Table 1 Characteristics of studies included
Study, year | Country | Population | Interventions | Diagnosis of VAP | Care Bundle |
|---|---|---|---|---|---|
Ayzac et al. 2016 [39] | France | Adults, invasive MV for ARDS, with severity criteria PaO2/FiO2 < 150 mmHg under FiO2 ≥ 0.6, PEEP ≥ 5 cm H2O, and VT = 6 ml/kg predicted body weight in previous 36 h, fulfilled after a 12–24 h stabilization period | ARM 1: Supine position; n = 229 ARM 2: Prone position, for at least 16 h consecutive; n = 237 | BAL ≥ 104 cfu/ml Tracheal aspirate ≥ 107 cfu/ml Wimberly brush ≥ 103 cfu/ml | Lung protective MV: VT = 6 ml/kg predicted body weight, neuromuscular blockade, and sedation, and weaning from MV |
Bassi et al. 2017 | Spain, Italy, Germany, Croatia, USA | Patients ≥ 18 years, expected to be on MV for at least 48 h, within 12 h from endotracheal intubation | ARM 1: Lateral Trendelenburg position; n = 194 ARM 2: Semi-recumbent position 30° angle; n = 201 | BAL or mini-BAL cultures ≥ 104 cfu/ml PSB ≥ 103 cfu/ml | Active humidification of respiratory gases. Every 6 h, patients were rotated from one side to the other |
Beuret et al. 2002 [40] | France | Invasive oral MV for coma, Glasgow ≤ 9. Initial settings were selected to obtain a VT = 10 ml/kg. They were further adjusted to PaCO2 = 5–40 mmHg, PEEP = 5 cm H2O | ARM 1: Supine position, head and trunk positioned at 0–20° angle; n = 28 ARM 2: Prone position, strictly horizontal, 4 h/day; n = 25 | PSB > 103 cfu/ml | NR |
Cai et al. 2006 | China | Adults admitted in ICU | ARM 1: Supine position, 0° angle; n = 27 ARM 2: Semi-recumbent position, 30° angle; n = 27 | Clinically suspected pneumonia: new, persistent or progressive radiographic infiltrate with at least two criteria: fever (Tª > 38 ℃ or < 35 ℃); leukocytosis or leucopenia (leucocytes > 10 × 109/L or < 3 × 109/L); and positive culture of tracheal secretion | NR |
Drakulovic et al. 1999 [46] | Spain | Patients intubated and with MV in two ICUs: respiratory and medical | ARM 1: Supine position, 0° angle; n = 47 ARM 2: Semi-recumbent position, 45° angle; n = 39 | Tracheobronchial aspirate > 105 cfu/ml BAL > 104 cfu/ml PSB > 103 cfu/ml | Sterile endotracheal suctioning; no change of MV tubing systems; stress ulcer prophylaxis; antacid medication |
Fernández et al. 2008 [42] | Spain | Intubated adult patients within 48 h of ARDS diagnosis | ARM 1: Supine position; n = 19 ARM 2: Prone position; at least 20 h/day; n = 21 | NR | Ventilator pattern, sedation and weaning protocoled |
Guérin et al. 2004 | France | Patients > 18 years, with MV through either oral or nasal tracheal intubation or tracheostomy; a PaO2/FIO2 of 300 or less. Expected duration of MV longer than 48 h | ARM 1: Semi-recumbent position; 30° angle n = 378 ARM 2: Prone position at least 8 h/day; n = 413 | BAL ≥ 104 cfu/ml Wimberley brush ≥ 103 cfu/ml | Periodic left and right lateral decubitus |
Hadi Hassankhan et al. 2017 [57] | Iran | Patients intubated with MV for ≥ 7 days (MODE = SIMV, VT = 6–8 ml/kg, PEEP = 2.5–7.5 cm H2O, FiO2 = < 50%, RR = 6–12/min) | ARM 1: Semi-recumbent position 45° angle; n = 11 ARM 2: Semi-recumbent position 60° angle; n = 10 | Sputum culture obtained by endotracheal suction technique | Oral and endotracheal suctioning routine; endotracheal cuff monitored; endotracheal with dorsal lumen and continuous suction; position changes every 2 h; prevention of stress ulcer; heparin and mouth washed with chlorhexidine |
Hang et al. 2012 [47] | China | Adult critical ventilated patients in ICU | ARM 1: Supine position, 0° angle; n = 19 ARM 2: Semi-recumbent position, 30° to 45° angle; n = 20 | Clinically suspected pneumonia: new, persistent or progressive radiographic infiltrate with at least two criteria: fever (Tª > 38 ℃ or < 35 ℃); leukocytosis or leucopenia (leucocytes > 10 × 109/L or < 3 × 109/ L); and positive culture of tracheal secretion | Enteral feeding and sucralfate or H2 antagonists for stress ulcer prophylaxis |
