Effect of kinetic therapy on pulmonary complications. Effect of air-supported, continuous, postural oscillation on the risk of early ICU pneumonia in nontraumatic critical illness. Evidence-Based Clinical Practice Guideline for the Prevention of Ventilator-Associated Pneumonia Continuous oscillation therapy for the treatment of pulmonary contusion. Use of the kinetic treatment table to prevent the pulmonary complications of multiple trauma. Kinetic therapy in critically ill trauma patients. Continuous oscillation: outcome in critically ill patients. Effects of continuous lateral rotation therapy on pulmonary complications in liver transplant patients. Effect of continuous lateral rotational therapy on the prevalence of ventilator-associated pneumonia in patients requiring long-term ventilatory care* Colonization and infection in surgical intensive care patients —a prospective study Prevention of ventilator-associated pneumonia: current practice in Canadian intensive care units. The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. The Canadian Critical Trials Group. Incidence of and Risk Factors for Ventilator-Associated Pneumonia in Critically Ill Patients Effectiveness of the kinetic treatment table for preventing and treating pulmonary complications in severely head-injured patients. Effect of continuous lateral rotational therapy on lung mucus transport in mechanically ventilated patients. Effect of a rotating bed on the incidence of pulmonary complications in critically ill patients. The efficacy of an oscillating bed in the prevention of lower respiratory tract infection in critically ill victims of blunt trauma. A prospective study.
BACKGROUND Optimal turning of critically ill patients is not well established . Kinetic therapy ( systematic mechanical rotation of patients with 40 degree turns ) may improve pulmonary function more than the improvement in function achieved via the st and ard 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 st and ard turning  and ( 2 ) the cost-effectiveness of kinetic therapy . METHODS A prospect i ve , r and omized , 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 dollars ) than in the control group ( 84,958 dollars ) , 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 STUDY OBJECTIVES We hypothesized that continuous , automatic turning utilizing a patient-friendly , low air loss surface would reduce the incidence of early ICU pneumonia in selected groups of critically ill medical patients . DESIGN Prospect i ve , r and omized , controlled clinical trial . SETTING Medical ICU of a large community teaching hospital . PATIENTS One hundred twenty-four critically ill new admissions to the medical ICU at Charity Hospital in New Orleans . INTERVENTIONS Patients were prospect ively r and omized within one of five diagnosis-related groups (DRG)--sepsis ( SEPSIS ) , obstructive airways disease ( OAD ) , metabolic coma , drug overdose , and stroke -- to either routine turning on a st and ard ICU bed or to continuous turning on an oscillating air-flotation bed for a total of five days . MEASUREMENTS AND RESULTS Patients were monitored daily during the treatment period for the development of pneumonia . The incidence of pneumonia during the first five ICU days was 22 percent in patients r and omized to the st and ard ICU bed vs 9 percent for the oscillating bed ( p = 0.05 ) . This treatment effect was greatest in the SEPSIS DRG ( 23 percent vs 3 percent , p = 0.04 ) . Continuous automatic oscillation did not significantly change the number of days of required mechanical ventilation , ICU stay , hospital stay , or hospital mortality overall or within any of the DRGs . CONCLUSIONS We conclude that air-supported automated turning during the first five ICU days reduces the incidence of early ICU pneumonia in selected DRGs ; however , this form of automated turning does not reduce other measured clinical outcome parameters Critically ill patients in the intensive care unit ( ICU ) are at high risk for infections associated with increased morbidity , mortality , and health care costs ( 1 - 3 ) . The overall infection rate in critically ill patients approaches 40 % and may be as high as 50 % or 60 % in patients who remain in the ICU for more than 5 days ( 4 , 5 ) . Respiratory tract infections account for 30 % to 60 % of all such infections . The incidence of pneumonia acquired in the ICU ranges from 10 % to 65 % ( 6 - 11 ) . Among patients at high risk for ventilator-associated pneumonia ( VAP ) are those who have chronic obstructive pulmonary disease , burns , neurosurgical conditions , the acute respiratory distress syndrome , and witnessed aspiration ; those who are reintubated ; and those who receive paralytic agents or enteral nutrition ( 12 , 13 ) . The attributable morbidity and mortality of VAP are clinical ly important . In a prospect i ve , matched cohort study , patients with VAP remained in the ICU 4.3 days ( 95 % CI , 1.5 to 7.0 days ) longer than patients who did not have VAP and had a trend toward an increased risk for death ( absolute risk increase , 5.8 % [ CI , 2.4 % to 14.0 % ] ) ( 14 ) . Six