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

Abstract

Introduction: 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 of the Institute for Health Care Improvement. This recommendation, however, is not an evidence-based one.

Methods: A 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.

Results: Three 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.

Conclusions: 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, this position could only be recommended as the preferred position with the necessary restrictions.

Figures

Figure 1

Summary estimates of associations between treatment and control groups: clinically suspected ventilator-associated pneumonia. 1GRADE Working Group grades of evidence: high quality, further research is very unlikely to change confidence in the estimate of effect; moderate quality, further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate; low quality, further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate; very low quality, the estimate effect is very uncertain. CI, confidence interval; M-H, Mantel Haenszel test; VAP, ventilator-associated pneumonia.

Figure 2

Summary estimates of associations between treatment and control group: microbiologically confirmed ventilator-associated pneumonia. 1GRADE Working Group grades of evidence: high quality, further research is very unlikely to change confidence in the estimate of effect; moderate quality, further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate; low quality, further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate; very low quality, the estimate effect is very uncertain. CI, confidence interval; M-H, Mantel Haenszel test; VAP, ventilator-associated pneumonia.

Figure 3

Summary estimates of associations between treatment and control group: ICU mortality. 1GRADE Working Group grades of evidence: high quality, further research is very unlikely to change confidence in the estimate of effect; moderate quality, further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate; low quality, further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate; very low quality, the estimate effect is very uncertain. CI, confidence interval; M-H, Mantel Haenszel test.

Figure 4

Summary estimates of associations between treatment and control group: pressure sores. 1GRADE Working Group grades of evidence: high quality, further research is very unlikely to change confidence in the estimate of effect; moderate quality, further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate; low quality, further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate; very low quality, the estimate effect is very uncertain. CI, confidence interval; M-H, Mantel Haenszel test.