What type of patient would benefit from an elevated head of the bed position ?*?
Background: Elevating the head of bed (HOB) to 30° to 45° is an evidence-based recommendation to prevent ventilator-associated pneumonia (VAP). However, the available scientific data are inconclusive regarding the optimal degree of HOB elevation which is safe and effective for mechanically ventilated patients. Show
Aims and objectives: To investigate the impact a of semirecumbent position at 30° and 45°on the development of VAP as compared with aHOB elevation to <30°. Methods: A 5-day, single centre, prospective, randomized, controlled, parallel group, three-arm study was conducted in adult patients on mechanical ventilation staying in the intensive care unit. Patients were randomly placed in <30°, 30°, or 45° HOB elevation position on the day of intubation and followed up for 5 days. They were assessed in terms of the development of microbiologically confirmed VAP (by the culture of endotracheal aspirate) over the study period. Results: Sixty patients (20 in each arm) completed the study. VAP occurred in 55%, 25%, and 20% of patients in the HOB elevation to <30°, 30°, and 45°study arms, respectively. The frequency of VAP was significantly lower in the 45° compared with the <30° study arm (P = .022); there were no significant differences between the <30° and 30° as well as the 45° and 30° study groups. Unlike the frequency of VAP, the timing of the VAP (early or late) was not dependent on the degree of HOB elevation (P = .703). Conclusions: Keeping the mechanically ventilated patients in a semirecumbent position as close to 45°as possible should be the goal to prevent the development of VAP. The backrest elevation <30° should be avoided unless medically indicated. Relevance to clinical practice: The study results reaffirm the crucial role of patient positioning, an essential nursing care intervention, in preventing VAP. Intensive care nurses can contribute to improving the VAP rates and outcomes by placing and keeping the patients in the correct position. Keywords: head of bed elevation; intensive care unit; mechanical ventilation; nursing care; ventilator associated pneumonia. The elevation of the head of bed (HOB) to a semirecumbent position (at least 30 degrees) is associated with a decreased incidence of aspiration and ventilator-associated pneumonia (VAP). The intervention is supported unanimously by all four leading guidelines, and newer publications in the field accept HOB elevation as an effective, low-cost, and low-risk intervention. Society for Healthcare Epidemiology of America2008—Society for Healthcare Epidemiology of America Guidelines: Strategies to prevent VAP in acute care hospitals: 2014 update1
ZAP the VAP: Ventilator-Associated Pneumonia2008—Canadian VAP Prevention Guidelines: Evidence-based, clinical practice guidelines for the prevention of VAP2
American Thoracic Society2004—Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia3
Centers for Disease Control and Prevention (CDC)2003—CDC Guidelines for preventing Health-Care-Associated Pneumonia; evidence-based, clinical practice guidelines for the prevention of healthcare-associated pneumonia, including VAP4
(Rose, 2010)5CON: Study focused on adult patients requiring mechanical ventilation in Australia and New Zealand intensive care units. Findings showed that actual backrest elevation was less than recommended and predominantly influenced by clinical and patient condition, where more acute patients had a lower head of bed (HOB). Authors felt that more study is warranted to determine if the perceived difference in ventilator-associated pneumonia (VAP) rates is due to this phenomenon.Randomized Controlled Trial (RCT) (van Nieuwenhoven, 2006)6CON: Randomized controlled trial (RCT) to assess the feasibility of the semirecumbent position for adult mechanically ventilated patients in the intensive care unit (ICU). Patients must have required mechanical ventilation for more than 48 hours. The target for HOB elevation was 45 degrees. Unfortunately, the study failed to meet the target elevation of 45 degrees, and investigators compared 10-degree elevation versus 28-degree elevation. Comparison failed to show VAP reduction.Quasi-experimental Study (Resar, 2005)7PRO: Quasi-experimental study. This study implemented the use of the Institute for Healthcare Improvement ventilator bundle. Findings showed that adherence to the bundle led to a significant reduction of VAP. One of the four interventions included in the bundle was HOB elevation to 30-45 degrees.RCT (Drakulovic, 1999)8PRO: RCT. 86 patients were randomly assigned to semirecumbent or supine position. Study focused on medical and respiratory patients who required mechanical ventilation in the intensive care unit. Findings showed the semirecumbent body position reduces frequency and risk of nosocomial pneumonia, especially in patients who receive enteral nutrition. Study was stopped early after planned interim analysis found significant differences between the two arms.Observational Study (Orozco-Levi, 1995)9PRO: Observational study focused on adult, critically ill patients requiring mechanical ventilation and nasogastric intubation. Study findings showed that irrespective of body position (supine or semirecumbent), patients with gastroesophageal reflex (GER) are at risk for gastric content aspiration. Additionally, the study concludes that while the semirecumbent position doesn’t completely protect from GER, it does protect against pulmonary aspiration of gastric contents.Cohort Study (Kollef 1993)10PRO: Cohort study focused on medical, surgical, and cardiothoracic patients that required mechanical ventilation for longer than 24 hours. Study findings showed four factors to be independently associated with VAP: an organ system failure index ≥3, patient age ≥60 years, prior antibiotic treatment, and supine head positioning.Crossover Trial (Torres, 1992)11PRO: Crossover trial focused on patients requiring mechanical ventilation and intubation. Study findings conclude that the supine position and length of time the patient is kept in this position are potential risk factors for aspiration of gastric contents.
(Li Bassi, 2011)12Literature review: Reviewed nine RCTs and two animal studies to evaluate the role of body positioning on VAP. Findings showed a decrease in VAP due to semirecumbent position and reduction in gastric aspiration.Clinical Review (Grap, 2010)13Clinical review: This review summarizes the epidemiology, pathophysiology, and risk factors associated with VAP and provides evidence-based recommendations for preventions. Review recommends the use of continuous backrest elevation of 30–45 degrees as an early prevention measure for VAP in the emergency department.Systematic Review and Meta-analysis (Alexiou, 2009)14Systematic review and meta-analysis: Study analyzed seven RCTs to evaluate the effect of body position of patients requiring mechanical ventilation. Study findings showed that patients in the semirecumbent position have a significantly lower rate of clinical diagnoses of VAP than patients positioned supinely.Clinical Review (Kollef, 2004)15Clinical review focused on clinical methods used for prevention of hospital-acquired pneumonia/VAP. With regard to HOB, the review recommends the implementation and use of semi-erect HOB positioning based on the findings of four randomized controlled trials.Systematic Review (Collard, 2003)16Systematic review focused on all interventions that are beneficial to the prevention of VAP. Regarding HOB elevation, review recommends the use of semirecumbent position based on findings of three RCTs. Annotated Bibliography
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