1. Section Editor(s): Winslow, Elizabeth H. RN, Phd, FAAN

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According to traditional nursing practice, patients with breathing problems should be placed in a high Fowler's (90[degrees]) position. This position probably is helpful for patients of average weight and build who don't have an artificial airway. However, a recent study shows that the high Fowler's position can be detrimental in some patients.


Suzanne Burns, who is both a master's-prepared nurse and a respiratory therapist, and her nurse/physician research team studied the effect of body position on spontaneous respiratory rate and tidal volume in 19 critically ill, intubated patients with obesity, abdominal distension, or ascites-a topic that has been investigated only rarely in recent years (Am.J.Crit.Care 3[2]:102-106, Mar. 1994). The seven men and 12 women ranged from 35 to 86 years of age and had a variety of diagnoses including chronic obstructive pulmonary disease, adult respiratory distress syndrome, flail chest, pneumonia, and liver transplant. Over a third of the patients also had failed to wean. All the patients were on continuous positive airway pressure or the pressure support ventilation mode and all had large abdomens, defined as a circumference at the level of the umbilicus more than 5 cm greater than the circumference below the breasts over the rib cage.


The patients were placed flat (0[degrees]) for five minutes and then in the semi-Fowler's (45[degrees]), high Fowler's (90[degrees]), and reverse Trendelenburg (RT) (45[degrees]) positions, randomly ordered. Data were collected after five minutes in each position. Patients were asked how they liked each position.


The results showed that the RT position made breathing easier, since respiratory rate was significantly lower in the RT position (21/minute) compared with the high Fowler's position (25/minute), while tidal volume was significantly higher in the RT position (573 mL/minute) compared with the high Fowler's (507 mL/minute). Respiratory rate was also significantly lower in the 45[degrees] position (21/minute) compared with the 90[degrees] position, and mean heart rate was significantly higher in high Fowler's (101.5) than in the flat position (96.2). Most patients preferred the RT or 45[degrees] positions.


If you have an intubated patient who's breathing spontaneously and has a large abdomen, try the RT or semi-Fowler's position to help him breathe more easily and effectively.