Outcomes
bradycardia, tachycardia, arrhythmia, orthostasis, agitation, hypotension, tachypnea, hypertension, loss of lung aeration
LUNG, ARRHYTHMIA, ADVERSE EVENTS, LUNG CONSOLIDATION, HYPERTENSION
The primary outcome was lung aeration assessed using the lung ultrasound score
(LUS) at the end of each verticalization protocol (sitting position and passive
orthostasis), while the patients were in the vertical position. The LUS was also
measured at 3 additional time points to assess the consistency of the findings:
while in the supine position in bed (baseline), while in the supine position in
bed after the sitting position, and while in the supine position in bed after
passive orthostasis. For measurements while in the supine position, the subjects
were placed with the headboard elevated to 30°. Lung aeration was assessed
through chest ultrasound (Sonosite®), for which a convex transducer was
used. The intercostal spaces of the anterior, lateral and posterior regions of
both lungs were investigated. The division landmark was the anterior and
posterior axillary lines, with each area being divided into upper and lower
regions. Thus, six representative zones of each lung were assessed. Following
the standards already established by the LUS, normal aeration was represented by
pleural sliding and horizontal A-lines or by at least three vertical B-lines,
and a score of 0 was assigned in this case. When a moderate loss of aeration
occurred, characterized by multiple B-lines, either regularly or irregularly
spaced, originating from the pleural line or small juxtapleural consolidations,
a score of 1 was assigned. When coalescent B-lines were present in several
intercostal spaces occupying the whole intercostal space and characterizing a
severe loss of lung aeration, a score of 2 was assigned. If there was a total
lung aeration loss, as observed in lung consolidation, with tissue echogenicity
and static and dynamic air bronchograms, the investigated region was given a
score of 3. The total LUS score was determined by summing the 12 areas examined,
with scores ranging from 0 to 36; the higher the score was, the worse the lung
aeration.Secondary outcomes included the variation tidal volume (expressed in mL),
respiratory rate (expressed in bpm), minute volume (expressed in L/minute) and
number of professionals required to perform the chest verticalization protocols.
Tidal volume and respiratory rate data were collected directly from the
mechanical ventilator monitor immediately at end 30 minutes of each vertical
position (as well as in the 3 moments in bed). The measurements were
standardized. We followed the proposal by Conti et al.The safety of the interventions was assessed by monitoring the occurrence of
following adverse events: hypertension (defined as a systolic blood pressure
> 200mmHg or a mean arterial blood pressure > 110mmHg) or hypotension
(defined as a mean arterial blood pressure < 65mmHg); a saturation drop
(defined as a peripheral oxygen saturation < 88%); tachycardia or bradycardia
(defined as a heart rate > 130bpm or < 40bpm, respectively); the onset of
arrhythmia; tachypnea or bradypnea (defined as a respiratory rate > 40bpm or
< 5bpm, respectively); patient suffering (evidenced by nonverbal signals or
gestures); agitation (an RASS score > +1); reduced level of consciousness;
becoming physically combative; patient falls; traction or the removal of any
devices from the patient; and the interruption of continuous hemodialysis
catheter flow. If any adverse events occurred, the protocol was interrupted, and
the patient was treated and monitored by the assistant team until clinical
stabilization.