A semi-upright position in ventilated patients is recommended to prevent ventilator-associated pneumonia (VAP) and is one of the components in the ventilator bundle recommended by the Institute for Healthcare Improvement (IHI). This recommendation, however, is not an evidence-based one, asserts Barbara Niel-Weise of Leiden University Medical Center in Leiden, Germany, and members of the Bed Head Elevation Study Group.
The researchers conducted a systematic review on the benefits and disadvantages of semi-upright position in ventilated patients 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.
Three trials (337 patients) were included in the review. The researchers report that the results showed that it was uncertain whether a 45-degree bed head elevation was effective or harmful with regard to the occurrence of clinically suspected ventilator-associated pneumonia (VAP), microbiologically confirmed VAP, decubitus and mortality, and that it was unknown whether 45 degrees 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-degree to 45-degree position and preferably in a [greater than or equal to] 30-degree position as long as it does not pose risks or conflicts with other nursing tasks, medical interventions or patients' wishes.
Although 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, the researchers say this position could only be recommended as the preferred position with the necessary restrictions. Their research was published in Critical Care.
Reference: Niel-Weise BS, Gastmeier P, Kola A, Vonberg RP, Wille JC and van den Broek PJ. An evidence-based recommendation on bed head elevation for mechanically ventilated patients. Critical Care 2011, 15:R111doi:10.1186/cc10135