Keeley 2007
Keeley 2007
Keeley 2007
ABSTRACT
Background: It has been suggested that placing critically ill ventilated patients in a semirecumbent position minimizes the
likelihood of nosocomial pneumonia.
Aim: This pilot study explores whether the incidence of ventilator-acquired pneumonia (VAP) can be reduced by elevating the head of
the bed to 45.
Methods: The design is quantitative in nature, using a randomized controlled trial. The method involves adult ventilated patients
being randomly assigned to one of two positions, i.e. 45 raised head of bed (treatment group) or 25 raised head of bed (control group).
Data collection relied upon the diagnosis of clinically suspected and microbiologically confirmed pneumonia defined by the Consensus
Conference on VAP.
Results: Thirty patients were included in the study – 17 in the treatment group and 13 in the control group. Results showed that 29%
(five) in the treatment group and 54% (seven) in the control group contracted VAP (P < 0176).
Conclusions: There was a trend towards a reduction in VAP in the patients nursed at 45. However, because of the sample size this
difference did not reach statistical significance.
Key words: Aspiration pneumonia • Care bundle • Gastric aspiration • Head of bed elevation • Ventilator-acquired pneumonia
ª 2007 The Author. Journal Compilation ª 2007 British Association of Critical Care Nurses, Nursing in Critical Care 2007 • Vol 12 No 6 287
Reducing the risk of ventilator-acquired pneumonia
development of VAP (Craven and Steger, 1996; Centre 10 in the control group). There was no difference in the
for Disease Control and Prevention, 1997; George et al., incidence of VAP.
1998). A number of other studies have demonstrated the
The use of histamine-2 receptor blockers for the difficulty in achieving the 45 head-up positioning
prevention of gastrointestinal bleeding may also suggested by Drakulovic et al. (1999). These studies
increase the incidence of VAP (Cook et al., 1998). These consistently demonstrate that patients are routinely
raise the intragastric pH, which in turn enhances nursed at between 20 and 30 head up despite guide-
gastric colonization with pathogens that commonly lines recommending more extreme head up position-
cause pneumonia. Placement of nasogastric feeding ing (Evans, 1994; Grap et al., 1999, 2003; Cook et al.,
tubes may facilitate the reflux of bacteria from the gut. 2002). Indeed, the current mean bed head elevation at
The nasogastric tube does impair the closure to the the author’s institution was found to be 25 in a random
upper oesophageal sphincter and prevents lower selection of patients prior to commencing the current
oesophageal sphincter closure (Hardy, 1988). However, study. It is not known whether there is any benefit in
Satiani et al. (1978) found a reduction of gastro- increasing the degree of bed head elevation from 25 to
oesophageal reflux during surgery when nasogastric 45 recommended by Drakulovic.
tubes were in place as a result of the venting This study aims to compare the effect of the current
mechanism reducing the volume of intragastric con- standard degree of bed head elevation (25) with 45
tents and gastric pressure. bed head elevation on the incidence of VAP.
It has been suggested that patient position may
influence reflux and microaspiration of infected gastric
contents and thus the incidence of VAP. A number of
Spanish groups (Ibanez et al., 1992; Torres et al., 1992; METHODS
Orozco-Levi et al., 1995) have evaluated the efficacy of The degree of bed head elevation to be used in the
a semirecumbent position in relation to aspiration. control group was established by measuring the cur-
These small studies all reported a decreased frequency rent degree of bed head elevation on the trial ICU.
of gastro-oesophageal reflux and aspiration with The angle of the head of the bed was measured on a
semirecumbent positioning. random selection of patients using a protractor and
There have been two larger randomized controlled plumb line.
trials of the semirecumbent position on the incidence Adult ventilated patients who met the inclusion
of VAP. The first study by Drakulovic et al. (1999) criteria were placed in two groups and randomly
randomized participants by a computer-generated list assigned to one of two positions, i.e. 45 raised head of
into two patient groups: one supine (control) and the bed (treatment group) or for the control group, 25
other 45 head up (treatment). The incidence of VAP raised head of bed (current practice within the ICU).
