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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 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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Lacerna, C., Patey, D., Block, L., Naik, S., Kevorkova, Y., Galin, J., Parker, M., Betts, R., Parodi, S. M., & Witt, D. J. (2020) · Infection Control and Hospital Epidemiology · doi:10.1017/ice.2019.368 · Cited by 35
Vidotto, M. C., Sogame, L. C., Gazzotti, M. R., Prandini, M. N., & Jardim, J. R. (2011) · Brazilian Journal of Medical and Biological Research · doi:10.1590/s0100-879x2011007500146 · Cited by 32
Quality and safety in intensive care—A means to an end is critical
Conroy, K. M., Elliott, D., & Burrell, A. R. (2010) · Australian Critical Care · doi:10.1016/j.aucc.2009.12.001 · Cited by 32
Spooner, A. J., Corley, A., Sharpe, N. A., Barnett, A. G., Caruana, L. R., Hammond, N. E., & Fraser, J. F. (2014) · Respiratory Care · doi:10.4187/respcare.02733 · Cited by 32
Intra-Abdominal Hypertension and the Abdominal Compartment Syndrome
Ball, C., & Kirkpatrick, A. (2007) · Scandinavian Journal of Surgery · doi:10.1177/145749690709600303 · Cited by 12
Thomas, P., Paratz, J. D., Stanton, W. R., Deans, R., & Lipman, J. (2006) · Australian Critical Care · doi:10.1016/s1036-7314(06)80025-1 · Cited by 33
Ventilator-associated pneumonia: recent issues on pathogenesis, prevention and diagnosis
Koeman, M., van der Ven, A. J. A. M., Ramsay, G., Hoepelman, I. M., & Bonten, M. J. M. (2001) · Journal of Hospital Infection · doi:10.1053/jhin.2001.1073 · Cited by 32
Nosocomial pneumonia: epidemiology, pathogenesis, diagnosis, treatment and prevention
Lode, H. M., Raffenberg, M., Erbes, R., Geerdes-Fenge, H. F., & Mauch, H. (2000) · Current Opinion in Infectious Diseases · doi:10.1097/00001432-200008000-00009 · Cited by 32
What is Evidence-Based Medicine and Why Should it be Practiced?
Montori, V. M., & Guyatt, G. H. (2001) · Respiratory Care · doi:10.1177/002013240104601103 · Cited by 32
Krinko (2007) · Robert-Koch-Institut (RKI) · doi:10.25646/157 · Cited by 32
Nosocomial pneumonia in non-invasive ventilation patients: incidence, characteristics, and outcomes
Zhang, Z., & Duan, J. (2015) · Journal of Hospital Infection · doi:10.1016/j.jhin.2015.06.016 · Cited by 31
“Orozco-Levi et al. reported that an oesophageal balloon can be a useful tool to reduce aspiration of gastric contents, and this may be an appropriate choice for the prevention of nosocomial pneumonia in NIV patients.19 Another method to reduce the chance of aspiration is to keep the patient in a semi-reclining positio…”
MethodInfluentialWilliams, Z., Chan, R. K., & Kelly, E. (2008) · Critical Care Medicine · doi:10.1097/ccm.0b013e318168fa59 · Cited by 31
“(7) performed a randomized trial assessing the frequency of clinically suspected and microbiologically confirmed nosocomial pneumonia in semirecumbent vs.”
BackgroundLippoldt, J., Pernicka, E., & Staudinger, T. (2014) · American Journal of Critical Care · doi:10.4037/ajcc2014670 · Cited by 31
Wolken, R., Woodruff, R. J., Smith, J., Albert, R. K., & Douglas, I. S. (2011) · Respiratory Care · doi:10.4187/respcare.01453 · Cited by 31
Schallom, M. E., Dykeman, B., Metheny, N. A., Kirby, J., & Pierce, J. D. (2014) · American Journal of Critical Care · doi:10.4037/ajcc2015781 · Cited by 31
Su, K., Kou, Y. R., Lin, F.-C., Wu, C.-H., Feng, J., Huang, S., Shiung, T.-F., Chung, K.-C., Tung, Y.-H., Yang, K., et al. (2017) · PLoS ONE · doi:10.1371/journal.pone.0182252 · Cited by 31
Long-Term Complications of Tracheal Intubation
Touman, A., & Stratakos, G. K. (2018) · InTech eBooks · doi:10.5772/intechopen.74160 · Cited by 31
“Positioning the patient in semirecumbent position: decrease the risk of VAP from 35 to 8% comparing to supine position [44].”
BackgroundAirway clearance therapy in acute paediatric respiratory illness: A state-of-the-art review
Morrow, B. M. (2019) · South African Journal of Physiotherapy · doi:10.4102/sajp.v75i1.1295 · Cited by 31
“…above closing capacity and thereby preventing airway closure) and oxygenation, and may protect against ventilator-associated pneumonia in the paediatric intensive care unit (PICU) context (Dellagrammaticas et al. 1991:429–432; Drakulovic et al. 1999:1851–1858; Nunn 1993; Stark et al. 1984:64–71).”
Background
Metadata
- 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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