Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial
Abstract
Background Risk factors for nosocomial pneumonia, such as gastro-oesophageal reflux and subsequent aspiration, can be reduced by semirecumbent body position in intensive-care patients. The objective of this study was to assess whether the incidence of nosocomial pneumonia can also be reduced by this measure.Methods This trial was stopped after the planned interim analysis. 86 intubated and mechanically ventilated patients of one medical and one respiratory intensive-care unit at a tertiary-care university hospital were randomly assigned to semirecumbent (n=39) or supine (n=47) body position. The frequency of clinically suspected and microbiologically confirmed nosocomial pneumonia (clinical plus quantitative bacteriological criteria) was assessed in both groups. Body position was analysed together with known risk factors for nosocomial pneumonia.Findings The frequency of clinically suspected nosocomial pneumonia was lower in the semirecumbent group than in the supine group (three of 39 [8%] vs 16 of 47 [34%]; 95% CI for difference 10.0-42.0, p=0.003). This was also true for microbiologically confirmed pneumonia (semirecumbent 2/39 [5%] vs supine 11/47 [23%]; 4.2-31.8, p=0.018). Supine body position (odds ratio 6.8 [1.7-26.7], p=0.006) and enteral nutrition (5.7 [1.5-22.8], p=0.013) were independent risk factors for nosocomial pneumonia and the frequency was highest for patients receiving enteral nutrition in the supine body position (14/28, 50%). Mechanical ventilation for 7 days or more (10.9 [3.0-40.4], p=0.001) and a Glasgow coma scale score of less than 9 were additional risk factors.Interpretation The semirecumbent body position reduces frequency and risk of nosocomial pneumonia, especially in patients who receive enteral nutrition. The risk of nosocomial pneumonia is increased by long-duration mechanical ventilation and decreased consciousness.
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Raising the head of the patient's bed decreases immigration to the lungs of gastric microbiota compared with supine positioning, but this practice also compromises microbial elimination from the lungs.
“Raising of the head of the patient’s bed decreases immigration to the lungs of gastric microbiota compared with supine positioning,149 but this practice also compromises microbial elimination from the lungs”
From The microbiome and critical illness (2016) · cites this paper as [149]
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“This finding likely has clinical significance and has been identified as a useful cut-point by other investigators (9, 21).”
ResultPrevention of hospital-associated pneumonia and ventilator-associated pneumonia
Kollef, M. H. (2004) · Critical Care Medicine · doi:10.1097/01.ccm.0000128569.09113.fb · Cited by 356 · see citing works
“One randomized trial demonstrated a three-fold reduction in the incidence of VAP and a trend toward a reduced hospital mortality rate in patients treated in the semirecumbent position (maintained at 45°) compared with patients treated completely supine (78).”
ResultGI Complications in Patients Receiving Mechanical Ventilation
Mutlu, G. M., Mutlu, E., & Factor, P. H. (2001) · CHEST Journal · doi:10.1378/chest.119.4.1222 · Cited by 360 · see citing works
Why we should be wary of single-center trials
Bellomo, R., Warrillow, S. J., & Reade, M. C. (2009) · Critical Care Medicine · doi:10.1097/ccm.0b013e3181bc7bd5 · Cited by 357 · see citing works
“In a single-center, randomized, controlled study of ventilator-associated pneumonia (1), placing patients in a semirecumbent position (45° vs.”
BackgroundDysphagia in acute stroke: incidence, burden and impact on clinical outcome
Arnold, M., Liesirova, K., Broeg-Morvay, A., Meisterernst, J., Schlager, M., Mono, M.-L., El-Koussy, M., Kägi, G., Jung, S., & Sarikaya, H. (2016) · PLOS ONE · doi:10.1371/journal.pone.0148424 · Cited by 398 · see citing works
Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals
Coffin, S. E., Klompas, M., Classen, D. C., Arias, K. M., Podgorny, K., Anderson, D. J., Burstin, H. R., Calfee, D. P., Dubberke, E. R., Fraser, V. J., et al. (2008) · Infection Control and Hospital Epidemiology · doi:10.1086/591062 · Cited by 337 · see citing works
“Maintain patients in a semirecumbent position (30 -45 elevation of the head of the bed) unless there are contraindications.(28,50,52,53,57,65,72-76) (a) Experimental trials have demonstrated that backrest elevation is associated with a reduced risk of pulmonary aspiration.”
