HEAD-OF-BED ELEVATION AND EARLY OUTCOMES OF GASTRIC REFLUX, ASPIRATION, AND PRESSURE ULCERS: A FEASIBILITY STUDY

Background Guidelines recommending head of bed (HOB) elevation greater than 30 degrees to prevent ventilator-associated pneumonia conflict with guidelines to prevent pressure ulcers, which recommend HOB elevation less than 30 degrees. Objectives To examine the feasibility of 45 degrees HOB elevation and describe and compare the occurrence of reflux, aspiration, and pressure ulcer development at 30 degrees and 45 degrees 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 tau correlations were conducted. Results Fifteen patients were enrolled; 11 completed both days. Patients were maintained at 30 degrees (mean, 30 degrees) for 96% of minutes and at 45 degrees (mean, 39 degrees) 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 30 degrees elevation (54%) than at 45 degrees elevation (20%). The median percentage of pepsin-positive tracheal secretions was not significantly higher (P = .37) at 30 degrees elevation (71%) than 45 elevation (67%). Deeper sedation correlated with increased reflux (P = .03). Conclusions HOB elevation greater than 30 degrees is feasible and preferred to 30 degrees for reducing oral secretion volume, reflux, and aspiration without pressure ulcer development in gastricfed patients receiving mechanical ventilation. More deeply sedated patients may benefit from higher HOB elevations.