An evidence-based recommendation on bed head elevation for mechanically ventilated patients

Abstract

IntroductionA semi-upright position in ventilated patients is recommended to prevent ventilator-associated pneumonia (VAP) and is one of the components in the Ventilator Bundle of the Institute for Health Care Improvement. This recommendation, however, is not an evidence-based one.MethodsA systematic review on the benefits and disadvantages of semi-upright position in ventilated patients was done according to PRISMA guidelines. Then a European expert panel developed a recommendation based on the results of the systematic review and considerations beyond the scientific evidence in a three-round electronic Delphi procedure.ResultsThree trials (337 patients) were included in the review. The results showed that it was uncertain whether a 45° bed head elevation was effective or harmful with regard to the occurrence of clinically suspected VAP, microbiologically confirmed VAP, decubitus and mortality, and that it was unknown whether 45° elevation for 24 hours a day increased the risk for thromboembolism or hemodynamic instability. A group of 22 experts recommended elevating the head of the bed of mechanically ventilated patients to a 20 to 45° position and preferably to a ≥30° position as long as it does not pose risks or conflicts with other nursing tasks, medical interventions or patients' wishes.ConclusionsAlthough the review failed to prove clinical benefits of bed head elevation, experts prefer this position in ventilated patients. They made clear that the position of a ventilated patient in bed depended on many determinants. Therefore, given the scientific uncertainty about the benefits and harms of a semi-upright position, this position could only be recommended as the preferred position with the necessary restrictions.

The Vexing Problem of Ventilator-Associated Pneumonia: Observations on Pathophysiology, Public Policy, and Clinical Science

“…Interestingly, there was no difference in the actual head-of-bed elevation within each treatment arm that could distinguish those who developed VAP from those who did not. A previous systematic review 113 and meta-analysis 114 of 3 clinical trials of subject positioning and VAP came to opposite conclusions. The former found the evidence inconclusive whether semirecumbent positioning at 45°head-of-bed elevation is either effective or harmful, whereas the latter stressed that positioning subjects at 15-30°head-ofbed elevation was ineffective, but positioning at 45°re-duced clinically diagnosed VAP.…”

Head-of-Bed Elevation in Critically Ill Patients: A Review

“…45 One aspect considered in the panel's deliberations was the paucity of data to support the use of a 45º HOB elevation for a sustained period. 45 The authors questioned whether a 45º HOB elevation for 24 hours a day might increase the risk for thrombo embolism, hemodynamic instability, and pressure ulcers.…”

Anaesthesiology and intensive care Possibilities of modification of risk factors for ventilator-associated pneumonia (VAP) in cardiac surgery patients

“…In order to reduce the risk of gastric aspiration, the patient should be maintained in a semirecumbent position, with the chest and head raised (30-45°); a flat dorsal position should be avoided [1,4,9,13,30]. According to the literature, VAP is 3 times more likely to occur in patients lying in a flat dorsal position than in those placed in a semirecumbent position [31].…”