Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients

Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial.

Drakulovic MB, Torres A, Bauer TT, et al.                                                                                                                   Lancet 1999; 354:1851-8

Respiratory Intensive Care Unit, Servei de Pneumologia i Al.lergia Respiratoria, Hospital Clinic, Universitat de Barcelona, Spain.

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.