Intensive Care Med.
7, 2 3 1 - 2 3 4 (1981)
The Effect of Lateral Positions on Gas Exchange in Patients with Unilateral
Lung Disease During Mechanical Ventilation
J. Ibaflez, J. M. Raurich, R. Abizanda, R. Claramonte, P. Ibafiez and J. Bergada
Servicio de Medicina Intensiva, Complejo Sanitario de la S.S. "Virgen de Lluch", Palma de Mallorca, Spain
Accepted: 19 December 1980
Abstract. Positional changes have long been known
to have a gravitational effect on the distribution of
pulmonary blood flow. The effects of body position,
supine, right and left lateral decubitus, on gas ex-
change were evaluated in 10 patients with predomi-
nantly unilateral lung disease. All patients were
treated with mechanical ventilation and PEEP.
Arterial blood gases, measured after 15 min in each of
the three positions, showed that lying on the side of
the "normal" lung resulted in a higher arterial pO 2
(mean: 144 mmHg) than lying on that of the
"damaged" lung (mean: 86 mmHg). The AAapO a
values were 334 to 391 mmHg. Both differences were
statistically significant (P < 0.005). No significant
changes in mean arterial carbon dioxide tensions were
noted.
Key words: Mechanical ventilation - Positive endex-
piratory pressure - Body position - Unilateral lung
disease - Arterial oxygenation
Introduction
In recent years the importance of the effect of body
position on ventilatory function and gas exchange has
been appreciated. Several authors [16] noted that oxy-
genation improved when patients with disease predo-
minantly confined to one lung were turned from a
supine to a lateral decubitus position with the diseased
lung in the nondependent position. The recognition of
these variations in pulmonary function has been
incorporated into the management of acute
respiratory failure [4, 10].
Unilateral lung disease associated with severe
respiratory failure has been treated with continuous
mechanical ventilation (CMV), but the use of a
positive endexpiratory pressure (PEEP) may fail to
Intensive
Care Medicine
9 Springer-Verlag 1981
improve oxygenation and can be detrimental [7];
hyperinflation of the unaffected lung and redistribu-
tion of pulmonary blood flow to the affected lung
creating a ventilation perfusion mismatch have been
documented [3, 7].
Although several observers [5, 9] have noted posi-
tional effects on arterial pO 2 (paO2) in patients with
unilateral lung disease, there is scant information on
the effects of lateral positioning, right and left lateral
decubitus versus supine decubitus positions, on gas
exchange in patients with unilateral lung disease
treated with continuous mechanical ventilation and
PEEP.
Materials and Methods
Ten patients admitted to the Intensive Care Unit with
acute respiratory failure were studied. There were
three women and seven men whose physical charac-
teristics and clinical diagnoses are given in Table 1.
Bedside anteroposterior chest X-rays were taken on
the day of the study and were interpreted by a radio-
logist who was unaware of the arterial blood gas
results. Assessment of each chest film was made as
follows: "Right" (R) if the disease was predominantly
or exclusively in the right lung and "Left" (L) if the
disease was predominantly or exclusively in the left
lung.
All patients received CMV with a MA-1 ventilator
and were sedated with diazepam and paralyzed with
pancuronium. The tidal volume (VT), respiratory rate
(f), PEEP and fractional concentration of inspired
oxygen (FiO2) were kept unchanged during the study
(Table 2). At the moment of the study patients
received PEEP because their arterial PaO 2 was better
than without PEEP, when they were in a supine
position.
0342-4642/81/0007/0231/$01.00
232 J. Ibafiez et al.: Lateral Positions in Unilateral L u n g Disease

Table 1. Physical characteristics and main diagnosis in 10 patients Table 3. P a O 2 values (mmHg) during the trial of supine versus
with unilateral lung disease lateral decubitus position

Patient Sex Age Diagnoses Outcome Patient FIO 2 PEEP PaO 2 Chest film
(years) abnor-
Supine R.L.D. L,LD, mality
1 M 44 Pneumonia Died
Postop. oesophagectomy 1 0.7 15 71 62 99 R
2 M 51 Pneumonia Died 2 1.0 16 76 99 109 R
Sepsis by Pseud. aer. 3 1.0 12 308 192 305 R
4 0.8 15 56 37 104 R
3 M 45 Pneumonia Died
5 0.4 5 97 64 97 R
L u n g Cancer 6 0.4 5 86 112 65 L
4 F 10 Influenza P n e u m o n i a Survived 7 0.5 8 64 59 131 R
5 M 51 Pneumonia Survived 8 0.8 20 88 70 105 R
6 F 28 Influenza P n e u m o n i a Survived 9 1.0 12 104 283 146 L
7 F 30 Pneumonia Survived 10 0,6 12 70 92 71 L