other studies using a matching strategy found a prolonged length of ICU stay associated with VAP ( range , 5 to 13 days ) and attributable mortality ranging from an absolute risk increase of 0 % to 50 % ( 15 - 20 ) . Therefore , strategies to decrease the incidence of VAP could decrease morbidity , mortality , and health care costs and improve patient safety . A survey of the use of VAP prevention strategies identified differences across countries ( 21 ) . For example , changing the ventilator circuit for each new patient was reported more frequently by French ICU directors than those in Canada ( 21 ) . This survey also showed that some effective strategies were used infrequently , suggesting inadequate translation of r and omized trial results into practice . One potential catalyst for knowledge translation is an evidence -based clinical practice guideline . Therefore , a Joint Planning Group of the Canadian Critical Care Society and Canadian Critical Care Trials Group commissioned the development of an evidence -based clinical practice guideline for the prevention of VAP . In this paper , we describe the methods used to create the guideline and the recommendations generated . Methods The Joint Planning Group selected an 11-member VAP Prevention Guideline Panel made up of 9 intensivists from university-affiliated and community hospitals , an ICU nurse , and an ICU respiratory therapist . Panel members were experts in critical care medicine ( n= 9 ) , VAP ( n= 4 ) , evidence -based medicine ( n= 4 ) , and guideline development ( n= 3 ) . The context was mechanically ventilated adult patients cared for in the ICU . The target audience was ICU clinicians in university-affiliated and community hospitals . To identify potentially relevant evidence , we search ed 3 bibliographic data bases ( MEDLINE , EMBASE , and the Cochrane Data base of Systematic Review s ) to 1 April 2003 for r and omized trials that evaluated interventions influencing VAP ( Appendix ) . We had no language restrictions . We also review ed personal files and practice guidelines on this subject previously published by the Centers for Disease Control and Prevention ( 22 ) and the American Thoracic Society ( 23 ) . We included r and omized trials and systematic review s of r and omized trials that 1 ) studied adult critically ill patients ; 2 ) had VAP as an outcome ; and 3 ) evaluated any of the following interventions : physical strategies ( route of endotracheal intubation , systematic search for maxillary sinusitis , frequency of ventilator circuit changes , type of airway humidification , frequency of humidifier changes , endotracheal suctioning system , subglottic secretion drainage , chest physiotherapy , and tracheostomy timing ) , positional strategies ( kinetic beds , semi-recumbent positioning , and prone positioning ) , and pharmacologic strategies ( stress ulcer prophylaxis and prophylactic antibiotics , including selective decontamination of the digestive tract ) . Since study authors used various definitions of VAP , we used the definitions they provided . The most common definition was a new or persistent radiographic infiltrate plus fever , leukocytosis , change in the volume or color of sputum , or isolation of a pathogen . If available , histologic evidence of pneumonia was also used . A priori , we decided to review only systematic review s of r and omized clinical trials for antibiotic prophylaxis and only r and omized clinical trials for all other topics . We excluded crossover and beforeafter studies . We also excluded r and omized trials of ventilator weaning , including noninvasive mechanical ventilation , and nutritional interventions evaluating VAP because guidelines addressing these topics have recently been published ( 24 , 25 ) . In duplicate and independently , 3 pairs of panel members critically appraised each trial ( 26 , 27 ) and systematic review ( 28 ) . Each member of a pair compared his or her independent appraisal of a given trial or systematic review with that of the other member of the pair . For each r and omized trial , we abstract ed sample , allocation , intervention , co- interventions , exclusions after r and omization , blinding of outcome assessment , definition of VAP , crude VAP events , relative risk for VAP , and other outcomes . For each intervention , we summarized the risk differences and calculated a pooled risk difference . For each systematic review , we abstract ed number of trials , population , intervention , selection criteria , search strategy , validity assessment , method of pooling results , homogeneity assessment , VAP definition , pooled event rates , and other outcomes . Before the panel meeting , each pair of appraisers achieved consensus on the validity and results of the trials they review ed . One month before the panel meeting , panel members received the evidence tables for review prepared by the 3 pairs of appraisers . A priori , panel members agreed to read all circulated documents and evidence tables in advance , to use levels of evidence to generate a status statement for each item , and to abide by the