Effect of Backrest Elevation on the Development of Ventilator-Associated Pneumonia

Abstract

• Background Ventilator-associated pneumonia is a common complication of mechanical ventilation. Backrest position and time spent supine are critical risk factors for aspiration, increasing the risk for pneumonia. Empirical evidence of the effect of backrest positions on the incidence of ventilator-associated pneumonia, especially during mechanical ventilation over time, is limited. • Objective To describe the relationship between backrest elevation and development of ventilator-associated pneumonia. • Methods A nonexperimental, longitudinal, descriptive design was used. The Clinical Pulmonary Infection Score was used to determine ventilator-associated pneumonia. Backrest elevation was measured continuously with a transducer system. Data were obtained from laboratory results and medical records from the start of mechanical ventilation up to 7 days. • Results Sixty-six subjects were monitored (276 patient days). Mean backrest elevation for the entire study period was 21.7°. Backrest elevations were less than 30° 72% of the time and less than 10° 39% of the time. The mean Clinical Pulmonary Infection Score increased but not significantly, and backrest elevation had no direct effect on mean scores. A model for predicting the Clinical Pulmonary Infection Score at day 4 included baseline score, percentage of time spent at less than 30° on study day 1, and score on the Acute Physiology and Chronic Health Evaluation II, explaining 81% of the variability (F=7.31, P=.003). • Conclusions Subjects spent the majority of the time at backrest elevations less than 30°. Only the combination of early, low backrest elevation and severity of illness affected the incidence of ventilator-associated pneumonia.

A prospective observational study of ICU patient position and frequency of turning

“…Standardised orders and provider education may help increase the percentage of patients who are placed in this position [31]. A study using a transducer system to monitor backrest elevation in 66 patients over 276 days found that backrest elevation was < 30° for 72% of the time and < 10° for 39% of the time [32]. VAP was more likely to develop in patients who were more severely ill and who spent longer with backrest elevations < 30° during the first 24 h after intubation.…”

Using Evidence-Based Practice to Prevent Ventilator-Associated Pneumonia

“…Grap et al 17 conducted a descriptive study of 66 patients treated with mechanical ventilation in a medical ICU to determine the relationship between backrest elevation and the development of VAP. Data were obtained from laboratory results and medical records from the start of mechanical ventilation up to day 7 of mechanical ventilation.…”

“…22 In addition, dental plaque can provide an environment for respiratory pathogens such as methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa. 17 Results from a meta-analysis 23 of 11 trials that included 3242 patients receiving mechanical ventilation who were treated with oral application of antibiotics or antiseptics or with placebo or standard oral care alone indicated that the incidence of VAP was significantly reduced by use of oral antiseptics, such as chlorhexidine (relative risk, 0.56; 95% CI, 0.39-0.81), but not by oral applications of antibiotics (relative risk, 0.69; 95% CI, 0.41-1.18). In a study of 66 patients treated with mechanical ventilation, Munro et al 24 examined the relationship between VAP, oral health status (a baseline count of decayed, missing, and filled teeth; an assessment of the oral cavity; culture of an oral specimen; measurement of salivary volume; and salivary levels of the immune components immunoglobulin A and lactoferrin), changes in oral health status during the first 7 days after intubation, and microbial colonization of the oropharynx and trachea.…”

“…Bundle modified because increasing mouth care to every 2 hours can decrease development of ventilatorassociated pneumonia 12,17,24 Alarms added to alert staff if the head of the bed is elevated less than 30°1 6,17…”

Infection Control and the Prevention of Nosocomial Infections in the Intensive Care Unit

“…89 Backrest elevation reduces risk of gastroesophageal reflux and aspiration 90,91 and risk of VAP. 92,93 However, backrest elevation has been underutilized. [94][95][96][97] Although patient positioning is a nursing activity, a written physician order for backrest elevation may increase time spent at 30 to 45 degrees.…”