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      S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders : Revision 2015: S2e guideline of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) Translated title: S2e-Leitlinie: Lagerungstherapie und Frühmobilisation zur Prophylaxe oder Therapie von pulmonalen Funktionsstörungen : Revision 2015: S2e-Leitlinie der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI)

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          Abstract

          The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioneda revision of the S2 guidelines on “positioning therapy for prophylaxis or therapy of pulmonary function disorders” from 2008. Because of the increasing clinical and scientificrelevance the guidelines were extended to include the issue of “early mobilization”and the following main topics are therefore included: use of positioning therapy and earlymobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

          Zusammenfassung

          Durch die Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) wurde der Auftrag erteilt, die seit 2008 bestehende S2-Leitlinie „Lagerungstherapie zur Prophylaxe oder Therapie von pulmonalen Funktionsstörungen“ zu revidieren. Aufgrund zunehmender klinischer und wissenschaftlicher Relevanz wurde die Leitlinie um den Themenkomplex „Frühmobilisation“ erweitert. Damit bezieht sie sich auf folgende thematische Schwerpunkte: Einsatz von Lagerungstherapie und Frühmobilisation zur Prophylaxe pulmonalerFunktionsstörungen, Einsatz von Lagerungstherapie und Frühmobilisation zur Therapie pulmonaler Funktionsstörungen, unerwünschte Wirkungen und Komplikationen von Lagerungstherapie und Frühmobilisation sowie praktische Aspekte beim Einsatz von Lagerungstherapie und Frühmobilisation. Diese Leitlinie ist das Ergebnis einersystematischen Literaturrecherche sowie der anschließenden kritischen Evidenzbewertungmit wissenschaftlichen Methoden. Das methodische Vorgehen des Leitlinienentwicklungsprozesses entspricht den Anforderungen an die evidenzbasierte Medizin, wie sie von der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften als Standard definiert wurden. Bezüglich der Lagerungstherapie wurden neu publizierte Arbeiten ab 2005 untersucht; der neu aufgenommene Aspekt der Frühmobilisation umfasst die gesamte bisher publizierte Literatur bis einschließlich 06/2014. Der vorliegende Beitrag gibt die Kurzversion der Leitlinie wieder.

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          Early intensive care unit mobility therapy in the treatment of acute respiratory failure.

          Immobilization and subsequent weakness are consequences of critical illness. Despite the theoretical advantages of physical therapy to address this problem, it has not been shown that physical therapy initiated in the intensive care unit offers benefit. Prospective cohort study in a university medical intensive care unit that assessed whether a mobility protocol increased the proportion of intensive care unit patients receiving physical therapy vs. usual care. Medical intensive care unit patients with acute respiratory failure requiring mechanical ventilation on admission: Protocol, n = 165; Usual Care, n = 165. An intensive care unit Mobility Team (critical care nurse, nursing assistant, physical therapist) initiated the protocol within 48 hrs of mechanical ventilation. The primary outcome was the proportion of patients receiving physical therapy in patients surviving to hospital discharge. Baseline characteristics were similar between groups. Outcome data are reflective of survivors. More Protocol patients received at least one physical therapy session than did Usual Care (80% vs. 47%, p < or = .001). Protocol patients were out of bed earlier (5 vs. 11 days, p < or = .001), had therapy initiated more frequently in the intensive care unit (91% vs. 13%, p < or = .001), and had similar low complication rates compared with Usual Care. For Protocol patients, intensive care unit length of stay was 5.5 vs. 6.9 days for Usual Care (p = .025); hospital length of stay for Protocol patients was 11.2 vs. 14.5 days for Usual Care (p = .006) (intensive care unit/hospital length of stay adjusted for body mass index, Acute Physiology and Chronic Health Evaluation II, vasopressor). There were no untoward events during an intensive care unit Mobility session and no cost difference (survivors + nonsurvivors) between the two arms, including Mobility Team costs. A Mobility Team using a mobility protocol initiated earlier physical therapy that was feasible, safe, did not increase costs, and was associated with decreased intensive care unit and hospital length of stay in survivors who received physical therapy during intensive care unit treatment compared with patients who received usual care.
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            Prone positioning in patients with moderate and severe acute respiratory distress syndrome: a randomized controlled trial.

            Post hoc analysis of a previous trial has suggested that prone positioning may improve survival in patients with severe hypoxemia and with acute respiratory distress syndrome (ARDS). To assess possible outcome benefits of prone positioning in patients with moderate and severe hypoxemia who are affected by ARDS. The Prone-Supine II Study, a multicenter, unblinded, randomized controlled trial conducted in 23 centers in Italy and 2 in Spain. Patients were 342 adults with ARDS receiving mechanical ventilation, enrolled from February 2004 through June 2008 and prospectively stratified into subgroups with moderate (n = 192) and severe (n = 150) hypoxemia. Patients were randomized to undergo supine (n = 174) or prone (20 hours per day; n = 168) positioning during ventilation. The primary outcome was 28-day all-cause mortality. Secondary outcomes were 6-month mortality and mortality at intensive care unit discharge, organ dysfunctions, and the complication rate related to prone positioning. Prone and supine patients from the entire study population had similar 28-day (31.0% vs 32.8%; relative risk [RR], 0.97; 95% confidence interval [CI], 0.84-1.13; P = .72) and 6-month (47.0% vs 52.3%; RR, 0.90; 95% CI, 0.73-1.11; P = .33) mortality rates, despite significantly higher complication rates in the prone group. Outcomes were also similar for patients with moderate hypoxemia in the prone and supine groups at 28 days (25.5% vs 22.5%; RR, 1.04; 95% CI, 0.89-1.22; P = .62) and at 6 months (42.6% vs 43.9%; RR, 0.98; 95% CI, 0.76-1.25; P = .85). The 28-day mortality of patients with severe hypoxemia was 37.8% in the prone and 46.1% in the supine group (RR, 0.87; 95% CI, 0.66-1.14; P = .31), while their 6-month mortality was 52.7% and 63.2%, respectively (RR, 0.78; 95% CI, 0.53-1.14; P = .19). Data from this study indicate that prone positioning does not provide significant survival benefit in patients with ARDS or in subgroups of patients with moderate and severe hypoxemia. clinicaltrials.gov Identifier: NCT00159939.
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              Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: systematic review and meta-analysis.

              Prone position ventilation for acute hypoxemic respiratory failure (AHRF) improves oxygenation but not survival, except possibly when AHRF is severe. To determine effects of prone versus supine ventilation in AHRF and severe hypoxemia [partial pressure of arterial oxygen (PaO(2))/inspired fraction of oxygen (FiO(2)) or =100 mmHg (RR 1.07, 95% CI 0.93-1.22; p = 0.36; seven trials, N = 1,169). Risk ratios differed significantly between subgroups (interaction p = 0.012). Post hoc analysis demonstrated statistically significant improved mortality in the more hypoxemic subgroup and significant differences between subgroups using a range of PaO(2)/FiO(2) thresholds up to approximately 140 mmHg. Prone ventilation improved oxygenation by 27-39% over the first 3 days of therapy but increased the risks of pressure ulcers (RR 1.29, 95% CI 1.16-1.44), endotracheal tube obstruction (RR 1.58, 95% CI 1.24-2.01), and chest tube dislodgement (RR 3.14, 95% CI 1.02-9.69). There was no statistical between-trial heterogeneity for most clinical outcomes. Prone ventilation reduces mortality in patients with severe hypoxemia. Given associated risks, this approach should not be routine in all patients with AHRF, but may be considered for severely hypoxemic patients.
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                Author and article information

                Contributors
                thomas.bein@klinik.uni-regensburg.de
                Journal
                Anaesthesist
                Anaesthesist
                Der Anaesthesist
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                0003-2417
                1432-055X
                3 September 2015
                3 September 2015
                2015
                : 64
                : 1-26
                Affiliations
                [ ]Clinic for Anaesthesiology, University Hospital Regensburg, 93042 Regensburg, Germany
                [ ]Physiotherapy Department, Clinic Donaustauf, Centre for Pneumology, 93093 Donaustauf, Germany
                [ ]Clinic for Anaesthesiology, Surgical Intensive Care Medicine, Emergency Care Medicine, Pain Management, Klinikum Herford, 32049 Herford, Germany
                [ ]HELIOS Clinic Siegburg, 53721 Siegburg, Germany
                [ ]Clinic for Anaesthesiology, Intensive Care Medicine and Pain Management, Elisabeth Hospital Essen, 45138 Essen, Germany
                [ ]Centre Hospitalier, Soins Intensifs Polyvalents, 1210 Luxembourg, Luxemburg
                [ ]Association of Scientific Medical Societies (AWMF), 35043 Marburg, Germany
                [ ]University Hospital for Internal Medicine I, Medical University of Wien, General Hospital of Vienna, 1090 Vienna, Austria
                [ ]Clinic for Anaesthesiology, Intensive Care Medicine and Pain Management, Klinikum Kassel, 34125 Kassel, Germany
                [ ]Clinic for Anaesthesiology and Surgical Intensive Care Medicine, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, 13353 Berlin, Germany
                [ ]Clinic and Policlinic for Anaesthesiology and Intensive Care Medicine, University Hospital Leipzig, 04103 Leipzig, Germany
                Article
                71
                10.1007/s00101-015-0071-1
                4712230
                26335630
                2da3fe63-aaa4-4fc2-a6ea-afcd1722b1ef
                © The Author(s) 2015

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                Categories
                Guidelines and Recommendations
                Custom metadata
                © Springer-Verlag Berlin Heidelberg 2015

                positioning therapy,early mobilisation,prone position,pulmonary disorder,backrest elevation,continuous lateral rotation,lagerungstherapie,frühmobilisation,bauchlagerung,pulmonale funktionsstörung,oberkörper hochlagerung,kontinuierliche laterale rotationstherapie

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