title: Head-of-bed elevation and early outcomes of gastric reflux, aspiration and pressure ulcers: a feasibility study.
abstract: BACKGROUND
  Guidelines recommending head of bed (HOB) elevation greater than 30º to prevent ventilator-associated pneumonia conflict with guidelines to prevent pressure ulcers, which recommend HOB elevation less than 30º.
  
  
  OBJECTIVE
  To examine the feasibility of 45º HOB elevation and describe and compare the occurrence of reflux, aspiration, and pressure ulcer development at 30º and 45º HOB elevation.
  
  
  METHODS
  A randomized 2-day crossover trial was conducted. HOB angle was measured every 30 seconds. Oral and tracheal secretions were analyzed for pepsin presence. Skin was assessed for pressure ulcers. Wilcoxon signed rank tests and Kendall τ correlations were conducted.
  
  
  RESULTS
  Fifteen patients were enrolled; 11 completed both days. Patients were maintained at 30º (mean, 30º) for 96% of minutes and at 45º (mean, 39º) for 77% of minutes. No patients showed signs of pressure ulcers. A total of 188 oral secretions were obtained, 82 (44%) were pepsin-positive; 174 tracheal secretions were obtained, 108 (62%) were pepsin-positive. The median percentage of pepsin-positive oral secretions was not significantly higher (P = .11) at 30º elevation (54%) than at 45º elevation (20%). The median percentage of pepsin-positive tracheal secretions was not significantly higher (P = .37) at 30º elevation (71%) than 45º elevation (67%). Deeper sedation correlated with increased reflux (P = .03).
  
  
  CONCLUSIONS
  HOB elevation greater than 30º is feasible and preferred to 30º for reducing oral secretion volume, reflux, and aspiration without pressure ulcer development in gastric-fed patients receiving mechanical ventilation. More deeply sedated patients may benefit from higher HOB elevations.
authors.affiliation: Marilyn Schallom is a is a clinical nurse specialist/research scientist for the Department of Research for Patient Care Services, Barnes-Jewish Hospital, St Louis, Missouri. Betsy Dykeman is a nurse educator in the surgical intensive care unit at Barnes-Jewish Hospital. Norma Metheny is the Dorothy A. Votsmier Endowed Chair in Nursing at St Louis University School of Nursing, St Louis, Missouri. John Kirby is is an associate professor at Washington University Medical School and medical director of the wound healing program at Barnes-Jewish Hospital. Janet Pierce is the Christine A. Hartley Endowed Professor of Nursing at the University of Kansas School of Nursing, Kansas City. mes4143@bjc.org.
authors.forename: Marilyn
authors.initials: M
authors.lastname: Schallom
authors.affiliation: Marilyn Schallom is a is a clinical nurse specialist/research scientist for the Department of Research for Patient Care Services, Barnes-Jewish Hospital, St Louis, Missouri. Betsy Dykeman is a nurse educator in the surgical intensive care unit at Barnes-Jewish Hospital. Norma Metheny is the Dorothy A. Votsmier Endowed Chair in Nursing at St Louis University School of Nursing, St Louis, Missouri. John Kirby is is an associate professor at Washington University Medical School and medical director of the wound healing program at Barnes-Jewish Hospital. Janet Pierce is the Christine A. Hartley Endowed Professor of Nursing at the University of Kansas School of Nursing, Kansas City.
authors.forename: Betsy
authors.initials: B
authors.lastname: Dykeman
authors.affiliation: Marilyn Schallom is a is a clinical nurse specialist/research scientist for the Department of Research for Patient Care Services, Barnes-Jewish Hospital, St Louis, Missouri. Betsy Dykeman is a nurse educator in the surgical intensive care unit at Barnes-Jewish Hospital. Norma Metheny is the Dorothy A. Votsmier Endowed Chair in Nursing at St Louis University School of Nursing, St Louis, Missouri. John Kirby is is an associate professor at Washington University Medical School and medical director of the wound healing program at Barnes-Jewish Hospital. Janet Pierce is the Christine A. Hartley Endowed Professor of Nursing at the University of Kansas School of Nursing, Kansas City.
authors.forename: Norma
authors.initials: N
authors.lastname: Metheny
authors.affiliation: Marilyn Schallom is a is a clinical nurse specialist/research scientist for the Department of Research for Patient Care Services, Barnes-Jewish Hospital, St Louis, Missouri. Betsy Dykeman is a nurse educator in the surgical intensive care unit at Barnes-Jewish Hospital. Norma Metheny is the Dorothy A. Votsmier Endowed Chair in Nursing at St Louis University School of Nursing, St Louis, Missouri. John Kirby is is an associate professor at Washington University Medical School and medical director of the wound healing program at Barnes-Jewish Hospital. Janet Pierce is the Christine A. Hartley Endowed Professor of Nursing at the University of Kansas School of Nursing, Kansas City.
authors.forename: John
authors.initials: J
authors.lastname: Kirby
authors.affiliation: Marilyn Schallom is a is a clinical nurse specialist/research scientist for the Department of Research for Patient Care Services, Barnes-Jewish Hospital, St Louis, Missouri. Betsy Dykeman is a nurse educator in the surgical intensive care unit at Barnes-Jewish Hospital. Norma Metheny is the Dorothy A. Votsmier Endowed Chair in Nursing at St Louis University School of Nursing, St Louis, Missouri. John Kirby is is an associate professor at Washington University Medical School and medical director of the wound healing program at Barnes-Jewish Hospital. Janet Pierce is the Christine A. Hartley Endowed Professor of Nursing at the University of Kansas School of Nursing, Kansas City.
authors.forename: Janet
authors.initials: J
authors.lastname: Pierce
mesh_terms: D018592:Cross-Over Studies; D005240:Feasibility Studies; D005260:Female; D005764:Gastroesophageal Reflux / Q000378:metabolism / Q000517:prevention & control*; D006801:Humans; D008297:Male; D008875:Middle Aged; D056888:Patient Positioning / Q000379:methods*; D010434:Pepsin A / Q000378:metabolism; D053717:Pneumonia, Ventilator-Associated / Q000517:prevention & control; D003668:Pressure Ulcer / Q000517:prevention & control*; D063466:Respiratory Aspiration of Gastric Contents / Q000378:metabolism / Q000517:prevention & control*
chemical_list: D010434:Pepsin A