group process and consensus methods . The Canadian Critical Care Society appointed a chair to ensure that the panel achieved its objectives through group process ( 29 ) . At the panel meeting , each member recorded any potential conflicts of interest ( 30 ) . The pair of panel members responsible for critical appraisal of each intervention provided a structured written and oral presentation of the evidence . After the panel discussion , the initial evidence summary was revised if necessary . The panel members assigned levels of evidence , semi-quantitative scores to summarize the evidence and describe the intervention , and a status statement . We classified trials as level 1 if they had all of the following : concealed r and omization , blinded outcome adjudication , an intention-to-treat analysis , and an explicit definition of VAP . Trials were classified as level 2 if any one of these characteristics was unfulfilled and as level 3 if allocation was not strictly r and omized . We used a semi-quantitative score ( 0 , 1 , 2 , or 3 ) to evaluate each intervention with respect to the validity of the r and omized trials ; the effect size of each intervention ; the confidence intervals around the estimate of effect ; the homogeneity of the trial results ; and the safety , feasibility , and economic consequences of the intervention . The language of the status statement for each item was keyed to the levels of evidence and the semi-quantitative scores . We used the term recommended if there were no reservations about endorsing an intervention and the term considered if the evidence supported an intervention but there were minor uncertainties about the benefits , harms , or costs . No recommendation was made if evidence regarding an intervention was inadequate or if there were major uncertainties about the benefits , harms , or costs . After the panel meeting , the chair compiled the summaries and status statements and sent them to all panel members to check accuracy and clarity . In addition , the pairs of evidence appraisers wrote background documents for the interventions they appraised , including the rationale for each intervention , appraisal of r and omized trials and systematic review s , and harms and costs of the interventions . The chair and the writing committee organized the background documents , the evidence summaries , a table of the semi-quantitative scores , and the status statement for each item . We formatted the document with a structured abstract ( 31 ) , a summary of the evidentiary basis for each recommendation , and a status statement for each item . We also created a quick reference guide . The draft guideline document was su bmi tted for structured external review by the executives of the Canadian Critical Care Society and the Canadian Critical Care Trials Group and the respective executives of the Canadian Association of Critical Care Nurses , Canadian Society of Respiratory Therapists , Canadian Infectious Disease Society , and Canadian Thoracic Society . External review ers were asked to critique whether the guideline was logical , clear , and practical and to critique the guideline development process . The panel revised the document on the basis of this feedback . The final guideline was returned to the external review ers for further comments and official endorsement by their respective organizations . The final guideline was then piloted in 2 institutions . To record the agreement of each panel member with the final status statement for each item , we sent the final document to all panel members . Independently , blinded to each other 's ratings , panel members used a Likert scale from 1 to 9 that was anchored by disagree completely at the low end and agree completely at the high end . The panel will formally review and up date this guideline every 2 years ( 32 ) . The funding source played no role in study selection for this guideline and had no role in its Pulmonary contusion as a result of blunt trauma carries significant morbidity and mortality . In an attempt to improve therapy , a prospect i ve study was performed in which 30 patients were r and omized to either receive or not receive continuous oscillation therapy on the Kinetic Treatment Table . Pulmonary contusion was defined by mechanism of injury ( blunt trauma secondary to a motor vehicle accident ) , hypoxemia , and radiographic confirmation . Patients who received continuous oscillation therapy had a significantly higher injury severity score ( more severely injured group of patients ) , yet had a hospital course similar to those patients who did not receive continuous oscillation therapy and had a significantly lower injury severity score The kinetic treatment table ( KTT ) has been developed to prevent and treat complications of immobility . Because atelectasis and pneumonia may be related to immobility , we studied the effect of the KTT on the prevention and treatment of pulmonary complications in a prospect i ve r and omized study of 30 patients with severe traumatic injuries . All were receiving mechanical ventilation  and were r and omly assigned to treatment with a KTT or a conventional bed . Both groups received conventional medical-surgical therapy while pulmonary function , chest roentgenograms , and the presence or absence of lung infection were monitored for one week . In the patients who began the study with a clear chest roentgenogram , atelectasis and pneumonia were significantly less frequent in those treated with a KTT ( P less than .05 ) . Thus , the KTT can reduce pulmonary complications in selected patients with multiple trauma . The effect of this benefit on overall outcome is uncertain OBJECTIVES To compare the incidence of pulmonary complications and hospital re source utilisation in patients treated with continuous rotation therapy versus manual turning in a traditional hospital bed .  