(the primary outcome) was reduced from 27/47 (57%)
in the control group to 5/39 (13%) in the treatment
Exclusion criteria:
group (P = 0003). The authors of this well-conducted
study conclude ‘Placing critically ill ventilated patients • Previous intubation within the last 30 days.
in a semi-recumbent position minimizes the likelihood • Recent abdominal surgery with vacuum dressing
of nosocomial pneumonia. Reducing the incidence of that requires changes of patient position to either
nosocomial pneumonia leads to decrease in antibiotic gain a seal or renew the dressing.
costs and length of stay in the Intensive Care and • Severely obese patients who are unable to tolerate
hospital’. This study is widely quoted in systematic head elevation of 45.
reviews of the prevention of VAP and has resulted in • Haemodynamic instability (i.e. mean arterial
45 head of bed elevation being included in increas- pressure below 60 mmHg for more than
ingly popular ventilation care bundles (Ferrer and 30 min) refractory to colloid therapy or inotropic
Artigas, 2001; Collard et al., 2003; American Thoracic support.
Society, 2005). • Patients receiving renal replacement therapy
The second trial (Van Nieuwenhoven et al., 2006) whose body position results in insufficient flow
attempted to replicate the Drakovic study and ran- to continue therapy.
domized ventilated patients to supine position (10 • Pregnancy.
head up) or semirecumbent position (45 head up). • Spinal surgery or trauma that necessitates nurs-
Although 221 patients were randomized, the target ing the patient flat.
elevation in the treatment group was not achieved, the • Patients intubated for more than 12 h prior to
average head of bed elevation being only 28 (versus admission to ICU.
288 ª 2007 The Author. Journal Compilation ª 2007 British Association of Critical Care Nurses
Reducing the risk of ventilator-acquired pneumonia
Gastric ulceration prophylaxis • at the request of the patient or the next of kin;
Ranitidine was administered to those patients who • change in the patient’s condition, which meant
were not established on enteral feed. Those patients that they fulfilled the exclusion criteria;
ª 2007 The Author. Journal Compilation ª 2007 British Association of Critical Care Nurses 289
Reducing the risk of ventilator-acquired pneumonia
• transfer of the patient to another critical care imen brush were done in the areas most prominently
department; affected on chest radiograph or in one segment of the
• increase in ventilatory requirements requiring lower lobes in cases with diffuse infiltrates. Bronchoal-
the patient to be nursed prone to improve veolar lavage was done by instillation of three 50-mL
oxygenation; aliquots of saline, and the first aspirated portion was
• change in the patient’s position, which meant that discarded.
they were out of their randomized position for The results from this study were analysed with the
more than 6 h in 24 h. assistance of a statistician using the Minitab computer
package. The statistical hypothesis testing and estima-
Follow-up period tion procedures used from this statistical package were
In surviving patients, follow-up was continued for the chi-squared test for association and the two-sample
72 h after a study end-point had been reached. Final t-test and confidence interval.
study outcome was documented at 72 h after the study The mean results were calculated and the data
end-point had been reached. checked for normal distribution to ensure that the
Chest radiography was only interpreted as an subsequent measures of central tendency and signifi-
outcome in the follow-up period if a chest X-ray had cance test methods were mathematically valid. Where
been ordered by the physician. If there were no chest X- data was normally distributed, the mean results were
rays during this period, it was assumed that the patient calculated. Both parametric and non-parametric meth-
did not clinically require one, and thus it was unlikely ods of statistical analysis were required because the
that the patient had developed VAP (although other data comprised nominal, ordinal and interval and
outcomes were still collected). were both symmetrical and skewed.
