The efficacy of an oscillating bed in the prevention of lower respiratory tract infection in critically ill victims of blunt trauma. A prospective study

The Use of a Kinetic Therapy Rotational Bed in Pediatric Acute Respiratory Distress Syndrome: A Case Series

Patients with acute respiratory distress syndrome (ARDS) commonly have dependent atelectasis and heterogeneous lung disease. Due to the heterogenous lung volumes seen, the application of positive end expiratory pressure (PEEP) can have both beneficial and deleterious effects. Alternating supine and prone positioning may be beneficial in ARDS by providing more homogenous distribution of PEEP and decreasing intrapulmonary shunt. In pediatrics, the pediatric acute lung injury and consensus conference (PALICC) recommended to consider it in severe pediatric ARDS (PARDS). Manually prone positioning patients can be burdensome in larger patients. In adults, the use of rotational beds has eased care of these patients. There is little published data about rotational bed therapy in children. Therefore, we sought to describe the use of a rotational bed in children with PARDS. We performed a retrospective case series of children who utilized a rotational bed as an adjunctive therapy for their PARDS. Patient data were collected and analyzed. Descriptive statistical analyses were performed and reported. Oxygenation indices (OI) pre- and post-prone positioning were analyzed. Twelve patients with PARDS were treated with a rotational bed with minimal adverse events. There were no complications noted. Three patients had malfunctioning of their arterial line while on the rotational bed. Oxygenation indices improved over time in 11 of the 12 patients included in the study while on the rotational bed. Rotational beds can be safely utilized in pediatric patients. In larger children with PARDS, where it may be more difficult to perform a manual prone position, use of a rotational bed can be considered a safe alternative.

[Continuous lateral rotational bed therapy in patients with traumatic lung injury: an analysis from the TraumaRegister DGU®]

BACKGROUND

Patients with severe thoracic trauma often receive continuous lateral rotational bed therapy (CLRT) for the treatment of lung contusions. In this study, the effects of CLRT on mortality, morbidity and length of stay (LOS) in the intensive care unit (ICU) and in the hospital were evaluated.

METHODS

Retrospective data from the TraumaRegister DGU® were analysed, focusing on patients with severe thoracic trauma. Patients treated with CLRT were compared to a control group with comparable trauma severity who had received conventional therapy.

RESULTS

A total of 1476 patients (239 with CLRT, 1237 without CLRT) were included in this study. Both groups were similar for demographic characteristics. The median CLRT duration was 6 (4-10) days. Patients receiving CLRT were ventilated for 17 (10-26) days compared to 14 (8-22) days (p = 0.001) in the control group. The ICU length of stay differed significantly (CLRT: 23 [14-32] days; control: 19 [13-28] days; p = 0.002). Also, organ failure occurred more frequently in patients treated with CLRT (CLRT: 76.6%, control: 67.6%; p = 0.006). No differences could be detected regarding mortality rates, multiple organ failure and hospital LOS.

CONCLUSIONS

The results of this retrospective analysis fail to detect a benefit for CLRT therapy in trauma patients. Considering inherent limitations of retrospective studies, caution should be exerted when interpreting these results. Further research is warranted to confirm these findings in a prospective trial.

Rotational therapy in thoracic injuries: what is the evidence?

PURPOSE OF REVIEW

To review the current use of continuous lateral rotational therapy (CLRT) in patients with thoracic injuries and its impact on clinical course, complications and outcome.

RECENT FINDINGS

Patient positioning is a key factor in the treatment of severe thoracic injuries and CLRT, and intermittent supine and prone position are basic options. There is a lack of randomized controlled studies for trauma patients with chest injury undergoing kinetic therapy as standard of care. A positive effect of kinetic therapy for prevention of secondary respiratory complications has been reported; nevertheless, no positive effect on mortality or length of hospital stay could be affirmed so far. In general, standardized therapeutic regimes for treatment of chest trauma have been implemented, including ventilator settings and positioning therapy. However, the available data do not allow a clear recommendation for rotational/kinetic therapy or prone positioning as superior or inferior.

SUMMARY

The benefit of changing the patients' position for secret mobilization and recruitment of atelectasis after chest trauma and therefore preventing secondary complications seems to be self-evident. Since only few studies report about the utility of CLRT in critically ill chest trauma patients, randomized controlled multicenter trials are necessary to analyze the overall benefit of such means.

Continuous lateral rotational therapy in trauma-A systematic review and meta-analysis

BACKGROUND

The purpose of this study was to evaluate the impact of continuous lateral rotational therapy (CLRT) on respiratory complications and mortality in patients suffering from trauma.

METHODS

The literature databases PubMed®/Medline® and the Cochrane Library® were systematically searched for prospective controlled trials comparing continuous lateral rotational therapy to conventional manual positioning in trauma patients.

RESULTS

A total of 8 publications (n= 422 patients) with comparable age and injury severity were included in the meta-analysis. A significant reduction in the incidence of nosocomial pneumonia (OR: 0.33, [95%CI: 0.17, 0.65], p=0.001) was observed in patients treated prophylactically with continuous lateral rotational therapy. When used with therapeutic intention, CLRT had no impact on the incidence of pneumonia. There were no significant differences in mortality, duration of mechanical ventilation, or ICU length of stay.

CONCLUSIONS

Analogous to studies evaluating CLRT in medical or mixed patient collectives, CLRT reduced the rates of nosocomial pneumonia in trauma patients. This, however, had no impact on overall mortality. The level of evidence of the studies included was limited by several factors. An adequately powered, well-designed multi-centre randomised controlled trial is required, to validly assess the utility of CLRT for the prevention and treatment of pulmonary complications in patients suffering from trauma.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.

Ventilator-Associated Pneumonia: A Review

Ventilator-associated pneumonia is the most frequent intensive care unit (ICU)-related infection in patients requiring mechanical ventilation. In contrast to other ICU-related infections, which have a low mortality rate, the mortality rate for ventilator-associated pneumonia ranges from 20% to 50%. These clinically significant infections prolong duration of mechanical ventilation and ICU length of stay, underscoring the financial burden these infections impose on the health care system. The causes of ventilator-associated pneumonia are varied and differ across different patient populations and different types of ICUs. This varied presentation underscores the need for the intensivist treating the patient with ventilator-associated pneumonia to have a clear knowledge of the ambient microbiologic flora in their ICU. Prevention of this disease process is of paramount importance and requires a multifaceted approach. Once a diagnosis of ventilator-associated pneumonia is suspected, early broad-spectrum antibiotic administration decreases morbidity and mortality and should be based on knowledge of the sensitivities of common infecting organisms in the ICU. De-escalation of therapy, once final culture results are available, is necessary to minimize development of resistant pathogens. Duration of therapy should be based on the patient’s clinical response, and every effort should be made to minimize duration of therapy, thus further minimizing the risk of resistance.