BackgroundVentilator-associated pneumonia
Members of the Task Force:, Bouza, E., Brun‐Buisson, C., Chastre, J. E., Ewig, S., Fagon, J.-Y., Marquette, C., Muñóz, P., Niederman, M. S., Papazian, L., et al. (2001) · European Respiratory Journal · doi:10.1183/09031936.01.17510340 · Cited by 337 · see citing works
“Moreover, the effect of semi-recumbent position on a reduction of VAP has been demonstrated [70].”
Improving patient safety in intensive care units in Michigan
Pronovost, P. J., Berenholtz, S. M., Goeschel, C. A., Thom, I., Watson, S. R., Holzmueller, C. G., Lyon, J. S., Lubomski, L. H., Thompson, D. A., Needham, D. M., et al. (2008) · Journal of Critical Care · doi:10.1016/j.jcrc.2007.09.002 · Cited by 326 · see citing works
“The ventilator bundle included 5 practices known to decrease morbidity, mortality, or duration of ventilator support that are associated with mechanical ventilation [31]: (1) elevate the head of the bed to at least 30°; (2) provide appropriate sedation—patient able to follow simple commands [32]; (3) provide appropria…”
BackgroundMasterton, R. G., Galloway, A., French, G. L., Street, M. K., Armstrong, J., Brown, E. A., Cleverley, J., Dilworth, P., Fry, C., Gascoigne, A. D., et al. (2008) · Journal of Antimicrobial Chemotherapy · doi:10.1093/jac/dkn162 · Cited by 321 · see citing works
Heyland, D. K., Drover, J., MacDonald, S., Novak, F. J., & Lam, M. (2001) · Critical Care Medicine · doi:10.1097/00003246-200108000-00001 · Cited by 312 · see citing works
“Furthermore, in a randomized trial of mechanically ventilated patients, elevating the head of the bed to 45° was associated with a significant reduction in pneumonia (both clinically and bronchoscopically diagnosed) compared with for patients treated in the supine position (31).”
ResultVentilator-Associated Pneumonia in Neonatal and Pediatric Intensive Care Unit Patients
Foglia, E. E., Meier, M. D., & Elward, A. M. (2007) · Clinical Microbiology Reviews · doi:10.1128/cmr.00041-06 · Cited by 314 · see citing works
Muscedere, J., Rewa, O., Mckechnie, K., Jiang, X., Laporta, D., & Heyland, D. K. (2011) · Critical Care Medicine · doi:10.1097/ccm.0b013e318218a4d9 · Cited by 311 · see citing works
“Strategies that aim to reduce the quantity of bacteria aspirated are semirecumbency positioning (32) and those that reduce the inoculums of bacteria in aspirated secretions, such as decontamination of the oral cavity with chlorhexidine (33) or selective decontamination of the digestive tract (34).”
BackgroundAspiration pneumonia: A review of modern trends
DiBardino, D. M., & Wunderink, R. G. (2014) · Journal of Critical Care · doi:10.1016/j.jcrc.2014.07.011 · Cited by 304 · see citing works
“Aspiration rates not only were higher in patients who were supine but were dependent on how much time was spent in the supine position [127].”
BackgroundPrevention of Ventilator-Associated Pneumonia: An Evidence-Based Systematic Review
Collard, H. R., Saint, S. K., & Matthay, M. A. (2003) · Annals of Internal Medicine · doi:10.7326/0003-4819-138-6-200303180-00015 · Cited by 302 · see citing works
“The third trial found a statistically significant reduction in ventilatorassociated pneumonia (14).”
BackgroundInfluentialDefining, treating and preventing hospital acquired pneumonia: European perspective
Torres, A., Ewig, S., Lode, H., Carlet, J. M., & For The European HAP working group (2008) · Intensive Care Medicine · doi:10.1007/s00134-008-1336-9 · Cited by 298 · see citing works
“Recently, a large body of evidence has shown that patient positioning is crucial in the development of VAP [181, 182].”
