Recovery Position for Persons with Decreased Level of Consciousness of Nontraumatic Etiology (FA #517): Scoping Review

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. There were no declared conflicts of interest

Task Force Scoping Review Citation

Douma MJ, Picard CT, Bendall JC, Singletary E, Zideman D, Berry DC, Borra V, Carlson JN, Cassan P, Chang W-T, Charlton NP, Djarv T, Epstein JL, Hood NA, Markenson DS, Meyran D, Orkin A, Sakamoto T, Woodin JA - on behalf of the International Liaison Committee on Resuscitation First Aid Task Force.

Recovery Position for Persons with Decreased Level of Consciousness of Nontraumatic Etiology Who Do Not Meet Criteria for Rescue Breathing or Chest Compressions: Scoping Review and Task Force Insights [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force, 2020 January 1. Available from: http://ilcor.org

Methodological Preamble and Link to Published Scoping Review

The continuous evidence evaluation process started with a scoping review of recovery positions for persons with a decreased level of consciousness of nontraumatic etiology who do not meet the criteria for rescue breathing or chest compressions, conducted by an ILCOR First Aid Task Force Scoping Review team with assistance from clinical experts. Evidence from adult and pediatric published and grey literature was sought and considered by the First Aid Task Force. A similar topic, use of a recovery position for persons who are unresponsive but breathing normally, was reviewed in 2015 using GRADE methodology and a Consensus on Science with Treatment Recommendations was published {Singletary 2015 S269}{Zideman 2015 e225}. Since then, there has been an ongoing debate regarding the optimal position and the potential risks associated with use of a recovery position. The goal of this scoping review is to provide a broad review, but with a focus on specific conditions that might require use of a recovery position, providing additional evidence to support current resuscitation and first aid guidelines or to identify evidence pointing to the need for a future systematic review.

Scoping Review

Not available at this time

PICOST

Search Strategies

Published Literature - Searches executed on November 4, 2019 without date restrictions. The search strategy used in 2014 and developed by Information Specialists with St. Michaels Hospital, Toronto, was modified to incorporate key words and terms associated with the revised wording.

Embase 1840 articles

'patient positioning'/de OR 'body position'/exp OR (patient NEXT/1 position*):ab,ti OR (body NEXT/1 position*):ab,ti OR (recovery NEXT/1 position*):ab,ti OR (lateral NEXT/1 position*):ab,ti OR ('side-lying' NEXT/1 position*):ab,ti OR haines:ab,ti OR 'high arm in endangered spine':ab,ti OR 'lateral recumbent':ab,ti AND ('unconsciousness'/de OR 'coma'/de OR 'faintness'/de OR 'shock'/exp OR 'heart arrest'/exp OR unconscious*:ab,ti OR unresponsive*:ab,ti OR 'altered level of consciousness':ab,ti OR syncope:ab,ti OR coma:ab,ti OR shock:ab,ti OR 'heart arrest':ab,ti OR 'cardiac arrest':ab,ti OR 'cardiopulmonary arrest':ab,ti OR 'cardiovascular arrest':ab,ti OR 'cardiopulmonary resuscitation':ab,ti OR 'cpr':ab,ti OR 'post-cardiac arrest':ab,ti OR 'post-heart arrest':ab,ti OR 'post-infarct':ab,ti OR 'postinfarct':ab,ti) NOT ('animal'/exp NOT 'human'/exp) NOT ([editorial]/lim OR [letter]/lim OR 'case report'/de) AND [embase]/lim