Inapparent Outbreaks of Ventilator-Associated Pneumonia An Ecologic Analysis of Prevention and Cohort Studies

Objective:

To compare ventilator-associated pneumonia (VAP) rates and patterns of isolates across studies of antibiotic and non-antibiotic methods for preventing VAP.

Design:

With the use of 42 cohort study groups as the reference standard, the prevalence of VAP was modeled in two linear regressions: one with the control groups and the other with the intervention groups of 96 VAP prevention studies. The proportion of patients admitted with trauma and the VAP diagnostic criteria were used as ecologic correlates. Also, the patterns of pathogenic isolates were available for 117 groups.

Results:

In the first regression model, the VAP rates for the control groups of antibiotic-based prevention studies were at least 18 (CI95, 12 to 24) per 100 patients higher than those in the cohort study groups (P< .001). By contrast, comparisons of cohort study groups with all other control and intervention groups in the first and second regression models yielded differences that were less than 6 per 100 and not significant (P> .05). For control groups with VAP rates greater than 35%, the patterns of VAP isolates, such as the proportion ofStaphylococcus aureus,more closely resembled those in the corresponding intervention groups than in the cohort groups.

Conclusions:

The rates of VAP in the control groups of the antibiotic prevention studies were significantly higher than expected and the patterns of pathogenic isolates were unusual. These observations suggest that inapparent outbreaks of VAP occurred in these studies. The possibility remains that antibiotic-based VAP prevention presents a major cross-infection hazard.

Lateral positioning for critically ill adult patients

BACKGROUND

Critically ill patients require regular body position changes to minimize the adverse effects of bed rest, inactivity and immobilization. However, uncertainty surrounds the effectiveness of lateral positioning for improving pulmonary gas exchange, aiding drainage of tracheobronchial secretions and preventing morbidity. In addition, it is unclear whether the perceived risk levied by respiratory and haemodynamic instability upon turning critically ill patients outweighs the respiratory benefits of side-to-side rotation. Thus, lack of certainty may contribute to variation in positioning practice and equivocal patient outcomes.

OBJECTIVES

To evaluate effects of the lateral position compared with other body positions on patient outcomes (mortality, morbidity and clinical adverse events) in critically ill adult patients. (Clinical adverse events include hypoxaemia, hypotension, low oxygen delivery and global indicators of impaired tissue oxygenation.) We examined single use of the lateral position (i.e. on the right or left side) and repeat use of the lateral position (i.e. lateral positioning) within a positioning schedule.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 5), MEDLINE (1950 to 23 May 2015), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 to 23 May 2015), the Allied and Complementary Medicine Database (AMED) (1984 to 23 May 2015), Latin American Caribbean Health Sciences Literature (LILACS) (1901 to 23 May 2015), Web of Science (1945 to 23 May 2015), Index to Theses in Great Britain and Ireland (1950 to 23 May 2015), Trove (2009 to 23 May 2015; previously Australasian Digital Theses Program (1997 to December 2008)) and Proquest Dissertations and Theses (2009 to 23 May 2015; previously Proquest Digital Dissertations (1980 to 23 May 2015)). We handsearched the reference lists of potentially relevant reports and two nursing journals.

SELECTION CRITERIA

We included randomized and quasi-randomized trials examining effects of lateral positioning in critically ill adults. We included manual or automated turns but limited eligibility to studies that included duration of body position of 10 minutes or longer. We examined each lateral position versus at least one comparator (opposite lateral position and/or another body position) for single therapy effects, and the lateral positioning schedule (repeated lateral turning) versus other positioning schedules for repetitive therapy effects.

DATA COLLECTION AND ANALYSIS

We pre-specified methods to be used for data collection, risk of bias assessment and analysis. Two independent review authors carried out each stage of selection and data extraction and settled differences in opinion by consensus, or by third party adjudication when disagreements remained unresolved. We planned analysis of pair-wise comparisons under composite time intervals with the aim of considering recommendations based on meta-analyses of studies with low risk of bias.

MAIN RESULTS

We included 24 studies of critically ill adults. No study reported mortality as an outcome of interest. Two randomized controlled trials (RCTs) examined lateral positioning for pulmonary morbidity outcomes but provided insufficient information for meta-analysis. A total of 22 randomized trials examined effects of lateral positioning (four parallel-group and 18 cross-over designs) by measuring various continuous data outcomes commonly used to detect adverse cardiopulmonary events within critical care areas. However, parallel-group studies were not comparable, and cross-over studies provided limited data as the result of unit of analysis errors. Eight studies provided some data; most of these were single studies with small effects that were imprecise. We pooled partial pressure of arterial oxygen (PaO2) as a measure to detect hypoxaemia from two small studies of participants with unilateral lung disease (n = 19). The mean difference (MD) between lateral positions (bad lung down versus good lung down) was approximately 50 mmHg (MD -49.26 mmHg, 95% confidence interval (CI) -67.33 to -31.18; P value < 0.00001). Despite a lower mean PaO2 for bad lung down, hypoxaemia (mean PaO2 < 60 mmHg) was not consistently reported. Furthermore, pooled data had methodological shortcomings with unclear risk of bias. We had similar doubts regarding internal validity for other studies included in the review.

AUTHORS' CONCLUSIONS

Review authors could provide no clinical practice recommendations based on the findings of included studies. Available research could not eliminate the uncertainty surrounding benefits and/or risks associated with lateral positioning of critically ill adult patients. Research gaps include the effectiveness of lateral positioning compared with semi recumbent positioning for mechanically ventilated patients, lateral positioning compared with prone positioning for acute respiratory distress syndrome (ARDS) and less frequent changes in body position. We recommend that future research be undertaken to address whether the routine practice of repositioning patients on their side benefits all, some or few critically ill patients.

S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders : Revision 2015: S2e guideline of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioneda revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientificrelevance the guidelines were extended to include the issue of "early mobilization"and the following main topics are therefore included: use of positioning therapy and earlymobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

Pneumonia in patients with severe head injury: incidence, risk factors, and outcomes

Object

The reported incidence of hospital-acquired bacterial pneumonia in critically ill trauma patients varies from as low as 4% to as high as 87%, with fatality rates varying from 6% to 59%. Clinical studies have identified the risk factors for pneumonia. The authors undertook this retrospective study to evaluate the incidence, risk factors, and outcomes of hospital-acquired bacterial pneumonia in a group of patients with severe head injuries.

Methods

This was a retrospective review of consecutive adult patients admitted to the neurosurgical ICU in the authors' hospital because of severe head injury (Glasgow Coma Scale scores ≤ 8) between January 2008 and December 2010.

