RATIONALE: Controversy exists on the use of head-down (HD) positioning for patients with severe brain injury (BI) during CPT. PURPOSE: This study compares the effects of HD and head-flat (HF) positioning during CPT in patients with severe BI. METHOD: In a prospective clinical study, 31 mechanically ventilated patients were randomly assigned to receive CPT (positioning, percussion, vibration and suctioning) either HD (N = 16) or HF (N = 15). Heart rate (HR), mean arterial blood pressure, intracranial pressure (ICP), cerebral perfusion pressure (CPP) and end-tidal C02(ETC02) were obtained during baseline, CPT, and after treatment. RESULTS: ICP rose (p < 0.0001) in both groups over the 15 minutes of CPT and ICP was greater (p = 0.02) while HD than HF. CPP did not differ between groups; it fell (p < 0.0001) during CPT but all mean values were > 60 mmHg. There was a rise (p = 0.0015) in ETC02 in the HD and HF groups during CPT. The 15th minute of CPT (suctioning) was associated with significant changes (p < 0.05) in HR, ICP and ETC02. All post CPT variables returned to baseline with the exception of ICP in the HD group, which was lower after CPT (9.8 +/- 1.1 mmHg) than before (13.2 +/- 0.6 mmHg). CONCLUSIONS: Patients with severe BI can tolerate CPT in a 9 degrees HD position for up to 15 minutes when strict guidelines are followed. The authors recommend using CPP compared to ICP as a better means to assess a patient's response to CPT.

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