Grade B Recommendation
The use of the semirecumbent position to reduce ventilator associated pneumonia.
This review may be edited
Author info
Posted By: Gordon S. Doig
E-Mail: gdoig@med.usyd.edu.au
Posted Date: 24 Jan 2003
Title: The use of the semirecumbent position to reduce ventilator associated pneumonia.
PubMed Resource Link: Click here to repeat the Medline search used to develop this EBR.
 
Evidence-based Recommendation
Best level of evidence
Level II randomized controlled trial.
Target Population
All mechanically ventilated patients at high risk of gastric reflux and subsequent nosocomial pneumonia.
Purpose
To reduce the rate of clinically suspected nosocomial pneumonia by approximately 20%.
  • 5 ventilated patients would have to be nursed in the semirecumbnet position to prevent one clinically suspected case of VAP.
  • Exclusion criteria
  • abdominal surgery within the last 7 days
  • neurosurgical intervention within the last 7 days
  • documented or suspected cervical spine instability
  • shock refractory to vasoactive drugs or volume (fluid) therapy
  • Recommendation
    Whenever possible, mechanically ventilated patients should be nursed in the semirecumbent position (45degrees head-up aka 'reverse trendelenburg','split the bed in the middle and sit them up') at all times. Special consideration for the use of the semirecumbent position should be given to patients at high risk of nosocomial pneumonia, which includes:
  • patients receiving continuous enteral feeding through a nasogastric tube,
  • patients who are comatose at ICU admission and,
  • patients who are intubated and consequtively require mechanical ventilation for 7 days or more.
    A water filled cushion should be placed under the sacral region to minimize pressure.
  • Potential harm
    Concerns about decubitus ulcers should be addressed by risk stratifying patients on the basis of factors such as illness severity, fecal incontinence and duration of ICU stay such that patients at high risk of ulcers can be positioned accordingly and interventions to prevent pressure ulcers can be employed.
    Development Information
    Date EBR last updated
    18 Jan 2006
    Literature source and search terms
    PubMed was searched from 1966 to 24 Jan 2003. The Therapy Clinical Queries filter, with emphasis placed on a Sensitive search, was used. This resulted in the following search statement:
    ((semirecumbency OR posture) AND (aspiration pneumonia OR gastroesophageal reflux)) AND (randomized controlled trial [PTYP] OR drug therapy [SH] OR therapeutic use [SH:NOEXP] OR random* [WORD])
    Study selection
    132 abstracts were retrieved and hand searched for randomized controlled trials reporting ventilator associated pneumonia as an outcome. Cross-over trials reporting reductions in gastroesophageal reflux were considered to provide pathophysiological rationale.
    References
  • Supine position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet 1999;354:1851-58.(Level II)
  • Toward understanding evidence uptake: Semirecumbency for pneumonia prevention. Crit Care Med 2002;30:1472-1477.
  • Semirecumbent position protects from pulmonary aspiration but not completely from gastroesophageal reflux in mechanically ventilated patients, Am J Respir Crit Care Med 1995;152:1387-1390.
  • Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: The effect of body position. Ann Intern Med 1992;116:540-543.
  • Gastroesophageal reflux in intubated patients receiving enteral nutrition: Effect of supine and semirecumbent positions. J Parenter Enteral Nutr 1992;16:419-422.

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    Page last modified on June 6, 2002
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