BackgroundEffect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia*
Zack, J. E., Garrison, T., Trovillion, E., Clinkscale, D., Coopersmith, C. M., Fraser, V. J., & Kollef, M. H. (2002) · Critical Care Medicine · doi:10.1097/00003246-200211000-00001 · Cited by 297 · see citing works
“These studies suggest that prevention of this nosocomial infection could improve patient outcomes as also suggested by studies of specific interventions aimed at avoiding risk factors associated with ventilator-associated pneumonia (29, 30).”
BackgroundHeyland, D., Schroter‐Noppe, D., Drover, J., Jain, M., Keefe, L., Dhaliwal, R., & Day, A. G. (2003) · Journal of Parenteral and Enteral Nutrition · doi:10.1177/014860710302700174 · Cited by 297 · see citing works
Mechanical Ventilator Weaning Protocols Driven by Nonphysician Health-Care Professionals
Ely, E. W., Meade, M. O., Haponik, E. F., Kollef, M. H., Cook, D. J., Guyatt, G. H., & Stoller, J. K. (2001) · CHEST Journal · doi:10.1378/chest.120.6_suppl.454s · Cited by 288 · see citing works
Muscedere, J., Dodek, P., Keenan, S., Fowler, R. A., Cook, D., & Heyland, D. K. (2008) · Journal of Critical Care · doi:10.1016/j.jcrc.2007.11.014 · Cited by 288 · see citing works
“Semirecumbent positioning On the basis of 1 level 1 [82] and 1 level 2 trial [83], we conclude that semirecumbent positioning may be associated with a decreased incidence of VAP.”
BackgroundGive your patient a fast hug (at least) once a day*
Vincent, J. (2005) · Critical Care Medicine · doi:10.1097/01.ccm.0000165962.16682.46 · Cited by 278 · see citing works
“Several studies have demonstrated that having the head of the bed inclined at 45 degrees can decrease the incidence of gastroesophageal reflux in mechanically ventilated patients (43, 44), and one randomized, controlled study demonstrated reduced rates of nosocomial pneumonia when patients were nursed semirecumbent (4…”
BackgroundRotstein, C., Evans, G. A., Born, A., Grossman, R. F., Light, R. B., Magder, S. A., McTaggart, B., Weiss, K., & Zhanel, G. G. (2007) · Canadian Journal of Infectious Diseases and Medical Microbiology · doi:10.1155/2008/593289 · Cited by 283 · see citing works
“9) and Glasgow Coma Scale scores of less than 9 (128).”
BackgroundBarbier, F., Andremont, A., Wolff, M., & Bouadma, L. (2013) · Current Opinion in Pulmonary Medicine · doi:10.1097/mcp.0b013e32835f27be · Cited by 281 · see citing works
Barriers to providing lung-protective ventilation to patients with acute lung injury
Rubenfeld, G. D., Cooper, C., Carter, G. L., Thompson, B., & Hudson, L. D. (2004) · Critical Care Medicine · doi:10.1097/01.ccm.0000127266.39560.96 · Cited by 273 · see citing works
Shander, A., Fleisher, L. A., Barie, P. S., Bigatello, L. M., Sladen, R. N., & Watson, C. B. (2011) · Critical Care Medicine · doi:10.1097/ccm.0b013e31821f0522 · Cited by 272 · see citing works
“It may also decrease the incidence of VAP (110).”
BackgroundJain, M. (2006) · BMJ Quality & Safety · doi:10.1136/qshc.2005.016576 · Cited by 270 · see citing works
ICU-Acquired Swallowing Disorders
Macht, M., Wimbish, T., Bodine, C., & Moss, M. (2013) · Critical Care Medicine · doi:10.1097/ccm.0b013e31829caf33 · Cited by 260 · see citing works
“Additionally, supine bed position and frequent gastroesophageal reflux in mechanically ventilated patients have been demonstrated to increase the risk for nosocomial pneumonia (62, 74, 75).”