Hu et al. 2012 [48] | China | Adult critical ventilated patients in ICU | ARM 1: Supine position, 0° angle; n = 43 ARM 2: Semi-recumbent position, 30° to 45° angle; n = 43 | Clinically suspected pneumonia, but not definition | Enteral feeding, H2 antagonists for stress ulcer prophylaxis, and use of antibiotic prophylaxis |
Keely et al. 2007 | UK | Adult critical ventilated patients in ICU | ARM 1: Supine position, 25° angle; n = 13 ARM 2: Semi-recumbent position, 45° angle; n = 17 | BAL Tracheobronchial aspirate PSB | Standard ICU practices: nasogastric tubes for enteral feeding and parenteral nutrition; gastric ulcer prophylaxis; no change of ventilator tubing |
Loan et al. 2012 | Vietnam | Adults and children (aged ≥ 1 year) admitted to the ICU with a clinical diagnosis of severe tetanus | ARM 1: Supine position, 0° angle; n = 106 ARM 2: Semi-recumbent position, 30° angle; n = 104 | No-BAL ≥ 105 cfu/ml | Tetanus antitoxin, benzodiazepines to control muscle spam and hypertonia |
Mancebo et al. 2006 [42] | Spain and Mexico | Patients > 18 years, intubated with MV, and severe ARDS diagnosis | ARM 1: Supine position; n = 60 ARM 2: Prone position; at least 20 h/day; n = 76 | NR | NR |
Tahereh Najafi Ghezeljeh et al. 2017 [51] | Iran | Age > 18 years, no history of VAP, hospitalized in the ICU, under MV support for 8 h after hospitalization, no injuries in the spine, and no pelvic unstable fracture | ARM 1: Supine position; n = 40 ARM 2: Semi-recumbent position 30° angle; n = 40 ARM 3: Semi-recumbent position 45° angle; n = 40 | Mini BAL | Changing the position every 2 h, assessment of pressure areas, changing wet sheets, rinsing with chlorhexidine, tracheal suction |
Van Nieuwenhoven et al. 2006 [52] | Netherlands | Adult patients intubated within 24 h of ICU admission and had an expected duration of VM of at least 48 h | ARM 1: Supine position, 10° angle; n = 109 ARM 2: Semi-recumbent position, 45° angle; n = 112 | BAL ≥ 104 cfu/ml | Sucralfate or H2 antagonists for stress ulcer prophylaxis. Enteral feeding via nasogastric tube |
Voggenreiter et al. 2005 [43] | Germany | Multiple trauma patients (18–80 years; ISS ≥ 16) who were receiving MV with a PaO2/FiO2 ≤ 200 or with a PEEP ≥ 5 cm of water, and (if measured) a pulmonary capillary wedge pressure ≥ 18 mm Hg, or the absence of clinical evidence of left atrial hypertension and pulmonary infiltrates on chest x-ray | ARM 1: Supine position; n = 19 ARM 2: Prone position; at least 8 h/day and maximum 23 h/day; n = 21 | BAL | NR |
Watanabe et al. 2002 [44] | Japan | Patients admitted in ICU who underwent three-field lymphadenectomy, with PaO2/FIO2 < 200, PEEP > 5 cm H2O, on the fifth postoperative day | ARM 1: Supine position; n = 8 ARM 2: Prone position; n = 8 | NR | NR |
Wu et al. 2009 [53] | China | Adult critical ventilated patients in ICU | ARM 1: Supine position, 0° angle; n = 56 ARM 2: Semi-recumbent position, 30° to 60° angle; n = 56 | Tracheobronchial aspirate > 105 cfu/ml BAL > 104 cfu/ml PSB > 103 cfu/ml | Enteral feeding and use of antibiotic prophylaxis |
Xue et al. 2012 [54] | China | Adult critical patients in ICU with VM > 48 h | ARM 1: Supine position, 0° angle; n = 48 ARM 2: Semi-recumbent position, 30° to 45° angle; n = 48 | Clinically suspected pneumonia: new, persistent or progressive radiographic infiltrate with at least two criteria: fever (Tª > 38 °C or < 35 °C); leukocytosis or leucopenia (leucocytes > 10 × 109/L or < 3 × 109/L); and positive culture of tracheal secretion | NR |
Yu et al. 2012 [55] | China | Adult critical ventilated patients in ICU | ARM 1: Supine position, 0° angle; n = 32 ARM 2: Semi-recumbent position, 30° angle; n = 33 | Clinically suspected pneumonia: new, persistent or progressive radiographic infiltrate with at least two criteria: fever (Tª > 38 °C or < 35 °C); leukocytosis or leucopenia (leucocytes > 10 × 109/L or < 3 × 109/L); and positive culture of tracheal secretion | NR |