EFFECT OF SEMI-RECUMBENT BODY POSITION ON REDUCING OF VENTILATOR ASSOCIATED PNEUMONIA IN ICU PATIENTS 主講者 : 張藖鏸 指導者 : 周幸生 副主任 時 間 : 101 年 12 月 19 日

BACKGROUND Ventilator-associated pneumonia (VAP) as defined as : Pneumonia develops more than 48 to 72 hours after endotracheal intubation with ventilator (ATS/IDSA,2005; National Institutes of Health, 2007 ) The most common one of the nosocomial infections, is important cause of morbidity and mortality in ICU ventilated critically ill patients ( Ashraf & Ostrosky- Zeichner, 2012; Gursel & Demirtas,2006 ） VAP ratio ranged from 10-25%, mortality of VAP 20% - 65% (Tejerina,2006,Trouillet 2012) VAP is increased utilization of healthcare resources, and excess cost. (Bird et al., 2010; Ramirez, Bassi, & Torres, 2012; Roberts & Moule, 2011)

BACKGROUND Pathogenesis of ventilator-associated pneumonia The Gastro-oesophageal reflux (GOR) and bronchoaspiration of gastric contentn into the lower airway Bacterial colonization of the aerodigestive tract might be one of the important origins causing VAP more aspiration of gastric contents in supine patients than in patients in a semicumbent 45° position (Torres,1995., Orozco-Levi et al ,.Zhang,2004))

BACKGROUND The semi-recumbent 45 ° position for ventilated patients has been promoted to prevent VAP (Drakulovic et al.,1999). The published guidelines recommend: Maintain patients in a semirecumbent position (30° ‐ 45°elevation of the head of the bed) unless there are contraindications especially when patients are receiving continuous eternal feeding through a nasogastric tube. (American Association of Critical Care Nurses, 2005; American Thoracic Society, 2005; Dodek et al., 2004; Tablen et al.,2004,CDC, 2010)

BACKGROUND Recently studies limitation These recommendations are not based on the findings of a systematic review This intervention is underused in clinical practices The compliance rate for semirecumbent positioning is poor and difficult to be achieved (Van Nieuwenhoven et al Rose, Baldwin, Crawford, & Parke, 2010) A feasibility of a 45°backrest position in the ‘real life’ of today’s ICUs is debated ? (Combes,2006). limited evidence to recommend the lowest orientation of the bed at which the patient can be safely maintained.

REVIEW QUESTION should bed head elevation be higher than standard practice on reducing VAP rate? how the degree of bed head elevation does more good than harm ?

OBJECTIVES : summarize the evidence of the benefits and disadvantages of semi-upright positioning in ventilated patients by a systematic review of the literature The aim of this review is to identify the effectiveness of semi-recumbent body position on reduce of ventilator associated pneumonia in intensive care unit patients

METHODS Criteria for considering studies for this review: Types of participants Types of interventions Types of outcome measures Types of studies

CategoriesInclusionexclusion ParticipantsAny age,critically ill patients with ventilator in icu Home therapy, community care or pulmonary rehabilitation in the extubation period Interventions head of bed elevation Backrest elevation semi-recumbent position semi-upright position Questionnaires Survey comparison comparing the semi-recumbent position to other positions. nil Outcome Primary outcome clinically suspected VAP microbiologically confirmed VAP Secondary outcome: outcome definitions used and present sufficient data nil Type of studiesrandomized control trial or quasi-randomized trial, language restriction on English and Chinese Single case studies, Individual opinions and editorials Thesis other quantitative research designs such as observation,before and after studies, cohort studies and case series/case. reports will be considered for inclusion in a narrative summary SELECTION CRITERIA

SEARCH STRATEGY By electronic searched in PubMed, Ovide- Medline CINAHL, JBI and Cochrane Library, CEPS (from 1995 to November 2012) Search terms including : head of bed elevation or Backrest elevation or semi-recumbent body postion or semi-upright position and VAP Furthermore, reviewed the lists of references, practice guidelines on this subject previously published by the Centers for Disease Control and Prevention and the American Thoracic Society, and Taiwan National Institutes of Health were checked for more trials. Two reviewers assessed all titles and abstracts independently to confirm the eligibility of the selected trials.

PubMed N=14 FLOW DIAGRAM OF THE REVIEWED STUDY Total Potentially relevant articles identified N=56 Articles excluded at the criteria N=49 Included paper for further evaluation N= 7 Articles excluded at the appraisal of paper N=2 RCTs is included our meta-analysis N= 3 (4-5) Medline Ovide N=25 Cochrane Library N=9 CINAHL N=7 CEPS N=1

METHODS OF REVIEW Critical Appraisal Quantitative All included in the literature will be assessed trial quality by two independent reviewers critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI,). Any disagreements that arise between the reviewers will be resolved through discussion

StudyYESNOUnclearnot Applicate 1.Was the assignment to treatment groups truly random? 2.Were participants blinded to treatment allocation? 3.Was allocation to treatment groups concealed from the allocator? 4.Were the outcomes of people who withdrew described and included in the analysis? 5.Were those assessing outcomes blind to the treatment allocation? 6.Were the control and treatment groups comparable at entry? 7.Were the groups treated identically other than for the named interventions? 8.Were outcomes measured in the same way for all groups? 9.Were outcomes measured in a reliable way? 10.Was appropriate statistical analysis used? Overall appraisal: Include ___ Exclude ___ Seek further info. ____ Comments (including reasons for exclusio JBI CRITICAL APPRAISAL CHECKLIST FOR RANDOMISED AND PSEUDO- RANDOMISED STUDIES

DATA EXTRACTION Quantitative data will be of extraction from all eligible articles in the review using the standardized data extraction tool from JBI- MAStARI Setting, year of publication, Characteristics of study population, number of patients enrolled Description of main intervention,Treatment and control groups position compared of patients Primary outcome : Confirmation of VAP diagnosis..\..\Data extraction.doc

DATA COLLECTION AND ANALYSIS Quantitative research study results will be pooled in statistical meta-analysis form Meta analysis, by Review manager software from the Cochrane Collaboration (Review manager V5.2). All results will be double entered. categorical data - Odds ratio continuous data- weighted mean differences Their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square.

Figure: summary estimates of associtation between treatment and control groups : clinically suspected ventilator associated pneumonia

To be continue ……….. Data extraction Data collection and analysis Data review to commence and to complete should bed head elevation be higher than standard Reduce vap rate ? Thanks for your attention attention