Intensive Care Med (2006) 32:16231626
DOI 10.1007/s00134-006-0299-y
Jean-Christophe M. Richard
Salvatore Maurizio Maggiore
Jordi Mancebo
Franois Lemaire
Bjorn Jonson
Laurent Brochard
Received: 7 November 2005
Accepted: 28 June 2006
Published online: 1 August 2006
Springer-Verlag 2006
Electronic supplementary material
Supplementary material is available
in the online version of this article at
http://dx.doi.org/10.1007/s00134-006-
0299-y and is accessible for authorized
users.
J.-C. M. Richard (u)
Rouen University Hospital Charles Nicolle,
Medical Intensive Care Unit,
UPRES EA 38 30,
1 rue de Germont, 76031 Rouen, France
e-mail:
Jean-Christophe.Richard@chu-rouen.fr
Tel.: +33-2-32888261
Fax: +33-2-32888314
S. M. Maggiore
Agostino Gemelli Hospital, Catholic
University of the Sacred Heart, Department
of Anesthesiology and Intensive care,
Rome, Italy
J. Mancebo
Hospital Sant Pau, Servei de Medicina
Intensiva,
Barcelona, Spain
F. Lemaire L. Brochard
Hpital Henri Mondor, INSERM U 651,
Universit Paris 12, Medical Intensive Care
Unit, AP-HP,
Crteil, France
B. Jonson
University Hospital of Lund, Department of
Clinical Physiology,
Lund, Sweden
BRIEF REPORT
Effects of vertical positioning on gas exchange
and lung volumes in acute respiratory distress
syndrome
Abstract Objective: Supine po- but not in nonresponders (n = 5;
sition may contribute to the loss 215 220 vs. 10 22 ml), suggest-
of aerated lung volume in patients ing a time-dependent recruitment.
with acute respiratory distress syn- Conclusions: Vertical positioning is
drome (ARDS). We hypothesized a simple technique that may improve
that verticalization increases lung oxygenation and lung recruitment in
volume and improves gas exchange ARDS patients.
by reducing the pressure surrounding
lung bases. Design and setting: Keywords Acute respiratory distress
Prospective observational physi- syndrome Mechanical ventilation
ological study in a medical ICU. Positioning Recruitment Lung
Subjects and intervention: In 16 volume Gas exchange
patients with ARDS we measured
arterial blood gases, pressure-volume
curves of the respiratory system
recorded from positive-end expiratory
pressure (PEEP), and changes in
lung volume in supine and vertical
positions (trunk elevated at 45 and
legs down at 45). Measurements
and results: Vertical positioning
increased PaO2 significantly from
94 33 to 142 49 mmHg, with
an increase higher than 40% in 11
responders. The volume at 20 cmH2 O
measured on the PV curve from PEEP
increased using the vertical position
only in responders (233 146 vs.
8 91 ml in nonresponders); this
change was correlated to oxygenation
change ( = 0.55). End-expiratory
lung volume variation from supine to
vertical and 1 h later back to supine,
measured in 12 patients showed
a significant increase during the 1-h
upright period in responders (n = 7)
1624

Introduction Measurements
In patients with acute respiratory distress syndrome Arterial blood gases and a pressure-volume (PV) curve
(ARDS), morphological computed tomography shows the recorded from positive end expiratory pressure (PEEP),
presence of a cephalocaudal gradient in the distribution were performed at the end of each evaluation period.
of densities, explaining why the lung basis adjacent to
the diaphragm is always collapsed [1, 2]. We have also
learned that body position may significantly affect lung PV curves
function [3, 4, 5, 6, 7, 8, 9]. Based on this physiological
background the aim of this study was to assess the effects
The method used for PV curves recording from PEEP is
of verticalization on gas exchange and lung volumes based on the oscillating low flow inflation technique as de-
following a change from supine to a verticalized position
scribed in detail elsewhere [10]. The PEEP PV curve was
in patients with ARDS. used to assess volumes and compliance at which the patient
was really ventilated in the considered PEEP and position
combination. The position and the shape of the PEEP PV
Methods curve above the relaxation volume of the respiratory sys-
tem at zero PEEP may be influenced by position-induced
Sixteen consecutive patients ventilated for an ARDS recruitment [6, 8, 9]. To express this change we arbitrary
were evaluated (Electronic Supplementary Material, chose to measure the volume at 20 cmH2 O (vol 20) on the
ESM: Table S1). The study was approved by the Ethics PV curve from PEEP.
Committee of Henri Mondor Hospital. Informed consent
was obtained from the patient or next-of-kin prior to
enrollment in the study. Change in end-expiratory lung volume