Pneumonia was diagnosed as either clinically The controlled variable of body position was
suspected or microbiologically confirmed according analysed using the chi-squared test. This was used to
to the criteria defined by the Consensus Conference on determine whether there was any association between
Ventilator Acquired Pneumonia (Rello et al., 2001): the two nominal variables of body position and
Clinical suspicion of pneumonia: incidence of VAP. The chi-squared test was used
because the data are nominal and not of an interval/
• New and persistent infiltrates on chest radiogra-
ratio level of measurement.
phy most likely to be associated with pulmonary
infection and at least two of the following three
criteria:
• fever (temperature >383C unmasked by RESULTS
paracetamol); Data were collected over a period of 35 months from
• leucopenia or leucocytosis (white blood cell 18 April 2005 to 1 August 2005. This resulted in a sample
count <4 109/L or >12 109/L); size of 54 patients. Following randomization, 29 patients
• purulent tracheal secretions. were allocated to the 45 (treatment) group and 25
patients were allocated to the 25 (control) group.
Microbiologically confirmed pneumonia:
Patient enrolment and allocation are summarized in
• The presence of clinical suspicion of pneumonia. Figure 1. The baseline characteristics of the enrolled
• At least one pathogenic microorganism in tra- patients are listed in Table 1. There were no significant
cheobronchial aspirate, bronchoalveolar lavage or differences between the groups at randomization.
protected specimen brush, with bacterial growth
above the defined thresholds for positive cultures Incidence of VAP
of blood or pleural fluid or both. Five of the treatment group (29%) developed VAP, four
confirmed and one suspected.
Tracheobronchial aspirate was obtained without
Seven of the control group (54%) developed VAP,
prior administration of saline in a standard sputum
five confirmed and two suspected. This 25% reduction
trap (Pennine product code MST-3070). For fibre-
in the incidence of VAP did not reach statistical
optic bronchoscopic examinations (Olympus, Keymed,
significance (P = 0176).
Southend On Sea, Essex, Model no. BF IT240), patients
Of those patients that developed VAP, the diagnosis
were premedicated with propofol or midazolam (they
was made on the following days:
may already have been receiving either of these agents
as continuous sedation while being ventilated). No • day 2, one patient;.
local anaesthetics were administered, and suction was • day 3, one patient;.
avoided. Bronchoalveolar lavage and protected spec- • day 4, two patients;.
290 ª 2007 The Author. Journal Compilation ª 2007 British Association of Critical Care Nurses
Reducing the risk of ventilator-acquired pneumonia
Exclusions (15)
• No assent sought (12)
• Too unstable (3)
Randomized (56)
Figure 1 Patient enrolment and allocation. ICU, intensive care unit; VAP, ventilator-acquired pneumonia.
ª 2007 The Author. Journal Compilation ª 2007 British Association of Critical Care Nurses 291
Reducing the risk of ventilator-acquired pneumonia
APACHE, acute physiology and chronic health evaluation; NG, naso-gastric; WCC, white cell count.
Percentages in parentheses. No patient received selective digestive-tract decontamination gel.
group of seven patients who developed VAP, four died current results suggests that a study of 130 patients
(all in ICU). Thus, the ICU mortality rate of those would be required to detect a 25% reduction in VAP
patients who developed VAP was 50%, with a hospital with a power of 08 (Lenth, 2006).
mortality rate of 58%. If this study is to produce reliable outcomes, the
proportional differences in occurrence of VAP must be
shown to be because of the treatment difference that
DISCUSSION was instigated (the angle of the bed head) and not
The aim of this study was to test the hypothesis because of the confounding variables in the patient’s
that there is a reduction in VAP when ventilated premorbid state or in the treatment they received
patients are nursed with the head of the bed elevated unrelated to the study. In the case of all confounding
to 45 compared with 25. Data were collected over variables tested, there was no significant difference
a period of 35 months, resulting in a sample size of between the treatment and control groups. Therefore,
30 patients. none of the attributes discussed showed any difference
From the available data, it is clear that there are between the two groups.
