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Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: A randomized study*

van Nieuwenhoven, Christianne A. MD; Vandenbroucke-Grauls, Christine PhD; van Tiel, Frank H. PhD; Joore, Hans C. A. MD; van Schijndel, Rob J. M. Strack MD; van der Tweel, Ingeborg PhD; Ramsay, Graham PhD; Bonten, Marc J. M. PhD

doi: 10.1097/01.CCM.0000198529.76602.5E
Clinical Investigations

Context: Reducing aspiration of gastric contents by placing mechanically ventilated patients in a semirecumbent position has been associated with lower incidences of ventilator-associated pneumonia (VAP). The feasibility and efficacy of this intervention in a larger patient population, however, are unknown.

Objective: Assessment of the feasibility of the semirecumbent position for intensive care unit patients and its influence on development of VAP.

Design: In a prospective multicentered trial, critically ill patients undergoing mechanical ventilation were randomly assigned to the semirecumbent position, with a target backrest elevation of 45°, or standard care (i.e., supine position) with a backrest elevation of 10°.

Main Outcome Measures: Backrest elevation was measured continuously during the first week of ventilation with a monitor-linked device. A deviation of position was defined as a change of the randomized position >5°. Diagnosis of VAP was made by quantitative cultures of samples obtained by bronchoscopic techniques.

Results: One hundred nine patients were assigned to the supine group and 112 to the semirecumbent group. Baseline characteristics were comparable for both groups. Average elevations were 9.8° and 16.1° at day 1 and day 7, respectively, for the supine group and 28.1° and 22.6° at day 1 and day 7, respectively, for the semirecumbent group (p < .001). The target semirecumbent position of 45° was not achieved for 85% of the study time, and these patients more frequently changed position than supine-positioned patients. VAP was diagnosed in eight patients (6.5%) in the supine group and in 13 (10.7%) in the semirecumbent group (NS), after a mean of 6 (range, 3–9) and 7 (range, 3–12) days, respectively. There were no differences in numbers of patients undergoing enteral feeding, receiving stress ulcer prophylaxis, or developing pressure sores or in mortality rates or duration of ventilation and intensive care unit stay between the groups.

Conclusions: The targeted backrest elevation of 45° for semirecumbent positioning was not reached in the conditions of the present randomized study. The achieved difference in treatment position (28° vs. 10°) did not prevent the development of VAP.

From the University Hospital Maastricht, Department of Intensive Care Medicine (CavN, GR; present affiliation of CavN: Medical Center Leeuwarden, Department of Plastic Surgery), Maastricht; Vrije Universiteit Medical Center Amsterdam, Department of Medical Microbiology (CV-G), Amsterdam; University Hospital Maastricht, Department of Medical Microbiology (FHvT), Maastricht; University Medical Center Utrecht, Department of Internal Medicine and Dermatology, Division of Acute Internal Medicine and Infectious Diseases (HCAJ, MJMB), Utrecht; Vrije Universiteit Medical Center Amsterdam, Department of Intensive Care Medicine (RJMSvS), Amsterdam; Center for Biostatistics, Utrecht University (IvdT), Utrecht, The Netherlands.

Supported in part by a grant from the Praevention Foundation (28–2125–2).

None of the authors have a commercial association or financial involvement that might pose a conflict of interest in connection with this article.

Address requests for reprints to: Marc J. M. Bonten, MD, PhD, Department of Medicine and Dermatology, Division of Acute Internal Medicine & Infectious Diseases, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands. E-mail:

© 2006 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins