PICO Assignment

Introduction

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Usually, a research question has to be directly associated with the patient’s problem and is phrased or classified so that it’s easy to seek the answer. PICO is such a format, which is a mnemonic for the vital part of a clinical question. A PICO question normally used for finding evidence against an intervention (Melnyk & Fineout-Overholt, 2015). In this report, a PICO question has been used for the finding out the effectiveness of positioning patients in semi-fowler position to prevent nosocomial infections in comparison to the supine position.

Research question

In mechanically ventilated ICU patients, does positioning the patient in semi-recumbent causes lower incidence of ventilator- associated pneumonia in comparison to the supine position?

Problem/ Population(P)	ICU patients
Intervention (I)	Positioning the patient in the semi recumbent position
Comparison ©	Supine position
Outcome (O)	Lower incidence of ventilator associated pneumonia infections

Summary of evidence

Ventilator-associated pneumonia (VAP) is a pulmonary infection caused by the pathogen directly prevalent in hospital settings. In general, VAP is caused in patients who had been ventilated mechanically. About 9-13 cases in 1000 ventilator days have VAP, although it varies with the intensive care units (Bassi et al., 2017). Aspiration of the accumulated oropharyngeal secretion along the endo-tracheal tube is the primary mechanism for developing the VAP. It is associated with the design of the cuff of the endotracheal tube, which is generally developed in the mechanically ventilated patient. There had been little strong evidence indicating that gastroesophageal colonization and the aspiration of the pathogen, gastroesophageal reflux, pulmonary aspiration of the contents of the oropharyngeal region, and clearance of the secretion of the airways. All these can be changes via altered positioning of the body (Bassi et al., 2017). To prove the above-mentioned clinical question, a literary search will be conducted to find suitable evidence supporting the claim.

Lermaet al., (2014) have stated that elevation of the bed above 30 degrees can be an effective attempt to prevent gastric contents aspiration. The basis of the intervention had come from the studies, which have used radiolabelled enteral feeding solutions, which have shown that aspiration of the gastric contents takes place to a larger extent. Many RCTs have validated the use of semi-recumbent position. RCT’s have found that elevation of the bed of the patient at nearly 5 degrees had caused a significant reduction of VAP (Lermaet al., 2014). However, the exact degree to which the head should be elevated is yet to be resolved. This paper is supported with credible references, although it is not primary research and is mainly based on secondary research.

Wang li et al., (2016) had studied the comparison between the semi-recumbent position versus supine position for the prevention of ventilator-associated pneumonia in adults who are needing mechanical ventilation. For that, ten studies that involved 878 participants have been selected. Twenty-eight participants were lost to the follow-up. Al the participants have been selected from the intensive care units, which received mechanical ventilation for more than 24 hours. However, some eight studies have found that a semi-recumbent position has been clinically reported to decrease the rate of clinically suspected VAP. The balance of the benefits and harms of the semi-recumbent position is still uncertain (Wang li et al., 2016). The Centre for disease control has recommended semi-recumbent positioning for the prevention of VAP in patients which had been mechanically ventilated. This paper had clearly described about the findings, along with the intervention. It has been stated that contamination of the oropharyngeal secretion and the gastric contents led to the reflux of the gastric contents. The semi-recumbent position might help to avoid these problems and reduce the VAP. The head of the bed positioning less than 30 degree is linked with an increase of the risk of VAP. Some of the systematic reviews have indicated the use of the semi-recumbent position. It has also been found that increased elevation of the head can increase the risk of the pressure ulcers. The semi-recumbent positioning necessary for limited pulmonary aspiration and improved mutual clearance.

Edwardson & Cairns (2019) have also supported the previous research, which include evidence, placing the patient in the semi-recumbent to reduce VAP in comparison to the placement in the supine position. This is particularly applicable to the ones who had been getting enteral nutrition (Edwardson & Cairns 2019). The paper is a systematic review that that has been made by the meta-analysis of most of the randomised controlled trials. However, one recent study by Bassi et al., (2017) have exhibited a drastic reduction in the occurrence of the VAP in animals who had been positioned in the semi-recumbent position with a tracheal and endo-tracheal tube, oriented below the horizontal. Furthermore, reduced risk of respiratory infection has been demonstrated in patients positioned laterally, who had turned from one side to another. This study is a randomised controlled trial in critically ill patients. An RC that is well executed can provide high level of evidence about the efficacy of the interventions. The strength of this study is the large sample study chosen. Secondly, an invasive method was being used for increasing the specificity of the diagnosis of the VAP. Appropriate statistical methods were being used. CACE analysis used for the adherence. However, there were few limitations, like the blinding of the attending physician had not been possible, there was no continuous monitoring of the body position. Again, a population who are at risk early onset of VAP has been selected. Thus, he semi-recumbent position might have cleared the germs aspired at the time of the intubation. Hence, the exact strength of the positioning cannot be assessed. Similar results have been suggested by Trubiano, & Padiglione, (2015), where the semi-recumbent positioning has been considered to reduce aspirations in patient. This paper is a narrative review, with very less evidence or references, which reduces the credibility of the paper. Bassi et al., (2017) have stated that patient, who are mechanically ventilated and endotracheal intubated patients who are in the supine position are at high risk of developing ventilator-associated pneumonia due to the aspiration of the gastric bacteria.

Hence, five of the research indicate that, a semi-recumbent position in ventilated patient’s is efficient in reducing VAP infections. But there are few researches, whereas comparison has been given. And the exact degree to which a patient has to be positioned is still not clear, however, the supine position has to be avoided. To cover these research gaps, more Randomised controlled trials are required to ensure the facts’ validity.

References

Bassi, G. L., Panigada, M., Ranzani, O. T., Zanella, A., Berra, L., Cressoni, M., … & Torres, A. (2017). Randomized, multicenter trial of lateral Trendelenburg versus semirecumbent body position for the prevention of ventilator-associated pneumonia. Intensive care medicine, 43(11), 1572-1584.

Bassi, G. L., Xiol, E. A., Pagliara, F., Hua, Y., & Torres, A. (2017, June). Body position and ventilator-associated pneumonia prevention. In Seminars in respiratory and critical care medicine (Vol. 38, No. 03, pp. 371-380). Thieme Medical Publishers. 10.1055/s-0037-1603111

Edwardson, S., & Cairns, C. (2019). Nosocomial infections in the ICU. Anaesthesia & Intensive Care Medicine, 20(1), 14-18. https://doi.org/10.1016/j.mpaic.2018.11.004

Lerma, F. Á., García, M. S., Lorente, L., Gordo, F., Añón, J. M., Álvarez, J., … & Jam, R. (2014). Guidelines for the prevention of ventilator-associated pneumonia and their implementation. The Spanish “Zero-VAP” bundle. Medicina intensiva, 38(4), 226-236. 10.1055/s-0037-1603111

Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing & healthcare. A guide to best practice (3rd ed.). Philadelphia,PA: Wolters Kluwer/Lippincott Williams & Wilkins.

Trubiano, J. A., & Padiglione, A. A. (2015). Nosocomial infections in the intensive care unit. Anaesthesia & Intensive Care Medicine, 16(12), 598-602.

Wang, L., Li, X., Yang, Z., Tang, X., Yuan, Q., Deng, L., & Sun, X. (2016). Semi‐recumbent position versus supine position for the prevention of ventilator‐associated pneumonia in adults requiring mechanical ventilation. Cochrane Database of Systematic Reviews, (1). https://doi.org/10.1002/14651858.CD009946.pub2