Results

During the study period, 290 patients were admitted to the neurosurgical ICU. Multivariate Cox regression analysis showed that age (HR 1.01, 95% CI 1.001–1.02), nasogastric tube insertion (HR 4.56, 95% CI 1.11–18.64), and hemiplegia or hemiparesis (HR 3.79, 95% CI 2.01–7.17) were significantly associated with the development of pneumonia.

Conclusions

The authors identified 3 risk factors (age, nasogastric tube insertion, and hemiplegia or hemiparesis) associated with the development of pneumonia in patients with severe head injury. This finding constituted the basis for developing a simple screening tool that can be used to assess the risk of occurrence of pneumonia in such patients.

Rotational bed therapy after blunt chest trauma: a nationwide online-survey on current concepts of care in Germany

INTRODUCTION

Blunt chest injuries are amongst the most life threatening injuries in adult multiple trauma patients. Nevertheless, the treatment of these thoracic injuries has not been standardized yet. Previous publications have reported on the prevention and the treatment of respiratory complications by using continuous lateral rotational bed therapy (CLRT), but there is still a lack of information using this approach in the presence of pulmonary contusions. Therefore current literature indicates a variety of treatment protocols and its use is contended.

METHODS

We submitted a 32-item online-questionnaire to 155 hospitals participating in the nationwide TraumaNetwork to assess current treatment concepts in multiple trauma patients suffering from blunt chest trauma including lung contusions with particular focus on the use of CLRT. Overall, 21 level I, 53 level II and 81 level III trauma centres were contacted. The questionnaire was created using "interview 123 5.5.b.de ND6".

RESULTS

The overall response rate was 35.5% (55/155) and responses were received from 10 level I (47.6%), 17 level II (32.1%) and 24 level III (29.6%) trauma centres. Thirty-five of the responders (63.6%) declared to be able to perform lateral rotational bed therapy. For level I and II trauma centres more than 80% were able to apply kinetic positioning in contrast to only 50% of level III trauma centres. Although 42.9% of the participants reported on the existence of standardized treatment protocols, 57.1% failed to report a standardized operating procedure for CLRT. The annual mean number of patients per centre treated via CLRT was 15 (0-130). Treatment modalities such as PEEP and the duration of CLRT also showed great variability. Against this background three out of four centres declared an urgent need for further clinical research in the field.

CONCLUSIONS

Our data reflect the wide range of different CLRT treatment strategies performed for blunt pulmonary trauma involving lung contusions in German trauma centres. We conclude that a high-quality randomized-controlled trial is warranted to critically assess the role of CLRT in multiple trauma patients with blunt chest trauma to provide a sound basis for future clinical guidelines.

A prospective, randomized trial of continuous lateral rotation ("kinetic therapy") in patients with cardiogenic shock

BACKGROUND

Continuous lateral rotation ["Kinetic therapy" (KT)] has been shown to reduce complications and to shorten hospital stay in trauma patients. Data in non-surgical patients is inconclusive. Retrospective data suggest a beneficial effect of KT in patients with cardiogenic shock (CS) requiring ventilator therapy. KT, however, has not been tested prospectively in those patients.

METHODS

A prospective, randomized, open-label trial was performed to compare KT using oscillating beds (TryaDyne Proventa, KCI) with standard care (SC). Patients with cardiogenic shock requiring ventilator therapy for more than 24 h were included. Primary endpoint was the occurrence of hospital-acquired pneumonia. Secondary endpoints were the occurrence of pressure ulcers during the hospital stay and 1-year all-cause mortality.

RESULTS

Forty-five patients were randomized to KT, and 44 to SC. All patients required at least one inotropic agent and one vasopressor for circulatory assistance. The groups were comparable in the etiology of heart disease, in the use of revascularization procedures, the use of balloon counterpulsation, and APACHE-II score (33 ± 5 vs. 33 ± 4) and SOFA score (11 ± 1 vs. 11 ± 1) at inclusion; however, more patients in SC were subject to resuscitation before inclusion. Hospital-acquired pneumonia occurred in 10 patients in KT and 28 patients in SC (p < 0.001); pressure ulcers were seen in 10 versus 2 patients (p < 0.001). Hospital mortality tended to be lower in KT, and 1-year all-cause mortality was 41 % in KT and 66 % in SC (p = 0.028).

CONCLUSION

The use of KT reduces rates of pneumonia and pressure ulcers as compared to SC. Moreover, in this study, patients with KT had a better outcome. The study suggests that KT should be used in patients with cardiogenic shock requiring ventilator therapy for a prolonged time.

Physiotherapy in critically ill patients

Prolonged stay in Intensive Care Unit (ICU) can cause muscle weakness, physical deconditioning, recurrent symptoms, mood alterations and poor quality of life. Physiotherapy is probably the only treatment likely to increase in the short- and long-term care of the patients admitted to these units. Recovery of physical and respiratory functions, coming off mechanical ventilation, prevention of the effects of bed-rest and improvement in the health status are the clinical objectives of a physiotherapy program in medical and surgical areas. To manage these patients, integrated programs dealing with both whole-body physical therapy and pulmonary care are needed. There is still limited scientific evidence to support such a comprehensive approach to all critically ill patients; therefore we need randomised studies with solid clinical short- and long-term outcome measures.

Automated prone positioning and axial rotation in critically ill, nontrauma patients with acute respiratory distress syndrome (ARDS)

The objective of this study was to evaluate the use of kinetic therapy beds for automated prone positioning and axial rotation in critically ill nontrauma patients with acute respiratory distress syndrome (ARDS). There were 17 patients with ARDS who underwent automated prone positioning using a kinetic therapy bed. The mean age was 51 + 14 years; 12 were females and 12 were Caucasian. The most common admission diagnosis was sepsis (n = 5). The mean Acute Physiology and Chronic Health Evaluation (APACHE) 2 score was 30 + 9 with mean predicted mortality of 65% + 25%. At the time of prone positioning, all patients met the criteria for ARDS. The mean ratio of PaO2 to FIO2 (P/F ratio) before initiation of prone positioning was 89 + 33 and rose to 224 + 92 after at least 30 minutes of prone positioning (P < .0001). There was no significant change in PaCO2 or mean airway pressure. There were no instances of accidental endotracheal tube and central or peripheral venous or arterial catheter dislodgement. Eleven (65%) patients developed new pressure ulcers, 10 (59%) patients developed new skin tears, and all had conjunctival edema during the course of prone positioning. The median duration of automated prone positioning was 6 (interquartile range [IQR] 3.5-8.5) days. Eleven (65%) patients died during hospitalization and 7 required percutaneous tracheostomy for long-term ventilator support. Automated prone positioning using a kinetic therapy bed is a safe and effective means of improving oxygenation in critically ill patients with ARDS. Larger randomized studies are needed to compare it to conventional ventilation strategies, conventional prone positioning, and to assess the impact on mortality.

