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An evidence-based recommendation on bed head elevation for mechanically ventilated patients

Barbara S Niël-Weise1*, Petra Gastmeier2, Axel Kola2, Ralf P Vonberg3, Jan C Wille4, Peterhans J van den Broek5 and the Bed Head Elevation Study Group

Author Affiliations

1 Leiden University Medical Center, Dutch Working Party Infection Prevention, C7-130, Postbus 9600, 2300 RC Leiden, Germany

2 Institute of Hygiene and Environmental Medicine, Charité-University Medicine Berlin, Hindenburgdamm 27, 12203 Berlin, Germany

3 Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany

4 CBO, Churchilllaan 11, 3527 GV Utrecht, Germany

5 Leiden University Medical Center, Department of Infectious Diseases, C5-P, Box 9600, 2300 RC Leiden, Germany

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Critical Care 2011, 15:R111  doi:10.1186/cc10135

See related commentary by Camporota and Brett,

Published: 11 April 2011



A semi-upright position in ventilated patients is recommended to prevent ventilator-associated pneumonia (VAP) and is one of the components in the Ventilator Bundle of the Institute for Health Care Improvement. This recommendation, however, is not an evidence-based one.


A systematic review on the benefits and disadvantages of semi-upright position in ventilated patients was done according to PRISMA guidelines. Then a European expert panel developed a recommendation based on the results of the systematic review and considerations beyond the scientific evidence in a three-round electronic Delphi procedure.


Three trials (337 patients) were included in the review. The results showed that it was uncertain whether a 45° bed head elevation was effective or harmful with regard to the occurrence of clinically suspected VAP, microbiologically confirmed VAP, decubitus and mortality, and that it was unknown whether 45° elevation for 24 hours a day increased the risk for thromboembolism or hemodynamic instability. A group of 22 experts recommended elevating the head of the bed of 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.


Although the review failed to prove clinical benefits of bed head elevation, experts prefer this position in ventilated patients. They made clear that the position of a ventilated patient in bed depended on many determinants. Therefore, given the scientific uncertainty about the benefits and harms of a semi-upright position, this position could only be recommended as the preferred position with the necessary restrictions.