To the Editor:

Patients with severe chronic airflow obstruction can experience a reduction in the sensation of dyspnea by assuming specific postures.(1-3) Leaning forward with the hands on the knees, the so-called "tripod position", for example, is a well-known posture associated with dyspnea relief.(4) We recently had the opportunity to meet, in the infirmary of our hospital, a 39-year-old cystic fibrosis inpatient who had adopted a distinct posture for respiratory comfort. He was seated on the bed, with his legs crossed, keeping his trunk straight. His overall positioning was reminiscent of the lotus position used for meditation. According to the patient, adopting this position, immediately after intense exercise, mitigated dyspnea, improved alertness, and prevented dizziness.

The patient had been hospitalized due to an acute episode of bronchiectasis caused by Pseudomonas aeruginosa infection. Spirometric results were as follows: FVC, 2.39 L (76% of predicted); FEV1, 1.34 L (50.6% of predicted); and FEV1/FVC ratio, 56.1%. During a period of clinical stabilization, arterial blood gas analysis revealed a pH of 7.43, a PaO2 of 66 mmHg, and a PaCO2 of 37 mmHg, on room air. In order to investigate the mechanisms related to the symptomatic improvement, we decided to measure physiological parameters with the patient in three different positions: standing; seated normally on the side of the bed; and seated in the lotus-like position on the bed. Measurements were taken 5 min after the patient had assumed each position.

As can be seen in Figure 1, the lotus position appeared to have several advantages over the standing position, increasing SpO2 (93% vs. 97%) and decreasing HR (118 bpm vs. 112 bpm), as well as increasing diastolic blood pressure and decreasing systolic blood pressure (130/70 mmHg vs. 110/80 mmHg). In addition, MIP and MEP, measured at the mouth, were lower when the patient was seated in the lotus-like position than when he was standing, although FEV1 and RR remained comparable (1.35 L vs. 1.38 L and 32 breaths/min vs. 30 breaths/min, respectively). In addition, FVC was higher for the lotus-like position than for the standing position (2.57 L vs. 2.45 L).




We believe that the symptomatic improvement reported by this patient is related to hemodynamic changes, secondary to the increase in venous return to the thorax, as has been previously observed in children with cyanotic heart defects.(5) In addition, the improved FVC might be related to the more erect position of the vertebral column. Simultaneous improvements in lung perfusion and ventilation would explain the increase in SpO2. These changes would be sufficient to improve the oxygenation of various tissues, including brain tissue.

Although adopting a lotus-like position could be problematic for some patients with COPD, these clinical findings warrant further investigation. In the meantime, the lotus-like position could be taught as a potential aid to increase respiratory comfort in selected patients with chronic lung diseases.


José Antônio Baddini Martinez
Associate Professor, Department of Clinical Medicine,
University of São Paulo at Ribeirão Preto School of Medicine, Ribeirão Preto, Brazil

Heloise Baldan Otero Rodrigues
Physical Therapist, Department of Pulmonology,
University of São Paulo at Ribeirão Preto School of Medicine Hospital das Clínicas, Ribeirão Preto, Brazil

Alexandre Martins Portelinha
Medical Student, University of São Paulo at Ribeirão Preto School of Medicine, Ribeirão Preto, Brazil


References

1. Barach AL. Chronic obstructive lung disease: postural relief of dyspnea. Arch Phys Med Rehabil. 1974;55(11):494-504.

2. Sharp JT, Drutz WS, Moisan T, Foster J, Machnach W. Postural relief of dyspnea in severe chronic obstructive pulmonary disease. Am Rev Respir Dis. 1980;122(2):201-11.

3. O'Neill S, McCarthy DS. Postural relief of dyspnoea in severe chronic airflow limitation: relationship to respiratory muscle strength. Thorax. 1983;38(8):595-600.

4. Bhatt SP, Guleria R, Luqman-Arafath TK, Gupta AK, Mohan A, Nanda S, et al. Effect of tripod position on objective parameters of respiratory function in stable chronic obstructive pulmonary disease. Indian J Chest Dis Allied Sci. 2009;51(2):83-5.


5. Webb GD, Smallhorn JF, Therrien J, Redington AN. Congenital heart disease. In: Bonow RO, Mann DL, Zipes DP, Libby P, editors. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Philadelphia: Elsevier-Saunders; 2011. p. 1411-67.