Pulmonary contusion: an update on recent advances in clinical management

Pulmonary contusion is a common finding after blunt chest trauma. The physiologic consequences of alveolar hemorrhage and pulmonary parenchymal destruction typically manifest themselves within hours of injury and usually resolve within approximately 7 days. Clinical symptoms, including respiratory distress with hypoxemia and hypercarbia, peak at about 72 h after injury. The timely diagnosis of pulmonary contusion requires a high degree of clinical suspicion when a patient presents with trauma caused by an appropriate mechanism of injury. The clinical diagnosis of acute parenchymal lung injury is usually confirmed by thoracic computed tomography, which is both highly sensitive in identifying pulmonary contusion and highly predictive of the need for subsequent mechanical ventilation. Management of pulmonary contusion is primarily supportive. Associated complications such as pneumonia, acute respiratory distress syndrome, and long-term pulmonary disability, however, are frequent sequelae of these injuries.

Recognition and prevention of nosocomial pneumonia in the intensive care unit and infection control in mechanical ventilation

Nosocomial pneumonia (NP) is a difficult diagnosis to establish in the critically ill patient due to the presence of underlying cardiopulmonary disorders (e.g., pulmonary contusion, acute respiratory distress syndrome, atelectasis) and the nonspecific radiographic and clinical signs associated with this infection. Additionally, the classification of NP in the intensive care unit setting has become increasingly complex, as the types of patients who develop NP become more diverse. The occurrence of NP is especially problematic as it is associated with a greater risk of hospital mortality, longer lengths of stay on mechanical ventilation and in the intensive care unit, a greater need for tracheostomy, and significantly increased medical care costs. The adverse effects of NP on healthcare outcomes has increased pressure on clinicians and healthcare systems to prevent this infection, as well as other nosocomial infections that complicate the hospital course of patients with respiratory failure. This manuscript will provide a brief overview of the current approaches for the diagnosis of NP and focus on strategies for prevention. Finally, we will provide some guidance on how standardized or protocolized care of mechanically ventilated patients can reduce the occurrence of and morbidity associated with complications like NP.

[Prophylactic ventilation of severely injured patients with thoracic trauma--does it always make sense?]

For therapy of blunt thoracic trauma in multiple injured patients, some studies have recommended prophylactic ventilation with kinetic therapy for 3-5 days. In contrast other clinics prefer to reduce the time of ventilation and to extubate as soon as possible. In this retrospective study our patient collective was investigated to find out if early extubation is linked to a higher complication rate. A total of 26 ventilated patients with severe thoracic trauma and an abbreviated injury scale score (AIS thorax) >3 were included in the study. The mean time of ventilation was 98.4 h and in patients without head injury 71.3 h. Out of 22 patients 4 had to be reintubated which had to be repeated for 2 patients. Of the patients 3 developed pneumonia but no cases of adult respiratory distress syndrome (ARDS) were observed. Of the patients 4 died due to other injuries. The mean stay on the intensive care unit was 6.3 days and the mean stay in hospital 22.6 days. Our findings indicate that even with early and aggressive weaning from a respirator with extensive lung contusions an adequate therapy of thorax trauma is possible without having a higher incidence of complications.

Reduction in the incidence of poststroke nosocomial pneumonia by using the "turn-mob" program

BACKGROUND

One of the most common complications in patients with acute ischemic stroke (AIS) is pneumonia, a complication that has an impact on the patient's survival. The purpose of this study was to establish whether the implementation of a passive turning and mobilization program can prevent the occurrence of nosocomial pneumonia (NP) in patients with AIS.

METHODS

We conducted a randomized clinical trial. Patients diagnosed with AIS within the last 48 hours and without mechanical ventilation were included. Group A was the "turn-mob" program: turning and passive mobilization carried out by a previously trained relative. Group B was the control group: standard treatment characterized by turning carried out by the nursing staff. The purpose was to demonstrate whether the implementation of a manual turning and passive mobilization program could reduce the incidence of NP in patients with AIS during their stay at the hospital and up to 14 days after discharge.

RESULTS

In all, 223 patients were included (group A, n = 111; group B, n = 112). Fourteen (12.6%) patients in group A and 30 (26.8%) in group B developed NP. The implementation of the turn-mob program was associated with a decrease in NP, with a relative risk of 0.39 (95% confidence interval .19-.79; P = .008).

CONCLUSION

The turn-mob program applied on patients during the acute phase of an ischemic stroke decreases the incidence of NP.

Continuous lateral rotation therapy to prevent ventilator-associated pneumonia

OBJECTIVE

To investigate the impact of prophylactic continuous lateral rotation therapy on the prevalence of ventilator-associated pneumonia, duration of mechanical ventilation, length of stay, and mortality in critically ill medical patients.

DESIGN

Prospective, randomized, clinical study.

SETTING

Three medical intensive care units of an university tertiary care hospital.

PATIENTS

Patients were randomized to continuous lateral rotation therapy or standard care if they were mechanically ventilated for <48 hrs and free from pneumonia. Primary study end point was development of ventilator-associated pneumonia. Ventilator-associated pneumonia was defined as infiltrate on the chest radiograph plus newly developed purulent tracheal secretion plus increasing signs of inflammation. The diagnosis had to be confirmed microbiologically and required the growth of a pathogen >10(4) colony-forming units/mL in bronchoalveolar lavage. Radiologists were blinded to randomization whereas clinical outcome assessors were not.

INTERVENTIONS

Rotation therapy was performed continuously in a specially designed bed over an arc of 90 degrees. Additional measures to prevent ventilator-associated pneumonia were equally standardized in both groups including semirecumbent position.

MEASUREMENTS AND MAIN RESULTS

Ventilator-associated pneumonia frequency during the intensive care unit stay was 11% in the rotation group and 23% in the control group (p = .048), respectively. Duration of ventilation (8 +/- 5 vs. 14 +/- 23 days, p = .02) and length of stay (25 +/- 22 days vs. 39 +/- 45 days, p = .01) were significantly shorter in the rotation group. In a forward stepwise logistic regression model including the continuous lateral rotation therapy, gender, Lung Injury Score, and Simplified Acute Physiology Score II, continuous lateral rotation therapy just failed to reach statistical significance with respect to development of ventilator-associated pneumonia (p = .08). Intolerance to continuous lateral rotation therapy during the weaning phase was observed in 29 patients (39%). Mortality was comparable in both groups.

CONCLUSIONS

Ventilator-associated pneumonia prevalence was significantly reduced by continuous lateral rotation therapy. Continuous lateral rotation therapy led to shorter ventilation time and length of stay. Continuous lateral rotation therapy should be considered in ventilated patients at risk for ventilator-associated pneumonia as a feasible method exerting additive effects to other preventive measures.