PubMed 2267 articles

((((((((((((((Posture[MeSH Terms]) OR "Patient Positioning"[Mesh:NoExp]) OR patient position*[Title/Abstract]) OR body position*[Title/Abstract]) OR recovery position*[Title/Abstract]) OR lateral position*[Title/Abstract]) OR side-lying position*[Title/Abstract]) OR HAINES[Title/Abstract]) OR lateral recumbent[Title/Abstract])) AND (((((((((((((((((((((Unconsciousness[Mesh:NoExp]) OR Coma[Mesh:NoExp]) OR Syncope[MeSH Terms]) OR Shock[MeSH Terms]) OR Heart Arrest[MeSH Terms]) OR Cardiopulmonary Resuscitation[MeSH Terms]) OR unconscious*[Title/Abstract]) OR unresponsive*[Title/Abstract]) OR altered level of consciousness[Title/Abstract]) OR syncope[Title/Abstract]) OR coma[Title/Abstract]) OR comas[Title/Abstract]) OR shock[Title/Abstract]) OR heart arrest[Title/Abstract]) OR cardiac arrest[Title/Abstract]) OR cardiopulmonary arrest[Title/Abstract]) OR cardiovascular arrest[Title/Abstract]) OR resuscitation[Title/Abstract]) OR post-cardiac arrest[Title/Abstract]) OR postinfarct*[Title/Abstract]) OR post-infarct*[Title/Abstract]))) NOT ((animals[mh] NOT humans[mh])))) NOT (("letter"[pt] OR "comment"[pt] OR "editorial"[pt] or Case Reports[ptyp]))

Cochrane 172 articles

([mh Posture] OR [mh ^"Patient Positioning"] OR "patient position*":ab,ti OR "body position*":ab,ti OR "recovery position*":ab,ti OR "lateral position*":ab,ti OR "side-lying position*":ab,ti OR HAINES:ab,ti OR "High Arm IN Endangered Spine":ab,ti OR "lateral recumbent":ab,ti) AND ([mh ^Unconsciousness] OR [mh ^Coma] OR [mh Syncope] OR [mh Shock] OR [mh "Heart Arrest"] OR [mh "Cardiopulmonary Resuscitation"] OR unconscious*:ab,ti OR unresponsive*:ab,ti OR "altered level of consciousness":ab,ti OR syncope:ab,ti OR coma:ab,ti OR shock:ab,ti OR "heart arrest":ab,ti OR "cardiac arrest":ab,ti OR "cardiopulmonary arrest":ab,ti OR "cardiovascular arrest":ab,ti OR resuscitation:ab,ti OR CPR:ab,ti OR "post-cardiac arrest":ab,ti OR "post-heart arrest":ab,ti OR "post-infarct":ab,ti OR postinfarct:ab,ti)

Google Scholar 6,660 articles (100 reviewed)

“recovery position”

Grey Literature Search

Google Search

Grey Literature Database Searches for the search term “recovery position”

Targeted website search: First aid and Opioid overdose treatment websites

Targeted websites were identified through an online survey to ILCOR First Aid Task Force Members and content experts.

Inclusion and Exclusion criteria

Inclusion: Humans of all ages, cadaver and human-simulation studies, care in all settings, all languages if an English abstract exists

Exclusion: Studies that do not address any component of the PICO question, animal studies

See separate appendix document: Figure One: PRISMA Diagram FA-517 Recovery position PRISMA Appendices

Data tables

See separate appendix document: data tables-FA-517 Recovery Position Data Tables

Table 1. Details of included studies: Decreased level of consciousness due to medical aetiology or intervention

Table 2. Details of included studies: Healthy volunteer studies with normal level of consciousness

Table 3. Details of included studies: Patient positioning for ventilation during sleep

Table 4. Details of included studies: Cadaver studies of spinal alignment in recovery positions

Task Force Insights

1. Why this topic was reviewed

The benefit of lateral positioning of individuals with decreased level of consciousness, (to maintain airway patency, avoid aspiration and facilitate effective ventilation), was first purported in the published literature in 1891{Bowles 1891 26} and has been widely adopted in international first aid guidelines. Unfortunately, the strength of the scientific evidence to support this intervention, and alternative positions, has remained lacking. The 2015 ILCOR Consensus on Science{Singletary 2015 S269}{Zideman 2015 e225} for this topic identified very low certainty evidence from 8 observational studies. At that time it was suggested that first aid providers position individuals who are unresponsive and breathing normally into a lateral, side-lying recovery (lateral recumbent) position as opposed to leaving them supine (weak recommendation, very low certainty evidence); however, there was little evidence to suggest the optimal recovery position.

Since the 2015 review a global opioid abuse crisis has resulted in increased overdose related deaths in many regions internationally. In response, we have included the management of opioid-associated decreased mental status and respiratory depression or compromise, which may necessitate use of a recovery position, in this review. Furthermore, in the past five years, some authors have expressed concern and provided evidence to suggest that placing individuals in the recovery position may impair the detection of cardiac arrest{Freire-Tellado 2016 e1}{Freire-Tellado 2017 173}{Navarro-Paton 2019 104}. Due to these phenomena, the search strategy used in 2014 has been revised.