In 12 of the patients end expiratory lung volume (EELV)

Procedure
Patients were studied successively in the following posi-
tions: (a) supine (strict horizontal position) for 1 h, (b) fol-
lowed by verticalization of the patient (combining a 45
head and upper body elevation with lower limbs down at
45) for 1 h (Fig. 1; although this is not a true vertical po-
sition, we use this term for simplicity), and (c) then placed
back in the supine position using a semiautomated bed
(see ESM: Fig. S1). The head and trunk were first elevated,
and then the legs were lowered. To return from vertical to
supine the reverse procedure was performed.
variation related to position was measured by continu-
ously recording inspired and expired tidal volume. This
change was measured during the switch from supine to
vertical (EELV1 ) and then 1 h later when the patient was
placed back from vertical to supine position (EELV2 ).
The difference (EELV2 minus EELV1 ) was calcu-
lated to assess the effect of 1-h duration on a gradual
increase in lung volume change that could have occurred
during verticalization. Responder patients were defined
according to change in oxygenation. The distribution
of changes in PaO2 was bimodal (i.e., no patient had
a PaO2 increase between 13% and 47%), and we sep-
arated the patients into two groups. Patients exhibiting
an increase in PaO2 higher than 40% of the baseline
value measured in the supine position were considered as
responders.

Statistical analysis

All values are given as mean standard deviation. Non-

parametric tests were chosen because of the small popu-
lation studied. The Wilcoxon test for paired samples was
used. Comparisons between supine and upright position
were made by using the Wilcoxon test for paired samples.
The Mann-Whitney test was performed for comparisons
between responders and nonresponders. Spearmans cor-
relation was performed when appropriate. Differences with
Fig. 1 Individual and mean (bold) values of volume measured at 20 a p level less than 0.05 were considered statistically signif-
cmH2 O (Vol 20) on the PV curve from PEEP, supine (SP) and in the icant (Statview statistical software, version 5; Cary, N.C.,
vertical position (V) in responders (left) and nonresponders (right) USA).
 1625

Results
Oxygenation

PaO2 was significantly higher in vertical than in supine

position (142 49 vs. 94 33 mmHg, p < 0.0032). PaO2
increased by more than 40% in 11 responders (91 31%,
from 48% to 161% of supine value) and did not change
or decrease in 5 nonresponders (9 14%, from 12% to
24% of baseline value supine; p < 0.0018). In responders,
SaO2 increased from 93 3% to 96 3%; p = 0.0033,
while it did not significantly change in nonresponders
(95 2% vs. 97 2%; p = 0.197). Mean arterial pressure
(75 16 vs. 74 15 mmHg in supine and upright posi- Fig. 2 Individual and mean (bold) values of end-expiratory lung vol-
tion, respectively; p = 0.506) and heart rate (107 18 vs. ume (EELV), measured immediately (V 1) and 1 h after verticaliza-
tion (V 2) in responders (left) and nonresponders (right)
108 16 mmHg in supine and upright position, respec-
tively; p = 0.785) were not influenced by positioning.