Continuous lateral rotation therapy for acute hypoxemic respiratory failure: the effect of timing

Previous studies have indicated a positive impact of continuous lateral rotational therapy on nosocomial pneumonia, but have shown mixed results in decreasing length of stay or ventilator days. The objective of the study was to determine if the use of a continuous lateral rotational therapy protocol would decrease mortality and morbidity, mean ventilator days, and/or intensive care unit and hospital length of stay in patients with a pulmonary diagnosis. The study also analyzed the effect of the lag time to the initiation of therapy. Prospectively enrolled subjects receiving continuous lateral rotational therapy based on predetermined indications were compared with retrospectively identified control subjects who met the same inclusion criteria from a similar time period in the previous year. Early initiation of continuous lateral rotational therapy resulted in significant decreases in ventilator days and intensive care unit length of stay. The therapeutic benefit of continuous lateral rotational therapy may be enhanced with early identification and treatment of appropriate patients.

Physiological rationale and current evidence for therapeutic positioning of critically ill patients

Prolonged bed rest is common in critically ill patients, and therapeutic positioning is important to prevent further complications and to improve patient outcomes. Nurses use therapeutic positioning to prevent complications of immobility. This article reviews therapeutic positions including stationary positions (supine, semirecumbent with head of bed elevation, lateral, and prone) and active repositioning (manual, continuous lateral rotation, and kinetic therapy). The physiological rationale and current evidence for each position are described. Applicable evidence-based practice guidelines are summarized. Special considerations for therapeutic positioning of critically ill obese and elderly patients are also discussed.

Clinical review: airway hygiene in the intensive care unit

Maintenance of airway secretion clearance, or airway hygiene, is important for the preservation of airway patency and the prevention of respiratory tract infection. Impaired airway clearance often prompts admission to the intensive care unit (ICU) and can be a cause and/or contributor to acute respiratory failure. Physical methods to augment airway clearance are often used in the ICU but few are substantiated by clinical data. This review focuses on the impact of oral hygiene, tracheal suctioning, bronchoscopy, mucus-controlling agents, and kinetic therapy on the incidence of hospital-acquired respiratory infections, length of stay in the hospital and the ICU, and mortality in critically ill patients. Available data are distilled into recommendations for the maintenance of airway hygiene in ICU patients.

Prone ventilation in trauma or surgical patients with acute lung injury and adult respiratory distress syndrome: is it beneficial?

BACKGROUND

To compare the effectiveness of supine versus prone kinetic therapy in mechanically ventilated trauma and surgical patients with acute lung injury (ALI) and adult respiratory distress syndrome (ARDS).

METHODS

A retrospective review of all patients with ALI/ARDS who were placed on either a supine (roto-rest) or prone (roto-prone) oscillating bed was performed. Data obtained included age, revised trauma score (RTS), base deficit, Injury Severity Score (ISS), head Abbreviated Injury Scale score (AIS), chest (AIS), PaO2/FiO2 ratio, FiO2 requirement, central venous pressure (CVP), days on the bed, ventilator days, use of pressors, complications, mortality, and pulmonary-associated mortality. Data are expressed as mean+/-SE with significance attributed to p<0.05.

RESULTS

From March 1, 2004 through May 31, 2006, 4,507 trauma patients were admitted and 221 were identified in the trauma registry as having ALI or ARDS. Of these, 53 met inclusion criteria. Additionally, 8 general surgery patients met inclusion criteria. Of these 61 patients, 44 patients were positioned supine, 13 were placed prone, and 4 patients that were initially placed supine were changed to prone positioning. There was no difference between the groups in age, CVP, ISS, RTS, base deficit, head AIS score, chest AIS score, abdominal AIS score, or probability of survival. The PaO2/FiO2 ratios were not different at study entry (149 vs. 153, p=NS), and both groups showed improvement in PaO2/FiO2 ratios. However, the prone group had better PaO2/FiO2 ratios than the supine group by day 5 (243 vs. 200, p=0.066). The prone group had fewer days on the ventilator (13.6 vs. 24.2, p=0.12), and shorter hospital lengths of stay (22 days vs. 40 days, p=0.08). There were four patients who failed to improve with supine kinetic therapy that were changed to prone kinetic therapy. These patients had significant improvements in PaO2/FiO2 ratio, and significantly lower FiO2 requirements. There were 18 deaths (7 pulmonary related) in the supine group and 1 death in the prone group (p < 0.01 by chi test).

CONCLUSIONS

ALI/ARDS patients who received prone kinetic therapy had greater improvement in PaO2/FiO2 ratio, lower mortality, and less pulmonary-related mortality than did supine positioned patients. The use of a prone-oscillating bed appears advantageous for trauma and surgical patients with ALI/ARDS and a prospective, randomized trial is warranted.

Log-rolling technique producing unacceptable motion during body position changes in patients with traumatic spinal cord injury

Object

The purpose of the present study was to compare spinal motion generated during log-rolling and kinetic therapy with that generated when using a kinetic treatment table (KTT). The authors' hypothesis was that the KTT would produce less spinal motion while maintaining the benefits of body position changes.

Methods

Cervical and lumbar instability was created in three fresh, unembalmed cadavers. Electromagnetic sensors were fixed to the C5–6 and T12–L2 segments to measure cervical and lumbar spine segmental motion. Body position changes were performed using the traditional log-roll method and a KTT. Spinal motion was measured during each maneuver.

Turning the cadaveric specimens on the KTT bed caused significantly less cervical motion than the log-roll technique as measured in flexion and axial rotation. The log-roll technique caused significantly greater cervical motion during body position changes than turning using the KTT.

Conclusions

Although the global instability will require surgical stabilization, consideration should be given to initial immobilization on a KTT to decrease the likelihood of secondary injury.

Kinetic therapy beds are associated with more complications in patients with thoracolumbar spinal column injuries

BACKGROUND AND PURPOSE

Traumatic spine injuries are an important cause of morbidity and mortality. Kinetic therapy (KT) beds were designed to minimize skin breakdown and enhance clearance of pulmonary secretions by rotating the patient from side to side. However, little evidence exists to suggest that fewer complications occur in patients with thoracolumbar spine injuries (TLSIs) treated preoperatively with a KT bed. We investigated the effect of KT bed use on infectious complications and respiratory failure in patients requiring surgery for TLSIs.

METHODS

We queried the trauma registry of a Level 1 trauma center for patients who had surgery for a TLSI from January 1, 1994, through June 30, 2001, and performed a retrospective medical record review. Patients were divided into two groups according to whether they were treated with a KT bed preoperatively. Patient data included age, injury severity score (ISS), admission Glasgow Coma Scale score (GCS), time to surgery, narcotics administered in total and during the first 24 h after injury, the lowest recorded systolic blood pressure, and acute resuscitation volume requirement. Outcome data included infectious complications, neurologic deficits, respiratory failure, hospital length of stay (LOS), and number of days of ventilator support. Infectious complications included pneumonia, urinary tract infections, and surgical site infections.