DESIGN Prospect i ve , r and omised clinical trial . SETTING Surgical intensive care unit of a large , tertiary care , urban hospital . PATIENTS One-hundred- and -thirty-seven consecutive injured patients admitted to the Surgical Intensive Care Unit were prospect ively r and omised to receive either the Rotorest Kinetic Treatment Table or a traditional hospital bed . One hundred of these patients met the study criteria and are the basis of this report . METHODS The patients ' medical records were review ed in a prospect i ve manner to determine the frequency and severity of pulmonary complications and re source utilisation in the two patient groups . MAIN RESULTS There were no significant differences in the minimum , average , or maximum pO 2 , pCO 2 , PEEP , IMV rate , or pre-extubation blood gases during the first seven days of the study . Fewer cardiac output measurements , arterial blood gas measurements , chest X-rays , respiratory therapies , hours intubated , days in the ICU , days in the step-down unit , days in the hospital , and lower ICU charges , respiratory care charges , and total hospital charges were utilised in the patients treated with the kinetic bed . The incidence of pulmonary event complications and process complications was lower in the group of patients treated on the Rotorest bed . ( ABSTRACT TRUNCATED AT 250 WORDS PURPOSE To compare turning by an oscillating bed to st and ard 2-hour turning . Outcomes were survival , length of stay ( LOS ) , duration of mechanical ventilation , and incidence of pneumonia . METHODS One hundred and three intensive care patients were r and omly assigned to st and ard turning or turning by an oscillating bed .  Data , collected at baseline , daily for 7 days , and then three times weekly until study discharge , included demographics , initial Acute Physiology and Chronic Health Evaluation ( APACHE II ) score , ventilatory/gas exchange parameters , indicators of pneumonia , nursing measures , and chest roentgenograph . RESULTS There were no significant differences for LOS , duration of ventilation , nor incidence of pneumonia . Higher survival for subjects on the oscillating bed reached borderline significance ( P = .056 ) for subjects with APACHE II greater than or equal to 20 . Longitudinal data were analyzed using the r and om effects model . No differences in ventilatory or gas exchange parameters were identified . Among subjects who developed pneumonia there was a significantly higher respiratory score ( nursing acuity scale ) for subjects on the oscillating bed . CONCLUSIONS In selected critically ill patients  oscillating therapy may improve survival and improve airway clearance . The frequency and degree of turning needed to prevent complications and improve outcome remains unclear . These newer beds should be used with discrimination so as to not increase hospital costs unnecessarily BACKGROUND When liver transplant c and i date s and recipients suffer from pulmonary complications of immobility , the results can be life-threatening . Continuous lateral rotation therapy has been reported to decrease complications of immobility . OBJECTIVES To determine whether continuous lateral rotation therapy decreases the duration of mechanical ventilation , intensive care unit length of stay , incidence or resolution of atelectasis , incidence or onset time of lower respiratory tract infection and pneumonia . METHODS Sixty-nine subjects admitted to a liver transplant intensive care unit at a university teaching hospital were r and omly assigned to continuous lateral rotation therapy or a stationary bed .  