill patients has
implications for the management of less critically ill patients. The continuous
mechanical rotation of the Rotobed® can be simulated by increasing the
frequency and arc of positions when manually positioning patients.
Practical considerations in positioning patients:

• Tendency to lose the position usually from compliance of

mattress and supporting pillow

• Prescriptive body positioning is more effective as compared

to
routine positioning

• Body positioning of patient should be in- coordinated with

other team members

• Extreme body position is always preferred over modified

body position
 Three plausible outcomes:

I. A favourable response

II. No response

III. Unfavourable response

All three outcomes deteriorate with passage of time

• Position should be changed or modified before or at the

first sign of deteriorating gas exchange
Monitoring Response to a Body Position
or Position Changes
The prescriptive parameters of body positioning and body position
changes include:
The body position selected

The duration in each position

The sequence of position changes

The cycle of all positions and

Position changes overall

• Monitoring is the basis for defining and modifying the
body positioning prescription

• The duration and frequency of position and position

change is a response-dependent rather than time-
dependent

• Monitoring of patient who is not critically ill includes

subjective and objective indexes of adequacy of oxygen
transport

• Among the most important are- oxygen delivery,

consumption extraction and gas exchange indicator
Subjectively-
• The patient’s facial expression

• Respiratory distress

• Dyspnea

• Anxiety

• Peripheral edema

• Discomfort

• Pain are assessed

Objectively-
• Heart rate

• Blood pressure

• Respiratory rate

• SaO2

• Flow rates

• Spirometry
Both subjective and objective measures should be valid and
reliable. Serial measures over a period of time should be taken.
• Measures and outcomes are recorded before,
during and periodic intervals following treatment

• A valid stable pretreatment baseline is essential for

therapeutic
• effect on oxygen transport in the given position

• Variables monitor ensures-

The treatment is having beneficial effect
Deleterious effect
THANK YOU