RESULTS

Patients treated with a KT bed and patients treated with a conventional bed were similar in age, ISS, admission GCS, time to surgery, total narcotics administered, lowest recorded systolic blood pressure, and resuscitation requirement during the first 24 h. However, patients with neurologic deficits were more frequently treated with a KT bed. Infectious complications were more common in patients receiving KT bed therapy than among those on conventional beds. The incidence of respiratory failure, the number of days of ventilator support, and hospital LOS also were significantly higher in patients treated with KT beds. The variables most predictive of infectious complications were the number of days of ventilator support, the amount of fluid administered during the first 24 h, and KT bed therapy (r2 = 0.459).

CONCLUSIONS

Patients with TLSIs treated with a KT bed had a higher incidence of infectious complications and respiratory failure and more days of ventilator support than patients treated with a conventional bed despite similar ISS and time to surgical repair. The longer hospital LOS in patients treated with a KT bed may be secondary to the higher incidence of infectious complications and respiratory failure and the greater number of days of ventilator support.

Ventilator-associated pneumonia and pressure ulcer prevention as targets for quality improvement in the ICU

The health care culture must change. Florence Nightingale wrote [8] "deep-rooted and universal is the conviction that to give a medicine is to be doing something, or rather everything and to give air, warmth, cleanliness etc. is to do nothing." Hygiene care practices and mobility activities are fundamental and independent care components in the nursing profession. When implemented using available evidence, they can significantly improve patient outcomes. It is time to claim and demonstrate the importance of consistent delivery of the fundamentals of basic nursing care. Interventional patient hygiene is an effective framework to ensure the the basics of nursing care are consistently applied to improve patient outcomes.

Biomechanical Analysis of Cervical and Thoracolumbar Spine Motion in Intact and Partially and Completely Unstable Cadaver Spine Models With Kinetic Bed Therapy or Traditional Log Roll

BACKGROUND

The main comorbidities associated with spinal cord injury patients are secondary to immobilization. Kinetic bed therapy is used currently to reduce the complications associated with immobilization, but the effect on the unstable spine has not been quantified. The purpose of this study was to compare the motion in the cervical and thoracolumbar spine when cadavers with spinal instabilities are log rolled (LR) on a standard hospital bed or rotated on a RotoRest kinetic treatment table (KTT).

METHODS

Cervical and lumbar instabilities were created surgically in three embalmed cadavers. An electromagnetic tracking device was used to measure the three-dimensional segmental motion generated at C5 to C6 and T12 to L2 during LR and KTT treatments.

RESULTS

In both the cervical and lumbar spine, significantly more motion was observed during LR than KTT treatment.

CONCLUSIONS

We found that in cadavers with severely unstable cervical spine, rotation using a KTT produced less flexion and lateral bending than the LR. Also, in cadavers with severely unstable lumbar spine, treatment with the KTT produced less axial rotation than the LR. Currently, we think that the best way to immobilize the spine while still allowing therapeutic motion is through the use of a KTT.

Rotational Bed Therapy to Prevent and Treat Respiratory Complications: A Review and Meta-Analysis

• Background Immobility is associated with complications involving many body systems.

• Objective To review the effect of rotational therapy (use of therapeutic surfaces that turn on their longitudinal axes) on prevention and/or treatment of respiratory complications in critically ill patients.

• Methods Published articles evaluating prophylaxis and/or treatment were reviewed. Prospective randomized controlled trials were assessed for quality and included in meta-analyses.

• Results A literature search yielded 15 nonrandomized, uncontrolled, or retrospective studies. Twenty prospective randomized controlled trials on rotational therapy were published between 1987 and 2004. Various types of beds were studied, but few details on the rotational parameters were reported. The usual control was manual turning of patients by nurses every 2 hours. One animal investigation and 12 clinical trials addressed the effectiveness of rotational therapy in preventing respiratory complications. Significant benefits were reported in the animal study and 4 of the trials. Significant benefits to patients were reported in 2 of another 4 studies focused on treatment of established complications. Researchers have examined the effects of rotational therapy on mucus transport, intrapulmonary shunt, hemodynamic effects, urine output, and intracranial pressure. Little convincing evidence is available, however, on the most effective rotation parameters (eg, degree, pause time, and amount of time per day). Meta-analysis suggests that rotational therapy decreases the incidence of pneumonia but has no effect on duration of mechanical ventilation, number of days in intensive care, or hospital mortality.

• Conclusions Rotational therapy may be useful for preventing and treating respiratory complications in selected critically ill patients receiving mechanical ventilation.

Intrapulmonary percussive ventilation in tracheostomized patients: a randomized controlled trial

OBJECTIVE

To investigate whether the addition of intrapulmonary percussive ventilation to the usual chest physiotherapy improves gas exchange and lung mechanics in tracheostomized patients.

DESIGN AND SETTING

Randomized multicenter trial in two weaning centers in northern Italy.

PATIENTS AND PARTICIPANTS

46 tracheostomized patients (age 70 +/- 7 years, 28 men, arterial blood pH 7.436 +/- 0.06, PaO(2)/FIO(2) 238 +/- 46) weaned from mechanical ventilation.

INTERVENTIONS

Patients were assigned to two treatment groups performing chest physiotherapy (control), or percussive ventilation (IMP2 Breas, Sweden) 10 min twice/day in addition to chest physiotherapy (intervention).

MEASUREMENTS AND RESULTS

Arterial blood gases, PaO(2)/FIO(2) ratio, and maximal expiratory pressure were assessed every 5th day for 15 day. Treatment complications that showed up in 1 month of follow-up were recorded. At 15 days the intervention group had a significantly better PaO(2)/FIO(2) ratio and higher maximal expiratory pressure; after follow-up this group also had a lower incidence of pneumonia.

CONCLUSIONS

The addition of percussive ventilation to the usual chest physiotherapy regimen in tracheostomized patients improves gas exchange and expiratory muscle performance and reduces the incidence of pneumonia.

Ventilator-associated pneumonia: diagnosis, treatment, and prevention

While critically ill patients experience a life-threatening illness, they commonly contract ventilator-associated pneumonia. This nosocomial infection increases morbidity and likely mortality as well as the cost of health care. This article reviews the literature with regard to diagnosis, treatment, and prevention. It provides conclusions that can be implemented in practice as well as an algorithm for the bedside clinician and also focuses on the controversies with regard to diagnostic tools and approaches, treatment plans, and prevention strategies.