All subjects were mechanically ventilated for 24 hours and had a Glasgow Coma Scale score of 11 or less upon admission to the study . Subjects were followed until out of bed , unable to rotate for 3 consecutive days , or transferred from the intensive care unit . Data and chest roentgenogram results were collected on admission and daily during the study . Sputum culture results were obtained if available as part of normal patient care . RESULTS Incidence of lower respiratory tract infection was significantly lower and length of time to occurrence of lower respiratory tract infection was significantly longer in the continuous lateral rotation therapy group than in the stationary bed group . CONCLUSIONS Although continuous lateral rotation therapy did not affect duration of mechanical ventilation , length of stay , or incidence of atelectasis , it was effective in decreasing the incidence of , and increasing onset time to , lower respiratory tract infection in the liver transplantation population 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 Prospect i ve 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 Nosocomial infections are a major problem in intensive care patients . Thirty-nine patients , requiring intensive care for 5 days or more ( mean 15.8 days ) were prospect ively investigated , to determine the relation between colonisation and nosocomial infection . Thrice weekly , cultures from the oropharynx , respiratory and digestive tract were obtained . Colonization with aerobic gram-negative microorganisms of the oropharynx , respiratory and digestive tract significantly increased during the stay in the Intensive Care Unit . In 29 patients ( 74 % ) 78 nosocomial infections were diagnosed . The most frequent nosocomial infections were pneumonia ( 26 patients , 66.6 % ) , catheterrelated bacteraemia ( 11 patients , 28.2 % ) , and wound infections ( 7 patients , 17.9 % ) . In 59 instances ( 75.6 % ) , colonization with the same potential pathogenic microorganism preceeded the nosocomial infection . The overall mortality was 25.6 % ( 10 patients ) , bacteraemia with aerobic gram-negative microorganisms being the cause of death in 7 patients OBJECTIVE To evaluate the current use of strategies to prevent  ventilator-associated pneumonia ( VAP )  and to identify interventions to target for quality -improvement initiatives . DESIGN Cross-sectional national survey . SETTING Canadian intensive care units ( ICUs ) with at least 8 beds . PATIENTS Seven hundred and two patients in 66 ICUs in 10 provinces in Canada . INTERVENTIONS None . MEASUREMENTS AND RESULTS The Canadian Critical Care Trials Group recently developed VAP prevention guidelines . Before these guidelines were disseminated , we documented the extent to which these recommendations were followed in practice by using 3 methods : survey of ICU directors , prospect i ve observation of patients on one day , and retrospective review of patient charts for a 12-day period . According to ICU directors , ventilator circuits were changed only for new patients or if the circuit was soiled in 7 of 66 ICUs ( 10 % ) , heat and moisture exchangers were used routinely in 53 of 66 ICUs ( 80 % ) , and closed-suction catheter systems were used in 58 of 66 ICUs ( 88 % ) . Neither subglottic secretion drainage tubes nor prophylactic antibiotics for VAP were used at all . Of the entire cohort of 702 patients , the average degree of elevation of the head of the bed was 29.9 degrees ( range , 0 degrees -90 degrees ) and 22 of 702 ( 3.1 % ) were observed to be on a kinetic bed . Of the 459 patients receiving any form of mechanical ventilation  , 56 ( 12.2 % ) were receiving noninvasive or mask ventilation  , 262 ( 57.1 % ) were orally intubated , 9 ( 1.9 % ) were nasally intubated , and 132 ( 28.8 % ) had received a tracheostomy . Of the 423 patients who received nutrition support , 373 ( 88.2 % ) received enteral nutrition . Small bowel feeding tubes were used during 16.4 % of study days on enteral feeds and sucralfate was prescribed for 1.7 % of study days . CONCLUSIONS Significant opportunities exist to improve VAP prevention practice s in Canada . These strategies include decreasing the frequency of ventilator circuit changes , and increasing the use of non-invasive ventilation , subglottic secretion drainage endotracheal tubes , kinetic bed therapy , small bowel feedings , and elevation of the head of the bed To evaluate the attributable morbidity and mortality of ventilator-associated pneumonia ( VAP ) in intensive care unit ( ICU ) patients , we conducted a prospect i ve , matched cohort study . Patients expected to be ventilated for > 48 h were prospect ively followed for the development of VAP . To determine the excess ICU stay and mortality attributable to VAP , we matched patients with VAP to patients who did not develop clinical ly suspected pneumonia . We also conducted sensitivity analyses to examine the effect of different population s , onset of pneumonia , diagnostic criteria , causative organisms , and adequacy of empiric treatment on the outcome of VAP . One hundred and seventy-seven patients developed VAP . As compared with matched patients who did not develop VAP , patients with VAP stayed in the ICU for 4.3 d ( 95 % confidence interval [ CI ] : 1.5 to 7 . 0 d ) longer and had a trend toward an increase in risk of death ( absolute risk increase : 5.8 % ; 95 % CI : -2.4 to 14.0 d ; relative risk ( RR ) increase : 32.3 % ; 95 % CI : -20.6 to 85.1 % ) . The attributable ICU length of stay was longer for medical than for surgical patients ( 6 . 5 versus 0.7 d , p < 0.004 ) , and for patients infected with " high risk " organisms as compared with " low risk " organisms ( 9.1 d versus 2.9 d ) . The attributable mortality was higher for medical patients than for surgical patients ( RR increase of 65 % versus -27.3 % , p = 0 . 