8 M 18 Bronchopneumonia Survived R.L.D. = right lateral decubitus; L,L.D. = left lateral decubitus;
9 M 27 L u n g Contusion Died R. = right; L = left
P u l m o n a r y hemorrhage
10 M 31 Bronchopneumonia Survived
The individual values of PaOa measured in the
three positions are given in Table 3. The P a O a
Table 2. U n c h a n g e d parameters of mechanical ventilation during increased consistently in all 10 patients on subsequent
the study turning f r o m the "worse" lateral decubitus to the
"best" lateral decubitus position, the best position
Mean Range
being the dependent lateral decubitus in which P a O 2
Vw 750 1 0 0 0 - 650 was higher (Fig. 1). The m e a n value of P a O 2 rose
f 15 12-20 f r o m 86 + 15 m m H g in the "worse" lateral position
FIO 2 0.7 1 - 0.4 to 144 _+ 25 m m H g in the best dependent lateral
P E E P cm H 2 0 12 5 - 20 position (P < 0.005). The mean P a O z for the supine
position was 102 + 23 m m H g and the mean change
on going to the best lateral decubitus was also
Arterial blood samples were taken f r o m a radial significant (P < 0.05).
arterial catheter in all patients and were immediately The differences produced by an unequal F I O a
analyzed for P O 2, P C O z and p H at 37~ with a were corrected with the P a O z / F I O a ratio which was
C o r n i n g - 165 analyzer. The A A a P O 2 was calculated also significant (P < 0.005) on going f r o m the worse
as, (barometric pressure (mmHg) - 47) x F I O 2 - to the best lateral position (112 and 189 respectively).
P a C O 2 - P a C O z. The F I O 2 was controlled with the The A A a P O 2 change between lateral position was also
PO 2 electrode (C - 165). significant (P < 0.005).
There was no contraindication to changing body In all our patients with unilateral lung disease, the
position in any of the patients studied, all had best position was obtained with the " n o r m a l " lung
continuous E C G and arterial blood pressure
monitoring and remained for 15 min in each position
before the blood sample was taken. No suctioning
was performed during the study. The order in which 9 D [A-a)O2
o PaO2
body position was assumed was randomly 400-
determined. '1-

A paired t-student test was applied to evaluate the E

E 300-
statistical significance o f the mean and S.E.
200-.