numerous factors that may contribute to the occur- The limitations of sample size could have been
rence of VAP, of which failing to elevate the head of the overcome by prolonging the length of the study to
bed of the ventilated patient sufficiently may be one. capture a larger sample or by making the study
Studies of prevention of VAP are notoriously difficult multicentre. The large number of patients who were
because of the numerous confounding variables and withdrawn (14) because of less than 24 h ventilation
the difficulty in accurately defining the occurrence of also contributed to the small sample size. Nine patients
VAP. Hubmayr (2002) states that ‘There are major were withdrawn who expressed discomfort or who
limitations to the existing studies of the epidemiology wished to be nursed in positions other than those to
of ICU acquired pneumonias. Some fail to distinguish which they were randomized. When gaining assent
between nosocomial pneumonia and VAP’. This view from the relatives, they were reassured that if the
is supported by Guyatt et al. (1995) who found that ‘. patient asked for a position change to increase their
terminology and definitions may significantly affect comfort, it would be done. Thus, a significant number
the epidemiology of VAP’. of the samples was withdrawn. As this was a small
This study found a clinically relevant difference in hypothesis, generating study intention to treat analysis
VAP rates between the two groups, although this was not performed, but similar numbers were with-
difference was not statistically significant. Unfortu- drawn in the treatment and control groups.
nately, the small sample size of this study may have According to Hubmayr (2002) ‘The duration of
resulted in a type 2 error (failure to detect a difference mechanical ventilation and antibiotic exposure prior
where one exists). Lowe (1993) discussed the problems to the onset of VAP are considered the most important
of overconcern with probability values in that results, factors in the incidence, microbiology and severity’.
which might look interesting might be dismissed as These two factors were not outcome measures of this
unimportant because of a ‘statistical non-significant’ study, although it is possible from the data collected to
test of significance, which does not relate to the likely comment on the length of ventilation prior to diagno-
size of that effect. A power calculation based on the sis. The majority of those patients with VAP were
292 ª 2007 The Author. Journal Compilation ª 2007 British Association of Critical Care Nurses
Reducing the risk of ventilator-acquired pneumonia
diagnosed on day 5, i.e. approximately 120 h after may be less acceptable to the patient who is not heavily
ventilation. Thus, four patients (33%) were ventilated sedated and may hamper positioning the patient
for 120 h before developing VAP. This is supported by on their side. This was evidenced by the number of
Cook et al. (1998) who found that the risk of VAP peaks patients withdrawn/not enrolled because of difficul-
around day 5 of mechanical ventilation. ties in achieving the 45 position. Whether ventilation
Although the causative organisms were identified, was impaired by this inability to turn the patients fully
the choice of antibiotic and length of therapy were not is not demonstrated by this study and remains unclear.
discussed. Antibiotics may eradicate susceptible or-
ganisms early in a patient’s stay or encourage the
emergence of resistant organisms later in the patient’s CONCLUSIONS
stay. In systematic reviews (D’Amico et al., 1998; The findings of this pilot study do not provide sufficient
Nathens and Marshall, 1999), strategies including evidence to support changing clinical practice. How-
intravenous antibiotics showed a beneficial effect on ever, the observed trend towards a reduction in the
survival. Data on the use of systemic antibiotics alone incidence of VAP by increasing the angle of bed head
to prevent VAP are conflicting (Mendelli et al., 1989; elevation from 25 to 45 warrants further investigation.
Sirvent et al., 1997). An adequately powered study to assess the effect of
The ventilator care bundle suggests elevating the different degrees of bed head elevation on VAP rates,
patient’s bed head to greater then 30. This is a low- mortality and patient comfort is certainly required.
risk intervention that may reduce the incidence of
VAP compared with the supine position. This work
has also shown that to implement this angle of bed ACKNOWLEDGEMENTS
head elevation, constant and careful measurement is The author thanks patients and relatives of the critical
required because, as indicated by the head of bed care unit; the nurses and all the staff who were in-
survey and supported by the two studies by Grap et al. volved in the data collection on critical care at Royal
(1999, 2003), nurses overestimate the degree of bed Sussex County Hospital Brighton; Dr Steve Drage for
head elevation. help with writing for publication and Dr Martin Street
Whether 30 head elevation is sufficient to reduce the for acting as clinical supervisor and Dympna Copley
risk of VAP remains unclear. Elevation in excess of 30 for her statistical input.
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