04 ) . Results were similar for three different VAP diagnostic criteria . We conclude that VAP prolongs ICU length of stay and may increase the risk of death in critically ill patients . The attributable risk of VAP appears to vary with patient population and infecting organism A recent international prevalence study involving more than 1000 intensive care units indicated that pneumonia is responsible for almost half of the infections in critically ill patients in Europe [ 1 ] . Ventilator-associated pneumonia accounts for approximately 90 % of infections in patients requiring assisted ventilation [ 2 , 3 ] . An independent contribution to mortality conferred by ventilator-associated pneumonia was recently suggested [ 4 , 5 ] . Although debate persists about the mortality attributable to ventilator-associated pneumonia among other causes of death in critically ill patients [ 1 , 4 - 7 ] , there is little doubt that ventilator-associated pneumonia causes substantial morbidity by increasing the duration of mechanical ventilation and intensive care unit stay [ 4 , 5 ] . It is therefore important to underst and the factors that are predictive of ventilator-associated pneumonia , to identify patients at highest risk , and to target these patients for the most effective preventive strategies as determined by r and omized trials [ 8 , 9 ] . Risk factors for nosocomial pneumonia have been evaluated in hospitalized elderly persons [ 10 ] , heterogeneous groups of hospitalized patients breathing spontaneously or requiring assisted ventilation [ 11 ] , and similar mixed population s admitted to the intensive care unit [ 2 , 12 - 15 ] . Investigations in ventilated critically ill patients only are needed to identify independent predictors of ventilator-associated pneumonia . Most studies of risk factors for ventilator-associated pneumonia have been conducted at single institutions , and different predictors have been examined . In cohort studies using multivariable analyses [ 16 - 21 ] , only reintubation [ 17 , 19 , 21 ] and antibiotic use [ 18 , 20 ] were identified as risk factors in more than one report . However , a direct relation between antibiotics and pneumonia was found in one study [ 18 ] , whereas an inverse relation was found in another [ 20 ] . We examined factors associated with ventilator-associated pneumonia . We explored baseline and time-dependent characteristics , including measures of illness severity , factors relating to mechanical ventilation , variables in the gastropulmonary route of infection , and drug exposure . Methods Patients We used a multicenter national data base of 1200 patients who received mechanical ventilation for 48 hours or more and were enrolled from October 1992 to May 1996 in a double-blind , concealed , r and omized trial of sucralfate compared with ranitidine to determine rates of ventilator-associated pneumonia and gastrointestinal bleeding [ 22 ] . Patients were followed until death , discharge , or clinical suspicion of ventilator-associated pneumonia as determined by the attending intensivist . Bronchoalveolar lavage or protected specimen brush was indicated for patients with a clinical suspicion of ventilator-associated pneumonia . A diagnosis of ventilator-associated pneumonia was considered only in patients who were receiving mechanical ventilation or who stopped receiving ventilation for less than 48 hours . In the absence of a reference st and ard for diagnosing pneumonia in critically ill patients [ 23 , 24 ] , each patient 's clinical , laboratory , and radiographic data were independently review ed by one of four pairs of adjudicators blinded to treatment group . The readers in each adjudication pair decided on the presence or absence of ventilator-associated pneumonia , resolving any disagreement through discussion . Consensus was achieved on all cases . The adjudicated outcome was used for the primary analysis [ 177 cases ] . However , each case of pneumonia was classified according to four additional definitions : 1 ) the bedside clinician 's diagnosis [ 233 cases ] ; 2 ) the modified Centers for Disease Control and Prevention criteria [ 25 ] , which require a new radiographic infiltrate persistent for 48 hours or more plus a body temperature greater than 38.5 C or less than 35.0 C , a leukocyte count of more than 10 cells 109/L or less than 3 cells 109/L , purulent sputum or change in character of sputum , or isolation of pathogenic bacteria from an endotracheal aspirate [ 211 cases ] ; 3 ) a Clinical Pulmonary Infection score of 7 or more [ 26 ] [ 194 cases ] ; or 4 ) a positive culture from bronchoalveolar lavage ( > 104 colony-forming units/mL ) or protected specimen brush ( < 103 colony-forming units/mL ) ( 97 cases ) . Statistical Analysis We expressed continuous variables as the mean ( SD ) or as the median and interquartile range if their distribution was skewed . We used the Student t-test to compare continuous variables and the chi-square test to compare proportions . All statistical tests were two-tailed . We performed a forward stepwise Cox proportional-hazards regression analysis to evaluate