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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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“[46] 7) Avoidance of paralytic medication: Deeply sedated and relaxed patients clearly are at a higher risk of aspiration and VAP.”
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“Adjunctive measures that improve outcomes of mechanically ventilated patients include maintaining the head of the bed 30° (71), thromboprophylaxis (72), gastric ulcer prophylaxis (73), daily awakenings from sedation (74), and daily weaning (75).”
BackgroundSweeney, R. M., McAuley, D. F., & Matthay, M. A. (2011) · Seminars in Respiratory and Critical Care Medicine · doi:10.1055/s-0031-1287870 · Cited by 24
“In addition to using low Vt and low airway pressures, ventilated patients should also be positioned in a semirecumbent position to minimize the risk of ventilator-associated pneumonia.(150) The duration of MV is significantly reduced with both interrupted sedation and daily spontaneous breathing trials.”
BackgroundLuna, C. M., Monteverde, A., Rodríguez, A. H., Apezteguía, C., Zabert, G. E., Ilutovich, S., Menga, G., Vasen, W., Díez, A. R., & Mera, J. (2005) · Archivos de Bronconeumología · doi:10.1157/13077956 · Cited by 22
Prevention of ventilator-associated pneumonia
Hong Kong East Cluster Task Force on Prevention of Ventilator-associated Pneumonia in Critical Care Areas, Lau, A. C., So, H., Tang, S., Yeung, A. W., Lam, S., & Yan, W. (2015) · Hong Kong Medical Journal · doi:10.12809/hkmj144367 · Cited by 22
Mycobacterium avium complex pulmonary disease: new epidemiology and management concepts
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Hypoxia and Complications of Oxygenation in Extracorporeal Membrane Oxygenation
Alexis-Ruiz, A., Ghadimi, K., Raiten, J. M., MacKay, E. J., Laudanski, K., Cannon, J. W., Ramakrishna, H., Evans, A. S., Augoustides, J. G., Vallabhajosyula, P., et al. (2018) · Journal of Cardiothoracic and Vascular Anesthesia · doi:10.1053/j.jvca.2018.05.028 · Cited by 22
Nseir, S., Gouge, A. L., Lascarrou, J.-B., Lachérade, J.-C., Jaillette, E., Mira, J. P., Mercier, E., Declercq, P.-L., Sirodot, M., Piton, G., et al. (2019) · Critical Care · doi:10.1186/s13054-019-2403-z · Cited by 22
Clinical estimation of trunk position among mechanically ventilated patients
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Treatment of Aspiration in Intensive Care Unit Patients
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Treatment of pneumonia in elderly patients
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“[47] in intubated patients; the authors found that supine position and enteral feeding were independent risk factors for nosocomial pneumonia.”
BackgroundNutrition in intensive care: give enough but choose the route wisely?
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Nutrition in the Critically Ill Patient: Part III. Enteral Nutrition
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Dollars and sense in the intensive care unit: The costs of ventilator-associated pneumonia *
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RISK FACTORS FOR NOSOCOMIAL PNEUMONIA
Fleming, C. A., Balaguera, H. U., & Craven, D. E. (2001) · Medical Clinics of North America · doi:10.1016/s0025-7125(05)70395-3 · Cited by 46
Tufegdzic, B., Lamperti, M., Siyam, A. M., & Röser, F. (2021) · Clinical Neurology and Neurosurgery · doi:10.1016/j.clineuro.2021.106904 · Cited by 21
Jayaram, R. H., Joo, P. Y., Gouzoulis, M. J., Ratnasamy, P. P., Caruana, D. L., & Grauer, J. N. (2023) · Spine · doi:10.1097/brs.0000000000004754 · Cited by 21
Causes of death in mucopolysaccharidoses
Rintz, E., Banacki, M., Ziemian, M., Kobus, B., & Węgrzyn, G. (2024) · Molecular Genetics and Metabolism · doi:10.1016/j.ymgme.2024.108507 · Cited by 23
Prevalence and associated factors of pneumonia in patients with vegetative state in Taiwan
Lin, L., Hsieh, P.-C., & Wu, S. (2007) · Journal of Clinical Nursing · doi:10.1111/j.1365-2702.2006.01883.x · Cited by 21
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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