Kinetic therapy reduces complications and shortens hospital stay in patients with cardiogenic shock - a retrospective analysis

BACKGROUND

Kinetic therapy (KT) has been shown to reduce complications and to shorten hospital stay in trauma patients. Data in non-surgical patients are inconclusive, and kinetic therapy has not been tested in patients with cardiogenic shock.

OBJECTIVE

The present analysis compares KT with standard care in patients with cardiogenic shock.

METHODS

A retrospective analysis of 133 patients with cardiogenic shock admitted to 1 academic heart center was performed. Patients with standard care (SC, turning every 2 h by the staff) were compared with kinetic therapy (KT, using oscillating air-flotation beds).

MEASUREMENTS AND MAIN RESULTS

68 patients with KT were compared with 65 patients with SC. Length of ventilator therapy was 11 days in KT and 18 days in SC (p=0.048). The mortality was comparable in both groups. Pneumonia occurred in 14 patients in KT and 39 patients in SC (p<0.001); pressure ulcers were reduced by 50% (p<0.001). Length of ICU stay (21 days in SC and 13 days in KT, p=0.009) and length of hospital stay were reduced in the patients treated with kinetic therapy.

CONCLUSION

The use of KT shortens hospital stay and reduces rates of pneumonia and pressure ulcers as compared to SC.

Kinetic bed therapy to prevent nosocomial pneumonia in mechanically ventilated patients: a systematic review and meta-analysis

INTRODUCTION

Nosocomial pneumonia is the most important infectious complication in patients admitted to intensive care units. Kinetic bed therapy may reduce the incidence of nosocomial pneumonia in mechanically ventilated patients. The objective of this study was to investigate whether kinetic bed therapy reduces the incidence of nosocomial pneumonia and improves outcomes in critically ill mechanically ventilated patients.

METHODS

We searched Medline, EMBASE, CINAHL, CENTRAL, and AMED for studies, as well as reviewed abstracts of conference proceedings, bibliographies of included studies and review articles and contacted the manufacturers of medical beds. Studies included were randomized or pseudo-randomized clinical trials of kinetic bed therapy compared to standard manual turning in critically ill mechanically ventilated adult patients. Two reviewers independently applied the study selection criteria and extracted data regarding study validity, type of bed used, intensity of kinetic therapy, and population under investigation. Outcomes assessed included the incidence of nosocomial pneumonia, mortality, duration of ventilation, and intensive care unit and hospital length of stay.

RESULTS

Fifteen prospective clinical trials were identified, which included a total of 1,169 participants. No trial met all the validity criteria. There was a significant reduction in the incidence of nosocomial pneumonia (pooled odds ratio (OR) 0.38, 95% confidence interval (CI) 0.28 to 0.53), but no reduction in mortality (pooled OR 0.96, 95%CI 0.66 to 1.14), duration of mechanical ventilation (pooled standardized mean difference (SMD) -0.14 days, 95%CI, -0.29 to 0.02), duration of intensive care unit stay (pooled SMD -0.064 days, 95% CI, -0.21 to 0.086) or duration of hospital stay (pooled SMD 0.05 days, 95% CI -0.18 to 0.27).

CONCLUSION

While kinetic bed therapy has been purported to reduce the incidence of nosocomial pneumonia in mechanically ventilated patients, the overall body of evidence is insufficient to support this conclusion. There appears to be a reduction in the incidence of nosocomial pneumonia, but no effect on mortality, duration of mechanical ventilation, or intensive care or hospital length of stay. Given the lack of consistent benefit and the poor methodological quality of the trials included in this analysis, definitive recommendations regarding the use of this therapy cannot be made at this time.

Prone positioning improves oxygenation in post-traumatic lung injury--a prospective randomized trial

BACKGROUND

In a prospective randomized trial the effect of prone positioning on the duration of mechanical ventilation was evaluated in multiple trauma patients and was compared with patients ventilated in supine position.

METHOD

Multiple trauma patients of the intensive care units of two university hospitals were considered eligible if they met the criteria for acute lung injury or the acute respiratory distress syndrome. Patients in the prone group (N = 21) were kept prone for at least eight hours and a maximum of 23 hours per day. Prone positioning was continued until a PaO2:FiO2 ratio of more than 300 was present in prone as well as supine position over a period of 48 hours. Patients in the supine group (N = 19) were positioned according to standard care guidelines.

RESULTS

The duration of ventilatory support did not differ significantly (30 +/- 17 days in the prone group and 33 +/- 23 days in the supine group). Worst case analysis (death and deterioration of gas exchange) displayed ventilatory support for 41 +/- 29 days in the prone group and 61 +/- 35 days in the supine group (p = 0.06). The PaO2:FiO2 ratio increased significantly more in the prone group in the first four days (p = 0.03). The prevalence of Acute Respiratory Distress Syndrome (ARDS) following acute lung injury (p = 0.03) and the prevalence of pneumonia (p = 0.048) were reduced also. One patient in the prone and three patients in the supine group died due to multi organ failure (p = 0.27).

CONCLUSIONS

Intermittent prone positioning was not able to reduce the duration of mechanical ventilation in this limited number of patients. However the oxygenation improved significantly over the first four days of treatment, and the prevalence of ARDS and pneumonia were reduced.

Early physiotherapy in the respiratory intensive care unit

Physiotherapy is an integral part of the management of patients in respiratory intensive care units (RICUs). The most important aim in this area is to enhance the overall patient's functional capacity and to restore his/her respiratory and physical independence, thus decreasing the risks of bed rest associated complications. This article is a review of evidence-based effectiveness of weaning practices and physiotherapy treatment for patients with respiratory insufficiency in a RICU. Literature searches were performed using general and specialty databases with appropriate keywords. The evidence for applying a weaning process and physiotherapy techniques in these patients has been described according to their individual rationale and efficacy. The growing number of patients treated in RICUs all over the world makes this non pharmacological approach both welcome and interesting. However, to date, there are only strong recommendations concerning the evidence-based strategies to speed weaning. Early physiotherapy may be effective in ICU: however, most techniques (postures, limb exercise and percussion/vibration in particular) need to be further studied in a large population. Evidence supporting physiotherapy intervention is limited as there are no studies examining the specific effects of interventions on long-term outcome.

Posição prona

A posição prona é uma manobra utilizada para combater a hipoxemia nos pacientes com síndrome do desconforto respiratório agudo. Apesar de hoje ser considerada um modo eficaz de melhorar a oxigenação, os mecanismos fisiológicos que levam à melhora da função respiratória ainda não estão completamente esclarecidos. O objetivo principal desta revisão é discutir os aspectos fisiológicos e clínicos da posição prona na síndrome do desconforto respiratório agudo.