potential risk factors for ventilator-associated pneumonia . The Cox model assesses the effect of each risk factor on the hazard rate of ventilator-associated pneumonia over time , adjusted for other factors in the model and allowing for censoring because of death or discharge . The hazard function in the Cox model can be used to estimate the event rate per day over the duration of stay in the intensive care unit . Independent variables recorded at baseline included age ; sex ; primary diagnosis ; medical or surgical status ; hospital admission in the fall or winter compared with spring or summer ; location before admission to the intensive care unit ; treatment center ; Acute Physiology and Chronic Health Evaluation II score ; Acute Physiology score ; Multiple Organ Dysfunction score [ 27 ] ; Glasgow Coma Scale score ; and chronic comorbid conditions , such as alcoholism , a smoking history of 10 or more pack-years , asthma , bronchiectasis , pulmonary fibrosis , cancer , and HIV infection ; organ transplantation ; and recent  corticosteroid therapy  or chemotherapy . Additional independent variables evaluated daily throughout the intensive care unit stay were classified as illness severity measures ( daily Multiple Organ Dysfunction score and change in Multiple Organ Dysfunction score from baseline ) , ventilation variables  ( mechanical ventilation , change or reinsertion of endotracheal tube , discontinuation and reinstitution of mechanical ventilation , and tracheostomy ) , nutritional variables ( nasoenteral nutrition , gastrostomy feeding , jejunostomy feeding , enteral nutrition through any route  ,  central parenteral nutrition , peripheral parenteral nutrition , and insulin requirement of more than 15 U/d ) , witnessed  aspiration , and  drug exposure ( stress-ulcer prophylaxis with ranitidine or sucralfate , paralytic agents , and antibiotics ) . The Multiple Organ Dysfunction Score combines measures of physiologic dysfunction in six domains : the cardiovascular system ( heart rate x right atrial pressure/mean arterial pressure ) , pulmonary system ( Pao 2:Fio 2 ratio ) , the renal system ( serum creatinine concentration ) , the hepatic system ( serum bilirubin level ) , the hematologic system ( platelet count ) , and the central nervous system ( Glasgow Coma Scale score ) [ 25 ] . These continuous variables are constructed in 5 categories so that 0 represents normal function and 4 reflects marked physiologic derangement and is associated with a mortality rate greater than 50 % . Composite scores provide a quantitative measure of global physiologic dysfunction at a discrete point in the intensive care unit stay . For individual domains , either the raw data or their score provides a measure of dysfunction in the system of interest . Variables that were associated with ventilator-associated pneumonia in the univariable analysis and had a P value less than 0.10 were entered into a multivariable regression analysis . Factors were considered significant if the P value was less than 0.05 in the multivariable analysis . We calculated risk ratios and 95 % CIs for all significant predictors of ventilator-associated pneumonia in the multivariable analysis using all five definitions . We tested for all pairwise interactions between significant risk factors in the multivariable model . We also tested for interactions between predictors in the multivariable model and factors that were significant in the univariable analysis . Finally , we investigated the possibility that the effects of risk factors may vary over the duration of stay in the intensive care unit ; this was done by using a nonproportional Cox model testing the interaction of each variable in the final model with time . For example , we hypothesized that the influence of antibiotics on ventilator-associated pneumonia may vary over time . Time was considered both a continuous variable and a discretized variable by using 3-day and 5-day intervals . We did not consider antibiotics administered 24 hours before the diagnosis of ventilator-associated pneumonia , so that drugs prescribed in response to early ventilator-associated pneumonia would be excluded [ 28 ] . Role of Study Sponsor Our funding sources had no role in the acquisition , analysis , or interpretation of data or in the su bmi ssion of this report . Results Of the 1200 patients enrolled in this study , 186 were excluded ( 85 were discharged , 71 died , and 30 had pneumonia in the first 48 hours ) , leaving 1014 patients ventilated for 48 hours or more who were free of pneumonia at admission to the intensive care unit . Of these patients , 177 ( 17.5 % ) developed ventilator-associated pneumonia 9.0 5.9 days after admission ( median , 7 days [ interquartile range , 5 to 10 days ] ) . The characteristics of patients with and without ventilator-associated pneumonia are shown in Table 1 . The total duration of mechanical ventilation among patients with ventilator-associated pneumonia was 19.3 16.0 days ( median , 15 days [ interquartile range , 9 to 23 days ] ) compared with 10.2 10.5 days ( median , 7 days [ interquartile range , 4 