The PICO question used in 2015 aimed to review possible recovery positions for persons who are unresponsive and breathing normally. There are few conditions that result in a person being unresponsive and breathing normally. We believe that in many communities the more common clinical scenario that a first aid provider will encounter, particularly with the opioid crisis, is a person who has diminished level of consciousness/responsiveness coupled with breathing abnormality (i.e., they are not breathing normally, but do not meet criteria for cardiopulmonary resuscitation (CPR). Therefore, the wording of this PICO question was revised from persons who are unresponsive and breathing normally to persons with decreased level of consciousness and who do not meet criteria for the initiation of CPR. The outcome list of this review was also expanded to include hypoxic events in addition to those from 2015: survival, need for airway management, incidence of aspiration or cardiac arrest, likelihood of cervical spine injury and any complications.

The purpose of these revisions and the adoption of a scoping review instead of a systematic review was to cast as wide a net for evidence as possible. We sought studies of persons with a medical or toxicological cause of decreased LOC (such as from alcohol or drug overdose, intracranial haemorrhage) and studies of body position interventions and their effect on breathing. The goals of this review are to:

• survey the range of research in patient positioning for breathing,
• determine if a future systematic review is possible on a subsection of the included studies,
• summarize the research identified,
• identify gaps in the knowledge base and
• support guideline authors.

This revised and updated search strategy has resulted in more indirect evidence being included. An example of this is the inclusion of research examining the role of patient positioning in obstructive sleep apnea (patients with decreased level of consciousness, undergoing positioning as an intervention, for the outcome of apnea-hypopnea index) and cadaver models of cervical spine instability (cadaver with cervical instability, rolled into different recovery positions, for the outcome of spinal alignment/displacement).

Although this scoping review does not allow for treatment recommendations per se, we hope that it provides a broad description of the published research related to positioning in persons with a decreased level of consciousness for future guidelines authors, decision-makers and researchers alike.

2. Narrative summary of evidence identified

Thirty-one studies, a case report and two letters to the editor were identified from our database and grey literature search. Nine studies involved patients with a medical or toxicological cause of, or medically induced, decreased level of consciousness (Table 1). Eight studies enrolled healthy participants (Table 2), 15 studies assessed patient positioning for ventilation during sleep (Table 3), and two studies involved cadaveric models of cervical spine instability in recovery positions (Table 4). Overall, the positions studied, the airway maneuvers used, and the outcomes reported in the included studies were all highly variable. Seven distinct lateral recumbent “recovery positions” were identified ranging from lateral to prone, and in many studies the position used was not described in detail regarding degree of torso rotation, arm and head position that would allow for reproducibility. Comparison positions, when reported, were also highly variable ranging from prone to semi-recumbent and supine with manual airway maneuvers such as the head-tilt-chin-lift. Included study heterogeneity prevents a meaningful follow-up systematic review and/or meta-analysis.

The grey literature search revealed a near universal adoption of the recovery position for a decreased level of consciousness with normal breathing for unknown etiologies as well as known or presumed etiologies such as seizure, stroke, poisoning and opioid overdose. Treatment guidelines for ski patrollers, lifeguards, prison guards, schoolteachers and combat medics all recommended a variation of the lateral recumbent recovery position.

Studies enrolling patients with a decreased level of consciousness due to medical aetiology or intervention (Table 1)

In one of the most direct sources of evidence for the recovery position, a prospective observational multicenter cohort study found an independent association between the recovery position and a decreased admission rate in children aged eight to 18 years with loss of consciousness of any duration, with an adjusted odds ratio of 0.28 (95% CI 0.17 to 0.48, p<0.0001){Julliand 2016 531}. The recovery position was associated with a decreased admission rate when a longer hospitalization was considered as outcome (conventional or pediatric intensive care unit hospitalization compared with direct discharge from the pediatric emergency department or admission in a short-stay observational unit): with an odds ratio of 0.43 (95% CI 0.21 to 0.88, p=0.02).

