A group of 22 experts in intensive care medicine from 11 European countries recommends elevating the head of the bed for mechanically ventilated patients to a 20 to 45° position and preferably to a ≥30° position as long as it does not pose risks or conflicts with other nursing tasks, medical interventions or patients' wishes. This recommendation was based on the results of a systematic review conducted by a Dutch-German review group and the considerations brought up by the European expert panel.
Three of the 22 experts disagreed with the recommendation and its rationale. One expert was of the opinion that no recommendation should be given because of the low quality of evidence and the lack of data on potential adverse effects and feasibility. The other two experts had some additional comments on the rationale that would, however, not have substantially changed the recommendation.
The systematic review showed that it is uncertain whether a 45° bed head elevation is effective or harmful with regard to the occurrence of clinically suspected VAP, microbiologically confirmed VAP, decubitus and mortality, and that it is unknown whether a 45° bed head elevation for 24 hours a day causes thromboembolism or hemodynamic instability. In the trial by van Nieuwenhoven and colleagues, the target elevation of 45° could not be reached [20
]. Grap and colleagues in 2005 also found that the mean backrest elevation was consistently lower than the recommended 30 to 45° [21
]. They found an average backrest elevation of merely 21.7° in ventilated patients [6
]. Because the desirable position for ventilated patients depends on nursing tasks, medical interventions and patients' wishes, maintaining a certain elevation for 24 hours a day is not feasible. The RCTs and the inclusion of bed head elevation in the ventilator bundle suggest to the relative outsider that a horizontal position is the standard in ventilated patients and that changing the position to a semi-upright position requires great changes in intensive care. The consultation with experienced physicians in intensive care medicine learned that some bed head elevation is common for most patients, suggesting that the trials used artificial controls. No trial will be able to replicate exact clinical practice and vice versa
. Furthermore, modern ICUs are so complex that investigating bed head elevations in all ventilated patients or extrapolating the results to all ventilated patients is not possible. Perhaps researchers should not want to investigate bed head elevation policies at all. In any case, future research should be limited to specific ICU subgroups.
In 2009 a meta-analysis was published on the impact of patient position on the incidence of VAP [22
]. This meta-analysis found that a 45° position significantly lowers the incidence of clinically diagnosed VAP compared with supine patients. Their conclusion is different from our conclusion. The main reasons are that in the previous meta-analysis the benefits and harms of a 45° position were not addressed; the overall quality of evidence by considering the items study quality and execution, inconsistency, indirectness, imprecision and publication bias were not assessed; and in their calculations of clinically diagnosed VAP, the authors pooled the data for clinically suspected VAP [8
] with those for overall VAP [19
]. We recalculated the overall incidence of VAP (clinically suspected VAP plus microbiologically confirmed VAP) using a random-effects model and did not find a significantly lower incidence of clinically diagnosed VAP.
The Ventilator Bundle of the Institute for Health Care Improvement is a series of five interventions related to ventilator care that, when implemented together, will achieve significantly better outcomes than each single intervention. Bed head elevation is one of the above components. Only patients with all five elements of the ventilator bundle in place are recorded as complying with the ventilator bundle. We would expect that bundles contain only interventions that could always be executed and that were strongly recommended. The European expert group found that the evidence was too weak, however, and that there were too many disadvantages of semi-upright positioning to formulate a strong recommendation. As such, we question whether compliance with the VAP bundle should depend on the adherence to this single item.
It is conceivable that the selected participants were not representative for all experts in intensive care medicine, but the question is whether this is desirable. In our opinion the selected participants had to be representative for the mean expert in VAP prevention. We do not see arguments that this would not be the case.
It is important to have a large expert group when going from evidence to recommendation, because the spread of answers to some questions was very diverse. Our expert group could have been a bit smaller, because we received too many of the same types of answers.