to 11 days ] ) in other patients ( P < 0.001 ) . Among the 177 patients with ventilator-associated pneumonia , 131 ( 74.0 % ) had bronchoscopic testing with bronchoalveolar lavage or protected specimen brush . Patients in the following admitting diagnostic The efficacy of using the Kinetic Treatment Table ( KTT ) to prevent or reduce pulmonary complications in severely head-injured patients is unclear . This study is a prospect i ve , r and omized trial using the KTT vs. conventional bed care in severely head-injured patients . Outcome measures were hospital length of stay ( LOS ) , mortality , CNS morbidity at hospital discharge , and rate of improvement of pulmonary status as gauged by chest radiograph , arterial/alveolar PO2 ratio , patient temperature , WBC count , suctioning frequency , sputum volume , and days on ventilator .  The KTT group ( n = 23 ) and conventional bed care group ( n = 26 ) were well matched for age , sex , severity of injury , and pulmonary status . There was no significant difference in mortality , CNS morbidity , LOS in ICU or hospital , or rate of pulmonary improvement between the groups . The efficacy of the KTT in reducing pulmonary complications in head-injured patients remains unclear PURPOSE Continuous lateral rotational therapy ( CLRT ) < 40 degrees is a method of altering the position of the ventilated patient to help clear secretions from the lung . CLRT has not been shown to reduce the incidence of atelectasis or pneumonia but potentially offers a way to maximize positional drainage in these patients without producing adverse effects . Treatment intervention , bracketed by two ( nonrotational ) control periods . The purpose of this study was to determine if CLRT alters mucus transport in critically ill , intubated patients in the intensive care unit of a teaching hospital . MATERIAL S AND METHODS Thirteen critically ill , but stable , mechanically ventilated patients , mean age 74 years , were enrolled . They were placed supine on a Biodyne bed ( KCI , San Antonio , Texas ) and pressures in the cushions adjusted to patient 's weight . A radiolabeled aerosol was delivered by bagging for 2 to 3 minutes and repeated measurements of lung radioactivity were obtained by imaging of the thorax over the following 3 hours . A 90-minute period of rotation of the bed , 30 degrees to either side was preceded and followed by two 45-minute control periods during which the patient remained supine and stationary on the bed . Coughs and suctions were recorded and blood gases obtained pre and post study . RESULTS ( 1 ) The mucous clearance was slower than that reported in normal subjects and in ambulatory patients with COPD ; ( 2 ) there was a slight , but not significant , increase in clearance during CLRT ; ( 3 ) clearance reverted to pre-oscillation levels following therapy . Lack of significant effect may be attributed to too shallow an angle for rotation or too short an intervention period . CONCLUSION Positional drainage effected by short duration CLRT did not appear to stimulate significant mucous removal from the lung in critically ill patients but also did not cause any adverse effects The risk of nosocomial pneumonia and atelectasis is high among critically ill immobilized patients . We hypothesized that continuous turning on the kinetic treatment table would reduce their incidence . Sixty-five critically ill patients , immobilized because of head injury or traction , were prospect ively r and omized for treatment in a  conventional bed ( n = 38 ) or the  kinetic treatment table  ( n = 27 ) . Patients were well matched for baseline demographic and pulmonary risk factors . Patients in the conventional bed group had a higher incidence of cigarette smoking . The combined incidence of significant atelectasis or pneumonia was higher ( 66 % ) in the conventional vs. kinetic treatment table ( 33 % ) groups ( p less than .01 ) . Atelectasis , pneumonia , adult respiratory distress syndrome , requirements for ventilator treatment , for PEEP , and for an FIO2 greater than 0.50 were not significantly different , but tended to be higher in the control group . Survival and the incidence of decubitus ulcers were similar We tested the hypothesis that the incidence of LRTI in critically ill blunt trauma victims can be reduced by employing continuous postural oscillation . Within 24 h of admission to the SICU , 106 patients were prospect ively r and omized to either a conventional bed or a RRKTT . Seven patients who were discharged from the SICU in less than 24 h were excluded from the data analyses . Until discharge from the SICU , patients were monitored daily for development of LRTI or pneumonia . Among 48 patients in the control group , 28 met criteria for LRTI and 19 met criteria for pneumonia . Among 51 patients in the RRKTT group , 13 developed LRTI and 7 developed pneumonia . The differences between groups for all LRTI and pneumonia were both significant . We conclude that continuous postural oscillation decreases the risk of pulmonary sepsis in victims of major blunt trauma
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 .