Evaluation of the effect of patient position in the management of chronic heart failure patients presenting with dyspnea
Keywords:Dyspnea, heart failure, patient position, upright sitting, Fowler's position
Background/Aim: One of the pathomechanisms of congestive heart failure is inadequate cardiac load, and one of the physiological ways to reduce cardiac load is to decrease venous return. Based on this mechanism, we aimed to reduce venous return and alleviate cardiac load in patients by drooping their legs. In this study, we aimed to evaluate the impact of leg position on patients' comfort and treatment, emphasize that patient position is valuable enough to be included in the treatment algorithm, and determine the effects of the patient sitting with legs hanging down position in an armchair (sitting position), or upright with the straight knees position on a stretcher with the stretcher’s head at 90°C (high Fowler's position) on the patient's perception of dyspnea in chronic heart failure (CHF). Methods: Patients over 18 years of age, followed-up with CHF diagnosis who presented to the emergency department (ED) with dyspnea were included in this case control study. The participants were divided into high Fowler's and sitting groups. According to the Visual Analog Scale (VAS) scoring, patients were asked to point to the severity of dyspnea. Patients’ vital signs, 30-day mortality, and VAS scores were recorded at the 0th, 15th, 30th, and 60th minutes. Results: A total of seventy-four patients were included in the study. Thirty-eight patients in the high Fowler’s group, and thirty-six patients in the sitting group were treated. VAS started to decrease significantly at 15 minutes in sitting position. Although baseline VAS scores were higher at sitting than at the high Fowler’s position, the end of the 60th minute VAS scores and respiratory rate were significantly lower in the sitting group (P=0.016, and P=0.008, respectively). The mortality rate was significantly higher in the high Fowler’s group (P=0.028). Conclusions: We concluded that patient position plays a vital role in patients' perception of dyspnea and mortality in the acute treatment of CHF patients presenting with dyspnea. Perception of dyspnea disappears earlier, and mortality is lower in the sitting position.
Gheorghiade M, Filippatos G, De Luca L, Burnett J. Congestion in acute heart failure syndromes: an essential target of evaluation and treatment. Am J Med. 2006;119:3-10. doi: 10.1016/j.amjmed.2006.09.011.
Yancy CW, Jessup M, Bozkurt B, Butler J, Donald EC, Mark H, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013:15;128(16):e240-327. doi: 10.1161/CIR.0b013e31829e8776. Epub 2013 Jun 5
West RL, Hernandez AF, O'Connor CM, Starling RC, Califf RM. A review of dyspnea in acute heart failure syndromes. Am Heart J. 2010;160:209-14. doi: 10.1016/ j.ahj.2010.05.020.
Placido R, Gigaud C, Gayat E, Ferryd A, SOLAL AC, Plaisance P, et al. Assessment of dyspnoea in the emergency department by numeric and visual scales: a pilot study. Anaesth Crit Care Pain Med. 2015;34:95-9. doi: 10.1016/j.accpm.2014.09.001. Epub 2015 Apr 7.
Pang PS, Cleland JG, Teerlink JR, Cleland JGF, Teerlink JR, Collins SP, et al. A proposal to standardize dyspnoea measurement in clinical trials of acute heart failure syndromes: the need for a uniform approach. Eur Heart J. 2008;29:816-24. doi: 10.1093/eurheartj/ehn048. Epub 2008 Mar 1.
Mebazaa A, Pang PS, Tavares M, Collins SP, Alan B. Storrow AB, et al. The impact of early standard therapy on dyspnoea in patients with acute heart failure: the URGENT-dyspnoea study. Eur Heart J. 2010;31:832-41. doi: 10.1093/eurheartj/ehp 458. Epub 2009 Nov 11.
Cleland JG, Coletta A, Witte K. Practical applications of intravenous diuretic therapy in decompensated heart failure. Am J Med. 2006;119:26-36.doi: 10.1016/j.amjmed. 2006.09.014.
