Manual vs Automated Lateral Rotation to Reduce Preventable Pulmonary Complications in Ventilator Patients

Sandra K. Hanneman, RN, PhD; Gary M. Gusick, RN, PhD; Shannan K. Hamlin, RN, PhD, ACNP-BC, CCRN; Sheryln J. Wachtel, RN, PhD; Stanley G. Cron, MSPH; Deborah J. Jones, RN, PhD; Sandra A. Oldham, MD


Am J Crit Care. 2015;24(1):24-32. 

In This Article

Abstract and Introduction


Purpose To estimate effect sizes for a trial to compare preventable pulmonary complications (PPCs), turning-related adverse events, mechanical ventilation duration, intensive care unit (ICU) length of stay, and ICU mortality between patients randomized to 2-hourly manual or continuous automated lateral rotation.

Methods Randomized controlled trial pilot study with 15 patients selected randomly from eligible medical-surgical ICU patients from 2 tertiary hospitals and assigned randomly to the manualturn or automated-turn protocol for up to 7 consecutive days. A radiologist blinded to group and site assessed serial chest radiographs for PPCs. Repeated-measures analysis with linear mixed models was used to estimate change in PPC score, and Wilcoxon rank sum or Fisher exact test was used to compare group differences in the secondary outcomes.

Results Of 16 patients enrolled, 12 (75%) completed the study. Data from 15 patients, 7 manual turn and 8 automated turn, were analyzed. Between-group differences in PPC incidence (67% overall), change in PPC score (β = 0.15, manual turn and β = -0.44, automated turn), and secondary outcomes were not significant (P > .05). Standardized effect sizes were small to moderate for the outcome variables. A sample size of 54 patients would be needed to detect statistically significant between-group differences in PPC over time.

Conclusions The incidence of PPCs in adult patients receiving mechanical ventilation in a medical-surgical ICU was high. Automated turning decreased PPCs with time but had little effect on secondary outcomes. Safety outcomes were not substantially different between groups. A modest efficacy effect supported reduced PPCs with automated turning to the lateral position.


Because of their reduced mobility, patients receiving mechanical ventilation in the intensive care unit (ICU) are at high risk for preventable pulmonary complications (PPCs). Such PPCs as atelectasis and pneumonia prolong the duration of mechanical ventilation and length of stay in the ICU and increase morbidity, mortality, and health care costs.[1–4] Guidelines for reducing PPCs in patients receiving mechanical ventilation[5–8] recommend elevating the head of the patient's bed at least 30°. Despite the fact that manual turning every 2 hours is the standard of care in the ICU,[9] guideline authors make no recommendation for horizontal positioning (ie, lateral rotation) because little evidence is available on the effectiveness of such positioning.

Evidence suggests that ICU patients are not turned every 2 hours[10–13] for a variety of reasons, including patients' medical instability and/or discomfort and other demands competing for nursing staff time. Specialty beds that provide continuous, automated lateral rotation theoretically avoid stimulation of the sympathetic nervous system by an abrupt change in position and relieve staff from regular turning. Consistent evidence, albeit of variable rigor, has demonstrated that automated turning reduces PPCs, but this mechanical therapy adds to ICU cost of care and thus is used selectively. Furthermore, up to 39% of patients do not tolerate automated turning[14–16] and require termination of the therapy or use of sedation to promote tolerance.

Automated turning has been tested in randomized controlled trials with medical-surgical ICU patients who are receiving mechanical ventilation,[14,16–22] and researchers in all but 2 studies[17,20] reported a significant reduction in PPCs. Researchers in 2 studies[16,22] reported shorter ICU stays in patients receiving automated turning, and researchers in another study[16] also reported decreased duration of mechanical ventilation. None of the trials demonstrated differences in mortality. Research design limitations, however, have prevented a legitimate comparison of automated and manual turning for efficacy and safety.[23] A particular concern is the lack of control over manual turning, which has served as the control group intervention in studies of turning with a specialty bed; consequently, there is no evidence that automated turning is as effective or more effective than 2-hourly manual turning.

Neither the safety of manual turning nor the safety of automated turning has been studied systematically, and turning-related adverse events can influence adherence to turning protocols. We conducted a pilot study for a randomized controlled trial to test the efficacy and safety of 2-hourly manual and continuous, automated turning. The purpose of the pilot study was to estimate effect sizes to determine the sample size needed for the randomized controlled trial to compare PPCs, turning-related adverse events, duration of mechanical ventilation, length of stay in the ICU, and ICU mortality in medical-surgical ICU patients receiving mechanical ventilation who were randomized to manual or automated lateral rotation.