Lung volume and compliance
Vol 20 measured on the PEEP PV curve was significantly
higher in vertical than in supine position (721 268
vs. 564 295 ml; p < 0.0038); interestingly, vol 20
increased significantly only in responders (751 246
vs. 519 285 ml; p < 0.0033) and did not change in
nonresponders (655 331 vs. 663 325 ml; p = 0.5).
Individual values are reported in Fig. 1. PaO2 in the
vertical position, expressed as a percentage of supine
value, was significantly correlated with vol 20 vertical,
expressed as a percentage of vol 20 supine ( = 0.55;
p = 0.033). Plateau pressure was significantly higher ver-
tical than supine (32 9 vs. 29 7 cmH2 O; p = 0.043).
Chord compliance measured in the linear part of the
PV curve recorded from PEEP decreased with vertical-
ization in responders (40 15 vs. 31 9 ml/cmH2 O,
supine and vertical, respectively; p < 0.0076) but did
not change significantly in nonresponders (47 23 vs.
33 10 ml/cmH2 O, supine and vertical, respectively;
p = 0.23).
EELV
EELV1 measured during immediate verticalization
(n = 12) was slightly but not significantly greater
in responders than in nonresponders (500 272 vs.
310 225 ml; p = 0.286). In contrast, EELV2 recorded
during the switch from vertical to supine was significantly
greater in responders than in nonresponders (837 329
vs. 320 231 ml; p = 0.0091). The difference between
EELV2 and EELV1 showed a time-dependent change
in lung volume suggestive of progressive recruitment Rationale for vertical positioning
during vertical position, in responders only (EELV1 -
EELV2 = 337 179 vs. 10 22 ml, respectively, in Our findings suggest that recruitment is an important
responders and nonresponders; p = 0.0144; Fig. 2).
Discussion
These preliminary results show that vertical positioning is
a simple technique that improves oxygenation in a signifi-
cant proportion of ARDS patients. The study also provides
physiological data showing that the effects of vertical posi-
tion on oxygenation are explained by a time-dependent in-
crease in lung volume suggestive of alveolar recruitment,
and this explains the difference observed among patients
in terms of oxygenation.
Effects of upright position on oxygenation
Bittner et al. [11] reported the effects of sitting position in
16 patients with acute lung injury ventilated after a surgi-
cal procedure. Oxygenation was not affected by position.
However, authors have underlined that the sitting position
which they used may compress the abdomen and then the
lung bases. This contrasts with the vertical position used
in our study (i.e., associating trunk up and legs down). An-
other study evaluated the effects of sitting and standing po-
sition on oxygenation in 12 patients after laparotomy [12].
Arterial oxygen saturation was significantly improved in
the sitting and standing position compared to supine, sug-
gesting a beneficial effect of overall verticalization. In the
present study oxygen improvement observed in 11 patients
in vertical position exceeded 40%, suggesting that FIO2
or PEEP can be significantly reduced while keeping PaO2
constant. Therefore this position can be considered inter-
esting for ARDS management as an alternative and simpler
approach to prone position [13].
component of the increase in lung volume during vertical
1626

positioning and one of the main determinant of changes
in oxygenation. Relief of abdominal compression on lung
bases associated with verticalization may allow caudal
displacement of the diaphragm and subsequently recruit-
ment of dependent lung area [4, 8]. The higher volumes
observed in responders in vertical position could result
either from alveolar recruitment, i.e., more volume at the
same pressure, or by an increase in respiratory system
compliance [10, 14]. Since chord compliance measured
vertical tended to be lower than supine, recruitment was
likely the main determinant of lung volume increase rather
than change in mechanical properties of the respiratory
system [10]. We and others have previously demonstrated
that recruitment is associated with a decrease in chord
compliance in the linear part of the PV curve [10, 14, 15].
The vertical position differs substantially from the
semirecumbent position recommended for pneumonia
prevention. Recent data show that a 45 angle is very
rarely applied in routine practice [16, 17, 18]. One pos-
sible explanation is that the patients tend to fall in the
middle of the bed and cannot keep the position. Another
explanation is that the angle of trunk flexion is frequently
overestimated by caregivers [16]. Therefore the position
tested here significantly differs from the posture in which
patients are usually ventilated.
In conclusion, these preliminary results show that ver-
tical position is a simple and well tolerated technique able
to improve oxygenation in selected ARDS patients. This
beneficial effect is probably due to complex physiologi-
cal mechanisms among which recruitment seems to be an
important component. Further investigations are needed to
confirm our findings before recommending a posture that
can substantially change clinical practice.
Acknowledgements. The authors thank Lucie Breton for her help
in collecting the data and Richard Medeiros, Rouen University Hos-
pital Medical Editor, for his advice en editing the manuscript.

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