Adherence to simple and effective measures reduces the incidence of ventilator-associated pneumonia

PURPOSE

Several modalities have been shown to be individually effective in reducing the incidence (and hence associated morbidity, mortality, and costs) of ventilator-associated pneumonia, but their implementation into clinical practice is inconsistent. We introduced an intensive care unit protocol and measured its effect on ventilator-associated pneumonia.

METHODS

A multidisciplinary team constructed a multifaceted protocol incorporating low risk and low cost strategies, many of which had independent advantages of their own. Some components were already in use, and their importance was emphasized to improve compliance. New strategies included elevation of the head of the bed, transpyloric enteral feeding, and antiseptic mouthwash. The approach to implementation and maintenance included education, monitoring, audits and feedback to encourage compliance with the protocol.

RESULTS

The implementation of this prevention protocol reduced the incidence of ventilator-associated pneumonia from a baseline of 94 cases per year or 26.7 per 1,000 ventilator days to 51.3 per year or 12.5 per 1,000 ventilator days, i.e., about 50% of the pre-protocol rate (P < 0.0001).

CONCLUSION

Adherence to simple and effective measures can reduce the incidence of ventilator-associated pneumonia. The protocol described was inexpensive and effective, and estimated savings are large. Implementation and maintenance of gains require a multidisciplinary approach, with buy-in from all team members, and ongoing monitoring, education, and feedback to the participants.

Kinetic therapy positively influences oxygenation in patients with ALI/ARDS

Acute respiratory distress syndrome (ARDS) is a fulminant form of respiratory failure, with diverse aetiology, despite technological advances in intensive care medicine; mortality rates remain 50-70%. Costs associated with the management of patients in intensive therapy unit (ITU) are very high; therefore, the requirement for those working in critical care to provide evidence-based practice is mandatory. One area of investigation is that kinetic therapy improves pulmonary complications in critically ill patients by positively influencing oxygenation and gaseous exchange. Whilst kinetic therapy does appear to be an effective therapy in ITU, there are inconsistencies in reported findings, and thus, clearly a need for further research into this innovative therapy to maximize its potential.

Effect Of Kinetic Therapy on Pulmonary Complications

• Background Optimal turning of critically ill patients is not well established. Kinetic therapy (systematic mechanical rotation of patients with 40° turns) may improve pulmonary function more than the improvement in function achieved via the standard of care (turning patients every 2 hours).

• Objective To determine (1) if patients receiving mechanical ventilation who tolerate kinetic therapy have better pulmonary function than do patients treated with standard turning and (2) the cost-effectiveness of kinetic therapy.

• Methods A prospective, randomized, multicenter study including 234 medical, surgical, and trauma patients (137 control patients, 97 patients receiving kinetic therapy).

• Results Kinetic therapy significantly decreased the occurrence of ventilator-associated pneumonia and lobar atelectasis. The risk of pneumonia developing was lower (P = .002) in patients receiving kinetic therapy than in the control patients. The risk of lobar atelectasis developing was decreased (P = .02) for the patients receiving kinetic therapy. Lengths of stay in the intensive care unit and in the hospital did not differ between the groups. Charges for intensive care were less in the kinetic therapy group ($81 700) than in the control group ($84 958), but not significantly less. Twenty-one patients did not tolerate kinetic therapy and were not included in the analysis.

• Conclusion Kinetic therapy helps prevent ventilator-associated pneumonia and lobar atelectasis in critically ill patients. Costs to rent the bed may be offset by the potential cost reduction associated with kinetic therapy.

Body positioning of intensive care patients: clinical practice versus standards

OBJECTIVE

The routine turning of immobilized critically ill patients at a minimum of every 2 hrs has become the accepted standard of care. There has never been an objective assessment of whether this standard is achieved routinely. To determine if immobilized patients in the intensive care unit (ICU) receive the prevailing standard of change in body position every 2 hrs. To determine prevailing attitudes about patient positioning among ICU physicians.

DESIGN

Prospective longitudinal observational study. E-mail survey of ICU physicians.

SETTING AND PARTICIPANTS

Convenience sample of mixed medical/surgical ICU patients at three tertiary care hospitals in two different cities in the United States. Random sampling of ICU professionals from a directory.

MAIN OUTCOME MEASURES

Changes in body position recorded at 15-min intervals. RESULTS Seventy-four patients were observed for a total of 566 total patient hours of observation, with a mean observation time per patient of 7.7 hrs (range, 5-12). On average, 49.3% of the observed time, patients remained without a change in body position for >2 hrs. Only two of 74 patients (2.7%) had a demonstrable change in body position every 2 hrs. A total of 80-90% of respondents to the survey agreed that turning every 2 hrs was the accepted standard and that it prevented complications, but only 57% believed it was being achieved in their ICUs.

CONCLUSIONS

The majority of critically ill patients may not be receiving the prevailing standard of changes in body position every 2 hrs. This warrants a reappraisal of our care of critically ill patients.

Methods for decreasing risk of aspiration pneumonia in critically ill patients

BACKGROUND

Pneumonia is a significant clinical concern in critically ill hospitalized patients, leading to increase in the use of antibiotics, length of hospital stay, and the risk of mortality. Pneumonia caused by aspiration of gastric contents is of particular concern in patients who need mechanical ventilation and feeding through a nasogastric tube. Therefore, methods for decreasing the risk of aspiration are very important.

METHODS

This review article summarizes factors that might influence the development of aspiration pneumonia, such as the position of the patient's body or type of hospital bed, methods of feeding, medications administered, suctioning of subglottic secretions, and bacterial decontamination.

RESULTS

Elevating the head of the bed (45 degrees), continuous subglottic suctioning, and oral decontamination seem to be effective in the prevention of aspiration pneumonia.

Effect of continuous lateral rotational therapy on the prevalence of ventilator-associated pneumonia in patients requiring long-term ventilatory care

OBJECTIVE

To evaluate the role of continuous lateral rotational therapy on the development of ventilator-associated pneumonia in patients requiring long-term mechanical ventilation.

DESIGN

Prospective control study.

SETTING

Chronic ventilator unit in tertiary care hospital.

METHODS

Thirty-seven patients requiring long-term mechanical ventilation were assigned to receive either continuous lateral rotational therapy or conventional therapy.

RESULTS

Patients receiving continuous lateral rotational therapy had a significantly lower prevalence of pneumonia (17.6%) as compared with control patients (50%, p<.05). The development of pneumonia after being entered into the study was also significantly delayed in continuous lateral rotational therapy patients, 29 +/- 8 days vs. 12 +/- 2 days in controls (p <.05). However, unit mortality, total ventilator days, and the number of patients successfully weaned were not significantly different between groups.

CONCLUSION

In patients requiring long-term ventilator care, continuous lateral rotational therapy reduced the prevalence of pneumonia but did not seem to affect mortality or the period of mechanical ventilation.