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            Nosocomial pneumonia is the leading cause of death from hospital-acquired infections and is considered as the most common ICU-acquired infection (Craven, Steger and Barber, 1991; Sole-Violan et al, 2001). VAP, as a type of nosocomial pneumonia, is one of the concerns of ICU nurses as it has a great chance to develop within a critically ill person. Mayhall (2001) defined Ventilator-associated pneumonia (VAP) as a nosocomial pneumonia in a patient on mechanical ventilatory support (by endotracheal tube or tracheostomy) for >48 hours. In other words, VAP is pneumonia in a patient receiving mechanical ventilation that was neither present nor developing at the time of intubation (Grap et al, 2005). This definition is based from diagnosis by the clinical criteria of Johanson et al (1972), which includes progressive pulmonary infiltrate, fever, leukocytosis, and purulent tracheobronchial secretions. Currently, there is still difficulty in diagnosing VAP as it remains controversial (Gould et al, 2003).  Techniques for accurate diagnosis such as bronchoscopically directed techniques and nonbronchoscopically directed diarnosis face certain issues such as being invasive, high cost and lack of validation (Mayhall, 2001).


            One of the issues in VAP is its relationship with backrest elevation, as researchers were trying to link the development of the former with the latter. A recent research by Grap et al (2005) showed that backrest elevation, combined with a severe illness, most likely to develop VAP. This confirms previous findings of the same topic – basically about the relationship between VAP and backrest elevation. However, it did not confirm previous findings that "the greater the length of time in lower backrest positions, the greater was the incidence of aspiration of gastric contents" (Torres et al, 1992). Furthermore, Grap et al's (2005) findings were limited in a sense that they only covered a small sample size and they lack bronchoscopic evaluation for diagnosis of pneumonia. Grap et al (2005) suggested that future studies should be conducted to confirm the results of their work. They also evaluated only those who have early onset VAP and not those who have later onset VAP. There is a need to evaluate the impact of backrest position on later onset VAP as well because this may show other implications.


            This paper proposes to explore and re-assess the relationship between VAP and backrest position on patients, specifically the impact of the latter to the former. Previous studies show positive relationships between the two. However, those findings were based on limited methods and procedures. Thus, there is a need for continuous evaluation so as findings can be confirmed and to make sure that there will be no contradictions among findings.


            The aim of this investigation is to confirm previous findings regarding the impact of backrest position on VAP. This study will be addressed through quantitative and qualitative research methods so as to have a variety of data options to analyze, to increase the validity of the findings. In this approach, observations, surveys and interviews on nurses will be conducted, as well as simple tests performed by Grap et al (2005) in their study.




            The problem that will be investigated in the study is the controversy regarding the effects or impact of backrest positioning on the onset of VAP. Studies show that "supine position is an independent risk factor for mortality in patients receiving mechanical ventilation" (Craven et al, 1986; Kollef, 1993). Mortality in the ICU is found greater with supine patients than with semirecumbent patients. There were findings that height of backrest position and time spent supine are both critical factors in the occurrence of aspiration, and such aspiration increases the risk of pneumonia in patients receiving mechanical ventilation (Kollef, 1995; Torres et al, 1992). Thus, bed angles should accurately be estimated so as the nurses can position the patients better while on critical care (Grap et al, 2002). Lower backrest positions and higher backrest positions are both required for different tasks such as hemodynamic monitoring and measurement. Grap et al (2002) stated that higher backrest positions are inadequate for patients in critical care and lower backrest positions are more preferred. However, decisions are still based on the nurses' accurate estimates of the patients' positions (Grap et al, 2002).


            Because of the belief that patient positioning is critical when it comes to mortality risks, and that VAP is usually associated with such positioning, specifically backrest positioning, many researchers investigated the relationship between the two and came up with similar positive findings with slight differences. However, their findings were limited with the number of samples they included and the methods they used to conduct the study. Thus, there is a need to confirm the findings further with new studies. This problem statement is given priority in this study.





The aim of the study is to confirm the positive relationship between VAP and backrest positioning of patients. However, unlike previous studies that performed only clinical trials, this study will also examine the issue with the use of traditional data collection approaches such as surveys and interviews. Clinical trials will also be performed such as diagnosis for VAP and observation of patients that are in the backrest positions.