In a prospective study designed to correlate the body position of overdosed individuals at the time of their discovery with the frequency of suspected aspiration pneumonia, the prone and semi-recumbent positions were associated with a significantly decreased rate of suspected aspiration pneumonia (p = 0.006), but lateral and supine positioning were not{Adnet 1999 745}.

Three studies{Arai 2004 1638}{Arai 2005 949}{Litman 2005 484} with small samples of anesthetized or deeply sedated children with adenotonsillar hypertrophy or undergoing magnetic resonance imaging of the head or neck region, were reviewed. They examined the role of patient positioning on stridor score and upper airway volume. Lateral positioning decreased stridor scores and the combination of lateral positioning and airway maneuvers was found to significantly improve airway patency (p < 0.05){Arai 2004 1638}. In a study of bronchoscopically measured anteroposterior and transverse airway dimensions and stridor scores, chin lift and jaw thrust maneuvers increased the airway dimensions which were found to be significantly associated with decreased stridor scores (p < 0.001){Arai 2005 949}. Magnetic resonance studies further support the assertion that lateral positioning increases the airway volume of the sedated child. The total airway volume in one study (mean +/- SD) was 6.0 +/- 2.9 ml³ in the supine position and 8.7 +/- 2.5 ml³ in the lateral position (p < 0.001){Litman 2005 484}.

Two studies{Svatikova 2011 262}{Turkington 2002 2037} in stroke patients with sleep-disordered breathing examined the relationship between sleeping position and apnea-hypopnea index or respiratory disturbance index. In a randomized, controlled, cross-over study of 3 months of sleeping ad lib compared with “positional pillows” to maintain lateral positioning in stroke patients (n=18), the apnea-hypopnea index was reduced by 19.5% (95% CI: 4.9–31.9% (P = 0.011)){Svatikova 2011 262}. Another observational study enrolling 120 stroke patients found significantly more severe upper airway obstruction when patients slept in the supine position (P < 0.0001), supine left (P < 0.005) and supine right (P < 0.03) positions than when they slept in the lateral or prone positions. The mean respiratory disturbance index scores were 14 per hour in the left lateral position, 12 per hour in the right lateral position and 29 per hour in the supine position p < 0.0001{Turkington 2002 2037}.

One case report and one letter to the editor{Kumar 1996 69}{Freire-Tellado 2016 e1} were included that reported potential complications or adverse events that may arise from placing individuals in the recovery position. In a case report of a 27-year-old man who remained in the recovery position for approximately 12 hours following heroin use and was left with lower motor nerve palsy of the left radial and left common peroneal nerves{Kumar 1996 69}. In a 2016 letter to the editor, a Spanish emergency medical service shared the experience of seven individuals who had been assessed as unresponsive and breathing normally who were placed in the recovery position only to be determined to be in unrecognized cardiac arrest when reassessed by the medical responders{Freire-Tellado 2016 e1}. This experience appeared to have led to two related studies on the detection of respiratory and cardiac arrest reviewed below{Freire-Tellado 2017 173}{Navarro-Paton 2019 104}.

Studies enrolling healthy volunteers with normal level of consciousness (Table 2)

A small cross-over trial{Fulstow 1993 89} compared the 1992 European Resuscitation Council (ERC) recovery position with the left lateral semi-prone recovery position recommended by the UK Resuscitation Council prior to 1992. Baseline measurements were collected during a supine position prior to a recovery position and a washout supine position was used between the recovery positions as well. Each recovery position was held for up to ten minutes while examining the perfusion of the dependent arm including skin temperature, colour, SpO2 and plethysmograph monitoring. The semi-prone recovery position did not result in any circulatory problems whereas four of the six participants placed in the ERC recovery position experienced venous engorgement and blotchy skin mottling in their dependent arm. Two of the six participants also experienced compromised arterial blood supply to their dependent arms as demonstrated by loss of the plethysmograph waveform and rapidly falling left index finger temperatures within three to four minutes of being placed in the ERC position. Discomfort, numbness and pain were also reported in the ERC position{Fulstow 1993 89}.

Four included studies{Rathgeber 1996 13}{Doxey 1998 161}{Leaves 1998 316}{Turner 1998 153} surveyed first aid trainees from the perspective of provider and patient comparing different recovery positions. These healthy volunteer studies examined spine alignment/misalignment in degrees, participant self-reported sensations such as pain or “pins and needles”, perception of safety in a position, circulatory problems such as plethysmography waveform and falling finger temperature.