Gheorghiade M, Follath F, Ponikowski P, Barsuk JH, Blair JEA, Cleland JG, et al. Assessing and grading congestion in acute heart failure: a scientific statement from the acute heart failure committee of the heart failure association of the European Society of Cardiology and endorsed by the European Society of Intensive Care Medicine. Eur J Heart Fail. 2010;12(5):423-33. doi: 10.1093/eurjhf/hfq045. Epub 2010 Mar 30.
Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016;37(27):2129-2200. doi: 10.1093/eurheartj/ehw128. Epub 2016 May 20.
Allen LA, Metra M, Milo-Cotter O, Filippatos G, Reisin LH, Bensimhon DR, et al. Improvements in signs and symptoms during hospitalization for acute heart failure follow different patterns and depend on the measurement scales used: an international, prospective registry to evaluate the evolution of measures of disease severity in acute heart failure (MEASURE-AHF). J Card Fail. 2008;14:777-84. doi: 10.1016/j.cardfail. 2008.07.188. Epub 2008 Aug 15.
Yürüktümen A, Karcıoğlu Ö, Topacoğlu H, Akarca FK. Dispne ile başvuran geriyatrik olgularda yakınma şiddeti ile klinik ve laboratuvar verilerinin değerlendirilmesi. Turk J Emerg Med. 2009;9(4):163-8.
Martin-Du P, Benoit R, Girardier L. The role of body position and gravity in the symptoms and treatment of various medical diseases. Swiss medical weekly. Swiss Med Wkly. 2004;134:543-51.
Katz S, Arish N, Rokach A, Zaltzman Y, Marcus EL. The effect of body position on pulmonary function: a systematic review. BMC Pulm Med. 2018 Oct 11;18:159. doi: 10.1186/s12890-018-0723-4.
Manning F, Dean E, Ross J, Abboud RT. Effects of side lying on lung function in older individuals. Phys Ther. 1999;79:456-66.
Melam GR, Buragadda S, Alhusaini A, Alghamdi MA, Alghamdi MS, Kaushal P. Effect of different positions on FVC and FEV1 measurements of asthmatic patients. Phys Ther Sci. 2014;26:591-3. doi: 10.1589/jpts.26.591. Epub 2014 Apr 23.
Mentz RJ, Mi X, Sharma PP, Qualls LG, devore AD, Johnson KW, et al. Relation of dyspnea severity on admission for acute heart failure with outcomes and costs. Am J Cardiol. 2015;115:75-81. doi: 10.1016/j.amjcard.2014.09.048. Epub 2014 Oct 15.
Nieminen MS, Harjola VP, Hochadel M, Drexler H, Komajda M, Brutsaert D, et al. Gender related differences in patients presenting with acute heart failure. Results from euroheart Failure Survey II. Eur J Heart Fail. 2008;10:140-8. doi: 10.1016/j.ejheart. 2007.12.012.
Faggiano P, D’Aloia AD, Simoni P, Gualeni A, Foglio K, Ambrosino N, et al. Effects of body position on the carbon monoxide diffusing capacity in patients with chronic heart failure: relation to hemodynamic changes. Cardiology. 1998;89:1-7. doi: 10.1159/000006735.Cardiology. 1998;89(1):1-7.
Vitacca M, Scalvini S, Volterrani M, Paneroni M, Giordano A, Ambrosino N. Physiological and symptom effects of changing posture from sitting to supine, and vice versa, in stable chronic heart failure. Acta Cardiol. 2016;71:543-548. doi: 10.2143/AC.71.5.3167497.
Harada K, Yamamoto T, Okumura T, Shigekiyo M, Terada, Okada A, et al. Intravenous nicorandil for treatment of the urgent phase acute heart failure syndromes: a randomized, controlled trial. Eur Heart J Acute Cardiovasc Care. 2017;6:329-338. doi: 10.1177/2048872616633837. Epub 2016 Feb 16
Solomonica A, Burger AJ, Aronson D. Hemodynamic determinants of dyspnea improvement in acute decompensated heart failure. Circulation: Circ Heart Fail. 2013;6:53-60. doi: 10.1161/cırcheartfaılure.112.970335. Epub 2012 Nov 14.
How to Cite
Copyright (c) 2021 Guleser Akpinar, Hakan Topacoglu
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.