Table 2 Recommendation on bed head elevation with its rationale

1. based on the results of the systematic review,

   • it is uncertain whether a 45° bed head elevation is effective or harmful with regard to the occurrence of clinically suspected VAP, microbiologically confirmed VAP, decubitus and mortality;

   • it is unknown whether a 45° bed head elevation for 24 hours a day causes thromboembolism or hemodynamic instability;

2. maintaining a semi-upright position for 24 hours a day may cause conflict with other nursing tasks or medical interventions like insertion of intravascular catheters, providing good hygiene to the patient, prevention of decubitus, intensive physiotherapy or wound care, so that semi-upright position must be abandoned;

3. there are absolute contraindications to nursing mechanically ventilated patients in a semi-upright position - that is, patients with recent thoracic or lumbar surgery of the spine and patients with thoracic or lumbar spine injury;

4. there are a relative large number of mechanically ventilated patients with relative contraindications where caution is indicated when the patient is placed in a semi-upright position - that is, patients with hemodynamic instability; trauma of the pelvic region; and severe sacral decubitus;

5. besides the possible prevention of VAP,

a) semi-upright position of ventilated patients,

   • might improve oxygenation and ventilation;

   • decreases facial edema;

b) semi-upright position of awake ventilated patients,

   • might promote easier communication between patients and relatives or staff, better orientation in the room and more effective coughing;

6.

   • semi-uptight position of ventilated patients interferes with the prevention of decubitus - that is, changing position frequently;

   • patients glide away to the foot end of the bed when using anti-decubitus mattresses;

7. the wish of awake patients to change body position regularly should be respected.

8. the intervention is no cost;

European experts in intensive medicine CONCLUDE that the recommendation should not be compelling, because the prevention of VAP is uncertain and the balance between benefits and harms is unknown, and maintaining semi-upright position interferes with other nursing tasks or with medical interventions.

The experts RECOMMEND to elevate the head of the bed of mechanically ventilated patients to a 20 to 45° position and preferably in a ≥30° position as long as it is does not pose risks and conflicts with other nursing tasks, medical interventions or with patients' wishes.