Results 100-

The distribution of lung disease f r o m examination o f ! |

"WORSE" LD. SUPINE "B ES~T" L.U
the chest X-rays showed seven patients with predo-
minant right lung disease and three patients with Fig. 1. Changes in paO 2 and A A a p O 2 values on going from the
disease on the left side. "worst" to the "best" lateral decubitus position
J. Ibafiez et al.: Lateral Positions in Unilateral Lung Disease
o Right sided disease patients
. Left sided disease patients
o~
. .9i ~ 3~176 9
tw
(~ 200. ~, 0 bilateral lung disease. We only did bedside antero-
100- 9 ;0
lo~ ' 260 360
PaO2 mm.Hg
L.L.D.
Fig. 2. Patients with predominant unilateral disease according to
the chest radiographic diagnoses, had greater paO 2 values when
they were lying on their "normal" lung than lying on the affected
lung. So patients with right sided disease (0) had better paO 2 values
lying on the left lateral decubitus (L.L.D.) than on the right lateral
decubitus (R.L.D.).
dependent. So when the disease was radiographicatly
predominantly or exclusively right sided, the PaO 2
was higher when patients were in the left lateral
decubitus position (mean: 136 mmHg) than in the
right decubitus position (mean: 83 mmHg). When the
disease was left sided, the PaO 2 was higher when they
were lying in the right decubitus position (mean: 162
mmHg) than on the left decubitus position (mean: 94
mmHg) (Fig. 2).
There were no significant changes in PaCO2 in
going from the best to the wors lateral decubitus
position: 39 to 38.6 mmHg respectively. The survival
rate was 60%. Four patients died while they were on
mechanical ventilation. Three of them died of sepsis
and one of a massive pulmonary hemorrhage.
Discussion
To date, other than an occasional report, there has
been no careful evaluation of gas exhange in severe
unilateral lung disease treated with CMV and PEEP
as it relates to the lateral decubitus position.
The important finding of our study was the
improvement in paO 2 in patients with unilateral lung
disease when they were lying on their "normal" lung
with the diseased lung uppermost. Zack et al. [16]
conducted a careful evaluation of gas exchange as a
function of lateral positions in a population with a
variety of pulmonary disorders. However, these
investigators did not specify whether any of their
patients received treatment with mechanical ventila-
tion. A careful examination of the individual results
233
of our patients reflected that while oxygenation
always improved when they were lying on the
"normal" lung instead of lying on the affected lung,
paO2 values in supine position were not always bet-
ween those of the two lateral positions. It is possible
that in some cases this was related to some degree of
posterior chest X-rays but are aware that it can be
particularly difficult without lateral films to interpret
the left lung base because of the heart shadow.
The mechanisms responsible for this improvement
have not been defined but several possibilities are
suggested. With mechanical ventilation of normal
paralyzed human subjects, the movement of the dia-
phragm is passive and the displacement of the non-
dependent regions of the lungs is greater than the
dependent regions [6], presumably because the
hydrostatic force opposing displacement of the dia-
phragm is lower in the nondependent than in the
dependent regions. Rehder et al. [13] have also shown
that the compliance of the dependent hemithorax is
less than that of the nondependent, which could
explain the preferential ventilation of nondependent
regions demonstrated by the same authors [13, 15].
With lateral decubitus position, the total FRC was
higher than in the supine position. The increment
occurred in the nondependent lung [13]. PEEP also
increased FRC in the lateral decubitus position but
with no differences in the change of the two lungs
[14], although is has been reported that PEEP mainly
displaced the nondependent part of the diaphragm
[6].
Otherwise, pulmonary blood flow is almost
entirely determined by the forces of gravity as Kaneko
has shown [8], although regional hypoxemia and
acidosis have a weak effect on the distribution of
blood flow. Arborelius et al. [1] have shown that in
the lateral position, hypoxemia cannot overcome the
effect of gravity on pulmonary blood flow.
The etiology of positional hypoxemia therefore
appears to be principally due to a ventilation-
perfusion mismatching. In the supine position PEEP
may divert pulmonary blood flow away from the
"normal" lung to the affected lung resulting in
perfusion of nonventilated alveoli [7]. With the
diseased lung in the nondependent position, the
overall ventilation-perfusion relationship is probably
improved. It is difficult to define the mechanisms that
produce the improvement in arterial blood oxygena-
tion in the lateral position but we feel that with the
normal lung dependent there is a redistribution of
blood flow to the healthy dependent lung resulting in
a better V/Q. We do not know if the preferential
ventilation to the nondependent lung demonstrated in
normal subjects in the paralyzed state and
234
m e c h a n i c a l l y ventilated is able to operate with
diseased n o n d e p e n d e n t lungs, i m p r o v i n g its ventila-
tion. F r o m our study it is n o t possible to k n o w
whether changes o f cardiac o u t p u t with the lateral
positions could be partially responsible for the p a O 2
m o d i f i c a t i o n s . W e o n l y m e a s u r e d arterial b l o o d pres-
sure a n d h e a r t rate a n d n o changes were observed du-
ring the study.
It m u s t e m p h a s i z e d t h a t these were o b s e r v a t i o n s at
a given p o i n t in time. Clearly in a critically ill p a t i e n t
such f i n d i n g s m a y change with time as clinical
changes such as infections, atelectasis could occur.
A n a r b i t r a r y limit o f 2 h for the best lateral p o s i t i o n
was chosen because o f o u r c o n c e r n that i n t r a p u l m o -
n a r y c r o s s - c o n t a m i n a t i o n could occur. F r e q u e n t
tracheal s u c t i o n i n g is necessary to p r e v e n t these
secretions f r o m b e i n g aspirated into the d e p e n d e n t
lung.
Several a u t h o r s have p r o p o s e d i n d e p e n d e n t l u n g
v e n t i l a t i o n to treat the severe f o r m s of r e s p i r a t o r y
failure in patients with u n i l a t e r a l l u n g disease [2],
either with two s y n c h r o n i z e d ventilators [12] or with
o n e v e n t i l a t o r with a selective v e n t i l a t i o n d i s t r i b u t i o n
circuit [11]; this f o r m of m e c h a n i c a l v e n t i l a t i o n
requires a n u n u s u a l availability of materials a n d per-
sonnel. T h e d i s a d v a n t a g e s o f p r o l o n g e d tracheo-
b r o n c h i a l i n t u b a t i o n with a C a r l e n s t u b e c a n n o t be
u n d e r s t i m a t e d , a l t h o u g h i e c e n t l y a new type o f
d o u b l e - l u m e n t u b e with h i g h - v o l u m e low-pressure
cuff is c o m m e r c i a l l y available.
A t the p r e s e n t time we do n o t k n o w which f o r m o f
t r e a t m e n t is m o r e helpful b u t we believe t h a t a
t h e r a p e u t i c p r o g r a m i n c o r p o r a t i n g a lateral p o s i t i o n
could be d o n e m o r e easily a n d s h o u l d be used b e f o r e
other m o r e sophisticated m e t h o d s in patients with
u n i l a t e r a l l u n g disease.
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Dr. J. Ibahez
Servicio de Medicina Intensiva
Complejo Sanitario S.S. "Virgen de Ltuch"
Palma de Mallorca, Spain