Recovery Position for Persons with Decreased Level of Consciousness of Nontraumatic Etiology Who Do Not Meet Criteria for Rescue Breathing or Chest Compressions (FA 517): Task Force Insights from a Scoping Review

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This Review is a draft version prepared by ILCOR, with the purpose to allow the public to comment and is labeled “Draft for Public Comment". The comments will be considered by ILCOR. The next version will be labelled “draft" to comply with copyright rules of journals. The final Review will be published on this website once a summary article has been published in a scientific Journal and labeled as “final”.

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.

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

PICOST

Description (with recommended text)

Population

Adults and children with decreased level of consciousness, due to medical illness or nonphysical trauma, that do not meet criteria for the initiation of rescue breathing or chest compressions (CPR)

Intervention

Positioning in any specific position

Comparison

Supine or other recovery position

Outcomes

Any relevant clinical outcomes including but not limited to:

1) survival (critical),

2) need for airway management (critical),

3) incidence of aspiration (critical),

4) hypoxia (critical),

5) incidence of cardiac arrest (critical)

6) likelihood of cervical spine injury (important)

7) complications (important)

venous occlusion

arterial insufficiency

left arm discomfort/pain

discomfort/pain

aspiration pneumonia

Study Design

Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion. Case series and case reports will also be considered for inclusion, in addition to unpublished studies and reporting (e.g., conference abstracts, trial protocols, technical reports, incident reports, medical examiner and coroners’ reports). As it is anticipated that there will be insufficient studies from which to draw a conclusion, the minimum number of cases for a case series to be included has been reduced for the default of 5 to 1 by the TFSR team.

Timeframe

Scoping search strategy: All years and all languages are included as long as there is an English abstract

Re-running existing search strategy with no date/time restrictions.

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.

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


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 hemorrhage) 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 reporting of the task force discussions (task force insights

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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