BackgroundVentilator associated pneumonia
Hunter, J. D. (2012) · BMJ · doi:10.1136/bmj.e3325 · Cited by 260 · see citing works
Plotting basic control charts: tutorial notes for healthcare practitioners
Mohammed, M. A., Worthington, P. L., & Woodall, W. H. (2008) · BMJ Quality & Safety · doi:10.1136/qshc.2004.012047 · Cited by 242 · see citing works
Risk Factors for Ventilator‐Associated Pneumonia: From Epidemiology to Patient Management
Bonten, M. J. M., Kollef, M. H., & Hall, J. B. (2004) · Clinical Infectious Diseases · doi:10.1086/383039 · Cited by 238 · see citing works
“with patients who were treated while completely supine [31].”
BackgroundChest physiotherapy for the prevention of ventilator-associated pneumonia
Ntoumenopoulos, G., Presneill, J., McElholum, M., & Cade, J. F. (2002) · Intensive Care Medicine · doi:10.1007/s00134-002-1342-2 · Cited by 234 · see citing works
“Many risk factors have been associated with VAP, including the presence of chronic obstructive airway disease, airway intubation, reduced conscious state, intracranial pressure monitoring, airway re-intubation, mechanical ventilation greater than 7 days, use of positive end-expiratory pressure, and supine patient posi…”
BackgroundInfluentialReducing ventilator-associated pneumonia in intensive care: Impact of implementing a care bundle*
Morris, A. C., Hay, A. W., Swann, D. G., Everingham, K., McCulloch, C., McNulty, J., Brooks, O., Laurenson, I. F., Cook, B., & Walsh, T. S. (2011) · Critical Care Medicine · doi:10.1097/ccm.0b013e3182227d52 · Cited by 232 · see citing works
“Several clinical interventions have been found to reduce the incidence of VAP, including elevation of the head of the bed (4, 5), a daily sedation break (6), a daily trial of ventilator weaning (7, 8), and topical oral chlorhexidine (9).”
BackgroundAn Educational Intervention to Reduce Ventilator-Associated Pneumonia in an Integrated Health System
Babcock, H. M., Zack, J. E., Garrison, T., Trovillion, E., Jones, M., Fraser, V. J., & Kollef, M. H. (2004) · CHEST Journal · doi:10.1378/chest.125.6.2224 · Cited by 227 · see citing works
Oral Care Reduces Incidence of Ventilator-Associated Pneumonia in ICU Populations
Mori, H., Hirasawa, H., Oda, S., Shiga, H., Matsuda, K., & Nakamura, M. (2005) · Intensive Care Medicine · doi:10.1007/s00134-005-0014-4 · Cited by 225 · see citing works
“Although the methods used for patient management in the present study were basically unchanged during the 8-year study period, some of the various methods for VAP prevention published during that period (semi-recumbent patient positioning, use of an endotracheal tube with a suction port for subglottic secretion draina…”
MethodMelsen, W. G., Rovers, M. M., Koeman, M., & Bonten, M. J. M. (2011) · Critical Care Medicine · doi:10.1097/ccm.0b013e3182281f33 · Cited by 210 · see citing works
Wafaisade, A., Lefering, R. L., Bouillon, B., Sakka, S. G., Thamm, O. C., Paffrath, T., Neugebauer, E. A. M., & Maegele, M. (2011) · Critical Care Medicine · doi:10.1097/ccm.0b013e318206d3df · Cited by 205 · see citing works
“, with respect to mechanical ventilation (21, 22) and weaning (23, 24).”
BackgroundEdsberg, L. E., Langemo, D. K., Baharestani, M. M., Posthauer, M. E., & Goldberg, M. (2014) · Journal of Wound Ostomy and Continence Nursing · doi:10.1097/won.0000000000000050 · Cited by 203 · see citing works
Insights into Severe Sepsis in Older Patients: From Epidemiology to Evidence-Based Management
Girard, T. D., Opal, S. M., & Ely, E. W. (2005) · Clinical Infectious Diseases · doi:10.1086/427876 · Cited by 197 · see citing works
“the risk of ventilator-associated pneumonia (grade C) [50].”
BackgroundValencia, M., Ferrer, M., Farré, R., Navajas, D., Badia, J. R., Nicolás, J. M., & Torres, A. (2007) · Critical Care Medicine · doi:10.1097/01.ccm.0000266686.95843.7d · Cited by 196 · see citing works
“97 Chronic alcohol abuse (current or former), n (%) 11 (15) 10 (15) .”
BackgroundInfluentialStrategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update
Klompas, M., Branson, R. D., Eichenwald, E. C., Greene, L. R., Howell, M. D., Lee, G. M., Magill, S. S., Maragakis, L. L., Priebe, G. P., Speck, K. A., et al. (2014) · Infection Control and Hospital Epidemiology · doi:10.1017/s0899823x00193894 · Cited by 194 · see citing works
“Elevating the head of the bed has been evaluated in only 3 randomized controlled trials enrolling 337 patients altogether.(84)"(86) One trial reported a 76% decrease in VAP rates, whereas the other 2 found no difference in VAP rates.”
Heyland, D. K., Drover, J., Dhaliwal, R., & Greenwood, J. K. (2002) · Journal of Parenteral and Enteral Nutrition · doi:10.1177/014860710202600608 · Cited by 185 · see citing works
Mechanical Ventilation in ARDS
Girard, T. D., & Bernard, G. R. (2007) · CHEST Journal · doi:10.1378/chest.06-1515 · Cited by 180 · see citing works
Booth, C. M., Heyland, D. K., & Paterson, W. G. (2002) · Critical Care Medicine · doi:10.1097/00003246-200207000-00005 · Cited by 180 · see citing works
“Strategies that can reduce the amount of duodenogastric reflux, gastric colonization, gastroesophageal regurgitation, and pulmonary aspiration, such as raising the head of the bed, have the potential for reducing the burden of illness associated with nosocomial pneumonia (68).”
BackgroundManzano, F., Fernández‐Mondejar, E., Colmenero, M., Poyatos, M. E., Rivera-Fernández, R., Machado, J., Catalán, I., & Artigas, A. (2008) · Critical Care Medicine · doi:10.1097/ccm.0b013e31817b8a92 · Cited by 179 · see citing works
“Other authors reported that a simple and effective maneuver to reduce pneumonia incidence, such as oral decontamination or semirecumbent position, had no effect on the length of time on mechanical ventilation or in the ICU (33, 34).”
BackgroundInfluentialO’Brien, J. M., Ali, N. A., Aberegg, S. K., & Abraham, E. H. (2007) · The American Journal of Medicine · doi:10.1016/j.amjmed.2007.01.035 · Cited by 179 · see citing works
Recommendations for sepsis management in resource-limited settings
Dünser, M. W., Festic, E., Dondorp, A., Kissoon, N., Ganbat, T., Kwizera, A., Haniffa, R., Baker, T., Schultz, M. J., & Global Intensive Care Working Group of the European Society of Intensive Care Medicine (2012) · Intensive Care Medicine · doi:10.1007/s00134-012-2468-5 · Cited by 176 · see citing works
“acquired pneumonia, particularly when mental state is impaired or enteral nutrition administered [51, 52].”
BackgroundDysphagia: Foundation, theory and practice
Cichero, J. A. Y., & Murdoch, B. E. (2006) · Cited by 175 · see citing works
Management of pneumonia in critically ill patients
Cillóniz, C., Torres, A., & Niederman, M. S. (2021) · BMJ · doi:10.1136/bmj-2021-065871 · Cited by 184 · see citing works
Associations Between Ventilator Bundle Components and Outcomes
Klompas, M., Li, L., KLEINMAN, K. P., Szumita, P. M., & Massaro, A. F. (2016) · JAMA Internal Medicine · doi:10.1001/jamainternmed.2016.2427 · Cited by 170 · see citing works
Wang, L., Li, X., Yang, Z., Tang, X., Yuan, Q., Deng, L., & Sun, X. (2016) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd009946.pub2 · Cited by 166 · see citing works
Evidence on measures for the prevention of ventilator-associated pneumonia
Lorente, L., Blot, S. I., & Rello, J. (2007) · European Respiratory Journal · doi:10.1183/09031936.00048507 · Cited by 165 · see citing works
Catastrophic Antiphospholipid Syndrome
Vora, S. K., Asherson, R. A., & Erkan, D. (2006) · Journal of Intensive Care Medicine · doi:10.1177/0885066606287041 · Cited by 165 · see citing works
“Mechanically ventilated patients with CAPS should be positioned with the head of the bed at 45° to reduce the incidence of ventilator-associated pneumonia [60].”