Rathgeber et al.{Rathgeber 1996 13} placed 20 volunteers in the American Heart Association (AHA) or European Resuscitation Council (ERC) recovery position for 15 minutes in randomized crossed over fashion and in a second series they positioned ten of the volunteers in the Morrison, Mirakhur and Craig (MMC), and then the Rautek recovery position in the same randomized and crossed over fashion. Discomfort was reported by 11/20 participants in the ERC position, 4/20 in the AHA position, 5/10 in the MMC position and 4/10 in the Rautek position. All recovery positions except the AHA decreased photoplethysmographic index and non-invasive peripheral blood pressure amplitude in the dependent arm.

One hundred basic life support trainees were shown the 1992 and 1997 recovery positions and practiced them both in pairs in an observational study{Doxey 1998 161}. Outcomes measured included their perceived safety, comfort, pain and discomfort. Differences were seen between both positions; 96 participants reported feeling safe when being turned in the 1992 position, compared with 58 (p <0.001) in the 1997 position. Eighty-three participants reported feeling comfortable during the turn using the 1992 position compared to 30 using the 1997 position (p <0.001). Thirty-nine participants experienced pain during the 1997 position as opposed to 12 during the 1992 position (p < 0.001). Once in the recovery position 84 participants felt comfortable in the 1992 position compared to 43 in the 1997 position (p < 0.001). Additional outcomes were reported for subgroups of the sample including those who described themselves as overweight, and/or having neck and shoulder problems.

In a letter to the editor (Leaves 1998 316) Leaves et al. describe their questionnaire administered to basic life support trainees comparing the European Resuscitation Council’s (ERC) 1992 recovery position and the ILCOR 1997 recommended recovery position. Trainees in the role of casualty were more likely to report positively on the near side arm position, the turning process and the final position (all p <0.001) of the ERC 1992 position.

A survey{Turner 1998 153} was administered to 687 life support trainees, trained in the 1992 or 1997 recovery position. Responding from the perspective of the patient, participants evaluated smoothness of role, ability to breath, comfort and stability. The median patient-participant scores were reported in a pooled fashion. The median combined score (higher being better using a modified 5-point scale) for the 1992 position was 29 compared to 24 for the 1997 position (p <0.001).

Two studies{Freire-Tellado 2017 173}{Navarro-Paton 2019 104} examined the role of the recovery position of the detection of respiratory and cardiac arrest.

In one study, basic life support trained university students were randomly divided into either a recovery positioned (RP) trained cohort or a head-tilt-chin-lift (HTCL) trained cohort for unresponsive but breathing patients{Freire-Tellado 2017 173}. A human simulation test was performed one week later which found 4 of 27 (51.85%) students in the recovery position group compared to 23 of 28 (82.14%) in the head tilt and chin lift group detected breathing arrest within 2 min p = 0.006 (OR 6.571){Freire-Tellado 2017 173}. The time to detect respiratory arrest (in participants who did recognize it) and initiate cardiac compression was 31.92 seconds on average in the RP group (range = 2–104; SD = 25.49) compared with an average of 17.52 seconds (range = 4–47; SD 11.37) in the HTCL group. The difference in the mean detection was statistically significant (p = 0.024).

The second study{Navarro-Paton 2019 104} of cardiac arrest recognition enrolled school children aged ten to 12 years and trained them to put unresponsive and breathing casualties in one of three positions: the recovery position and assess their breathing regularly (RPregularly), the recovery position and assess their breathing every minute (RPminute) or keep them supine and maintain airway patency with a head-tilt-chin-lift (HTCL). A human simulation test was performed with a trained actor who simulated regular then agonal breathing followed by apnea. One hundred and eighty-two children (86 males (47.25%) and 96 females (52.75%) were evaluated for the primary outcome (59 in the RPregularly group, 61 in RPminute group and 62 in the HTCL group). All of the 182 participants completed the intervention with the technique they had been allocated. One hundred and thirteen participants detected cardiac arrest before the end of the simulation: 16 (26.2%) out of the 59 participants in the RPregularly group, 41 (67.20%) out of 61 in the RPminute group, and 56 (90.3%) out of 62 in the HTCL group. Statistically significant differences were found between RPregularly and RPminute groups (p < 0.001; OR = 5.766, CI 2.63–12.60), RPregularly and HTCL groups (p < 0.001; OR = 21.094, CI 7.57–58.80) and between RPminute and HTCL groups (p = 0.002; OR = 4.553, CI 1.679–12.943). When cardiac arrest was detected by the participants, the average time required for identification was 87.57 seconds (SD = 19.06) (range from 54 to 110 seconds) in the RPregularly group, 86.53 seconds (SD = 17.52) (40– 114 seconds) in the RPminute group and 24.76 seconds (SD=22.81) (6–105.69 seconds) in the HTCL group. The differences were statistically significant (p < 0.001).

In a healthy volunteer study{Blake 2002 289} (n=38) of a recovery position intended to reduce spine motion, the modified High Arm IN Endangered Spine (HAINES) position was evaluated. Participants had their spinal alignment assessed in the lateral recovery position and later in the modified HAINES position. In each position four digital photographs were taken: one from in front, one from behind, one from above and one along the longitudinal axis of the body from the head end. A total of 304 digital images were analysed. Assessments were made of six angles allowing measurement of thoraco-lumbar flexion, lateral flexion and rotation and cervical flexion, lateral flexion and rotation. There was greater cervical lateral flexion and extension of the cervical spine in the lateral recovery position compared to the modified HAINES position, mean different 12.98 degrees (95% CI 7.47 to 18.49) (p< 0.001). There was more thoracic/lumbar spine rotation and lateral flexion in the modified HAINES group, mean difference 9.86 (95% CI 6.41 to 13.31) (p < 0.01). Two participants reported “pins and needles” in their abducted arm in the HAINES position.

Studies enrolling patients with obstructive sleep apnea or sleep disordered breathing (Table 3)

This scoping review is not a comprehensive review of the substantial obstructive sleep apnea and sleep disordered breathing literature; however, 14 studies and 1 systematic review and meta-analysis were identified and included based their indirect relevance to the role of positional therapies for ventilation in patients with decreased level of consciousness. Fourteen studies and one systematic review and meta-analysis were included in this scoping review on positional interventions for obstructive sleep apnea and/or sleep disordered breathing (see Table 3). The included studies examined the roll of patient position, typically lateral compared with supine, on a variety of ventilation and respiration related outcomes such as the apnea-hypopnea index, SpO₂, airway closing pressure, airway diameters, mean inspiratory volume, upper airway resistance, minute ventilation, apnea duration, time between desaturation and others. The vast majority of these outcomes were improved by adopting a non-supine position, but the rigor and methodological certainty of the studies is variable.

A meta-analysis of four studies (206 participants) for the primary outcome of apnea hypopnea index found a significant reduction in AHI favoring positional techniques over other non-standard therapies (mean difference 9.59 events per hour, 95% CI 12.48 to 6.69), p < 0.00001){Barnes 2017 107}. There was a significant improvement in oxygen desaturation index (4% desaturation) (mean difference -2.19 events per hour, 95% CI -2.91 to -1.47, p < 0.00001, two studies, 90 participants), favoring positional techniques. The authors conclude that the literature supports the use of positional techniques for supine obstructive sleep apnea{Barnes 2017 107}. See Table 3 for additional studies and outcomes.

Studies of cadavers with surgically induced cervical spine injuries (Table 4)

The concern that moving a patient who is breathing normally but unresponsive, who has an unknown spinal injury that may be aggravated by movement into the recovery position, is common. Two studies{Del Rossi 2014 539}{Hyldmo 2016 1003} were included that used cadaveric models of cervical spine injuries to explore the different amount of angulation or displacement in the cervical spine using different recovery positions. In a repeated measures cadaveric study of cervical spine injury ten cadavers with no previous cervical pathology underwent a surgical segmental injury creation at the C5-C6 level{Del Rossi 2014 539}. The cadavers were then placed in the recovery position as well as the High Arm IN Endangered Spine (HAINES) position. An electromagnetic tracking device was used to capture all linear translation motions produced between the C5–C6 segment. No statistically significant results were reported in this study comparing C5/C6 lateral-medial, compression-distraction or anterior-posterior movement.

Additionally, a second cadaveric cervical spine injury study was included{Hyldmo 2016 1003}. Five cadavers with surgically induced cervical instability at C5-C6 had baseline ROM assessed for flexion, extension, rotation and lateral bending prior to induction of instability. After spinal lesions were created cadavers were placed in four positions and underwent electronic cervical spine motion tracking. The positions were: recovery position, HAINES position with one leg flexed, HAINES position with two legs flexed, and the lateral trauma position (LTP). Regression analyses estimates indicated statistically significant differences between the recovery position and the three other positions. For the recovery position, the estimate in lateral bending was 11.9°. While both HAINES positions caused a similar range of motion, the motion caused by lateral trauma position was 2.6°less (P=0.037). The linear axial range of motion in the recovery position was 13.0 mm. In comparison, the HAINES 1 and 2 showed significantly less motion (-5.8 and -4.6 mm, respectively), while the LTP did not (-4.0 mm, P=0.067). In this cadaver study the lateral trauma position appeared to result in the least amount of cervical spine movement when rolling from supine.

3. Narrative reporting of the task force discussions

The identified studies were all of low or very low certainty based on study design alone. The majority of studies on the recovery position were performed in healthy volunteers and report outcomes such as dependent arm perfusion and comfort associated with positioning. For the focus area of opioid overdose, only a single study was identified, suggesting that a semi-recumbent position may be preferable to lateral position{Adnet 1999 745} and the Task Force (TF) agrees that additional studies are needed to confirm this finding. For other medical causes of decreased mental status such as stroke, induced sedation, and decreased level of consciousness, the lateral recumbent position was reported as associated with beneficial outcomes.

The TF discussed how the recovery position in its many forms has become universally recommended for persons with a decreased level of consciousness from non-traumatic cause in first aid settings, and who do not require rescue breathing or chest compressions, despite a true paucity of research to support its use. Moreover, our grey literature review did not identify any first aid guidelines recommending an alternative approach such as the supine position with or without manual airway maneuvers or adjuncts over the recovery position.

TF discussions suggest that studies of positional interventions for sleep disordered breathing help describe the effect of body position on ventilation in persons with decreased level of consciousness. The majority of studies reviewed report lateral positioning improving outcomes of interest such as apnea, hypopnea and oxygen desaturation. However, they may not be directly applicable to the use of the recovery position for persons with decreased level of consciousness from medical, toxicological and non-traumatic etiology.

In light of the overall paucity of evidence of spinal injuries related to patient movement into the recovery position in undetected cervical spine injury, cadaveric studies were included in this review{Del Rossi 2014 539}{Hyldmo 2016 1003} in addition to a healthy volunteer study{Blake 2002 289}. There was no clear positional superiority between the lateral trauma position (which included a cervical collar), HAINES position and the standard left lateral position. The TF discussion about these studies echoed the 2015 Recovery Position Consensus on Science and Treatment Recommendation, emphasizing the need for guideline authors to continue to clearly address situations in which a first aid provider should not move a person into a recovery position, such as in the presence of pelvic or spinal injury.

The studies of Freire-Tellado & Navarro-Paton{Freire-Tellado 2017 173}{Navarro-Paton 2019 104} demonstrated that use of the supine position and a head-tilt-chin-lift manoeuvre improved the detection of cardiac arrest in human simulation studies. This resulted in much TF discussion regarding the optimal position to promote adequate breathing while optimizing the detection of respiratory and/or cardiac arrest. Although the included evidence is of low or very low certainty and favors the use of a lateral recumbent position, there remains concerns in the TF about the use of a recovery position in scenarios where hypoxic respiratory arrest or impending cardiopulmonary arrest may occur, such as from opioid overdose. It is the consensus of the TF that this topic should be the subject of a future systematic review.

Knowledge Gaps

• There is no direct prospective evidence for the recovery position over other positions for outcomes of critical importance
• There is an urgent need for prehospital studies of the recovery position, especially as it relates to the detection of cardiac arrest and the management of opioid overdose
• Further research is needed to determine the ideal methods to monitor for and promote adequate breathing of individuals placed in the recovery position

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