Nutrition Support Blog: Get Ready to be Turned on Your Head
April 4, 2013
A number of studies have reported that backrest elevation (semi-recumbent position) during enteral feeding decreases aspiration and pneumonia in ICU patients, especially in those receiving enteral nutrition. Although it is clear that backrest elevation is safer than supine position, there is no robust data about what degree of backrest elevation is adequate.1-2 Most guidelines recommend backrest elevation to 30-45 degrees to help decrease ventilator-associated pneumonia (VAP), but several studies have reported that there are chronic problems with maintaining compliance with goals for backrest elevation.1-2 We routinely observe the position of our patients, and work with the primary team and nurse to optimize patient position where possible. However, there is some developing research that may end up turning our traditional ideas about ideal patient position (and our patients) on their head.
Several researchers have investigated the possibility that a lateral or head-down position (lateral Trendelenburg) in intubated patients, with the ETT/trachea below the horizontal plane may be superior to supine position.3-5 Although it may seem alarmingly counter-intuitive to invert our patients to prevent VAP, the fact is that the upright position allows nonsterile oropharyngeal secretions to accumulate above the ETT cuff, with eventual penetration into the airway. The theory is that lateral Trendelenburg position may allow better drainage of pulmonary secretions.2 However, at present the only data about lateral slight-Trendelenberg position are from animal studies, a small short-term study in infants, and a pilot/feasibility trial in adults.3-5
While we would need much more data before routinely positioning all of our patients in a lateral slight-Trendelenberg position (and a more succinct name or good acronym), it is time to start thinking about incorporating nutrition issues and ideal feeding tube position into the research as it develops. There is currently a randomized, multi-center study of lateral Trendelenburg positioning on VAP incidence that is recruiting patients, so I expect we will be hearing more about this topic in the future (see link below). At least now you won’t panic if you walk into your ICU someday and see your patients being fed “upside down.”
1. O'Grady NP, Murray PR, Ames N. Preventing ventilator-associated pneumonia: does the evidence support the practice? JAMA 2012;307(23):2534-2539.
2. Li Bassi G, Torres A. Ventilator-associated pneumonia: role of positioning. Curr Opin Crit Care 2011;17(1):57-63.
3. Panigada M, Berra L, Greco G, et al. Bacterial colonization of the respiratory tract following tracheal intubation-effect of gravity: an experimental study. Crit Care Med 2003;31:729–737.
4. Aly H, Badawy M, El-Kholy A, Nabil R, Mohamed A. Randomized, controlled trial on tracheal colonization of ventilated infants: can gravity prevent ventilator-associated pneumonia? Pediatrics 2008;122(4):770-774.
5. Mauri T, Berra L, Kumwilaisak K, et al. Lateral-horizontal patient position and horizontal orientation of the endotracheal tube to prevent aspiration in adult surgical intensive care unit patients: a feasibility study. Respir Care 2010;55(3):294-302.
“The mind that opens to a new idea never returns to its original size.”
― Albert Einstein