Outcomes Associated With Enteral Tube Feedings in a Medical Intensive Care Unit
Elpern, E. H., Stutz, L., Peterson, S. J., Gurka, D. P., & Skipper, A. (2004) · American Journal of Critical Care · doi:10.4037/ajcc2004.13.3.221 · Cited by 162 · see citing works
“Although aspiration increased when patients were supine, the length of time a patient was kept in this position was critical in determining risk.(17)”
BackgroundBundles to prevent ventilator-associated pneumonia: how valuable are they?
Wip, C., & Napolitano, L. M. (2009) · Current Opinion in Infectious Diseases · doi:10.1097/qco.0b013e3283295e7b · Cited by 160 · see citing works
Toward understanding evidence uptake: Semirecumbency for pneumonia prevention
Cook, D. J., Meade, M. O., Hand, L. E., & McMullin, J. P. (2002) · Critical Care Medicine · doi:10.1097/00003246-200207000-00012 · Cited by 159 · see citing works
“A recent randomized trial showed that mechanically ventilated patients cared for in the semirecumbent position had lower rates of clinically suspected and microbiologically confirmed pneumonia than patients in the supine position (9).”
BackgroundVentilator-Associated Pneumonia: A Review
Davis, K. A. (2006) · Journal of Intensive Care Medicine · doi:10.1177/0885066606288837 · Cited by 153 · see citing works
Ventilator Associated Pneumonia: Evolving Definitions and Preventive Strategies
Mietto, C., Pinciroli, R., Patel, N. G., & Berra, L. M. (2013) · Respiratory Care · doi:10.4187/respcare.02380 · Cited by 155 · see citing works
“Am J Respir Crit Care Med 1996;154(1):111-115.”
Pathophysiology of the systemic inflammatory response after major accidental trauma
Brøchner, A. C., & Toft, P. (2009) · Scandinavian Journal of Trauma Resuscitation and Emergency Medicine · doi:10.1186/1757-7241-17-43 · Cited by 154 · see citing works
“The benefit of postponing reconstructive surgery therefore has to be balanced against these risks [62,63].”
Strategies for Prevention of Health Care–Associated Infections in the NICU
Polin, R. A., Denson, S. E., Brady, M. T., Papile, L. A., Baley, J. E., Carlo, W. A., Cummings, J. J., Kumar, P., Tan, R. C., Watterberg, K. L., et al. (2012) · PEDIATRICS · doi:10.1542/peds.2012-0145 · Cited by 154 · see citing works
Oral Care Practices for Orally Intubated Critically Ill Adults
Feider, L. L., Mitchell, P. H., & Bridges, E. J. (2010) · American Journal of Critical Care · doi:10.4037/ajcc2010816 · Cited by 154 · see citing works
- Authors
- Drakulovic, M. B., Torres, A., Bauer, T. T., Nicolas, J. M., Nogué, S., & Ferrer, M.
- Affiliations
- Hospital Clínic de Barcelona (ES)
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 1999-11
- Volume
- 354
- Issue
- 9193
- Pages
- 1851-1858
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- OpenAlex
- W2143385226
- Cited by
- 1,243
- References
- 37
- Citations by year
- 2026: 15 · 2025: 13 · 2024: 19 · 2023: 19 · 2022: 22 · 2021: 20 · 2020: 19 · 2019: 20 · 2018: 25 · 2017: 44 · 2016: 40 · 2015: 50 · 2014: 60 · 2013: 58 · 2012: 61
- FWCI
- 31.48
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Lancet (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Nosocomial Infections in ICU
- Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Intensive Care Unit Cognitive Disorders
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Respiratory Support and Mechanisms
- Keywords
- nosocomial pneumonia, semi-recumbent position, mechanical ventilation, intensive care unit patients, enteral nutrition, risk factors, mechanical ventilation duration, Glasgow Coma Scale
- MeSH terms
- Aged, Analysis of Variance, Cross Infection, Enteral Nutrition, Female, Humans, Intensive Care Units, Male, Middle Aged, Pneumonia, Aspiration, Posture, Respiration, Artificial, Risk Factors, Spain, Time Factors, Incidence, Logistic Models, Odds Ratio, Supine Position, Hospital Mortality
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