The objectives of the study are as follows:

1.                  To conduct a diagnosis of patients with early and later onset VAP.

2.                  To measure the head elevation using a 2 transducer system, similar to what Grap et al (2005) used in their study.

3.                  To determine the amount of time spent by patients on backrest elevation.

4.                  To interview nurses about their experiences on backrest elevation leading or worsening a VAP.

5.                  To survey the hospital about the number of cases that relates backrest elevation with VAP.

6.                  To categorize and analyze data to form a coherent conclusion.






The study will be significant for medical and healthcare practitioners because it covers one of the most important and controversial issues in nursing. The importance of positioning has been well-emphasized by various studies, but its relationship with several difficult-to-diagnose diseases such as VAP still fall short in terms of confirmation of data. Through this study, previous findings can either be strengthened or weakened, but either way, this can be a great help to the healthcare sector. If ever previous findings will be supported, the findings of this study may influences practitioners to take careful measures on bed positioning of patients. On the other hand, if ever the findings will contradict with previous studies, it may influence other researchers to challenge its findings, which may contribute to the growth of research in the topic, and ultimately may lead in the development of more effective interventions.


The study will also be significant to nursing students as this can serve them as reference to their studies. This study may also used as reference for future studies that will tackle the same topic.





Design and Sample


            The study will be categorized into two samples: the patients and the nurses. The patients will undergo specific measures specifically the level of head elevation using the 2 transducer system used by Grap et al (2005), and the measurement of their time spent on backrest elevation. Other clinical data about the patients will also be acquired such as the daily doctor's report about the patient's condition. Similar to the study of Grap et al (2005), patient respondents in this study will be kept in only the minimum of 10 because of the difficulty to monitor a higher number of patients simultaneously. The duration of the investigation will also be lesser than Grap et al (2005) since the study will focus more on patients with later onset VAP. Late-onset VAP occurs after 4 days of continuous mechanical ventilation (Grap et al, 2005).


            Two variables will be measured among the patients: this include backrest elevation and VAP. As mentioned, the level of head elevation will be measured using transducer, while the time patient spent on backrest position will be monitored and will later be transformed to statistical figures. On the other hand, the diagnosis of the VAP will be conducted using bronchoscopic techniques. A flexible bronchoscope will be used to acquire tissue samples from the patients.


            On the other hand, the nurse samples will be interviewed and surveyed regarding their experiences and observations on the relationship between VAP and backrest elevation. This will include their views on backrest elevation and how they estimate the position of the patients, and to which factors do they base their decisions.


Data Analysis



            Similar to Grap et al (2005), the study will be analyzed using descriptive statistical analysis. Similarly, percentages for discrete variables and means and SDs for continuous variables will be calculated. Summaries for backrest elevation, nutritional data, and oral care interventions will be generated for each study day. The research will commit a total of 90 study days for the investigation.


            The formulas for the descriptive analysis are as follows:


1.                  Percentage – to determine the magnitude of the responses to the questionnaire.


% = -------- x 100        ;           n – number of responses

            N                                 N – total number of respondents

2.       Weighted Mean

            f1x1 + f2x2  + f3x3 + f4x4  + f5x5

x = ---------------------------------------------  ;


where:             f – weight given to each response

                        x – number of responses

                        xt – total number of responses


On the other hand, interviews and surveys with the nurses will be conducted with semi-structured questionnaires. Interviews will be conducted informally and occasionally. The questionnaires will be in the form of a 5-point Likert Scale where the respondents will choose on whether they agree or disagree on a particular statement. Other questions will be asked with an open question type so as the respondents will have the option to further elaborate their answers.


            The overall data will be categorized and compared. Each result per day will be recorded and computed after all the study days were conducted. This is similar with what Grap et al (2005) did, but as the researchers stated, there is still a need to confirm their findings with different samples. Conclusion will be derived from the analyzed data.


Ethical Considerations



            Because this will be a clinical research, ethical considerations will be well-observed in the study. For instance, the confidentiality of data such as personal information of nurses and patients will be observed. Furthermore, the researchers will submit to requests of doctors and nurses if ever there is a need for one such as those concerning the patient's welfare. Tests such the bronchoscopy will be conducted with the assistance of experts on the machine.





            Like previous studies, this current study is limited on patient respondents because of the restraint in manpower and time to monitor a larger population sample. The study is also limited only to descriptive data analysis, meaning it will just present facts about the relationship between the two variables but not to the point wherein personal and in-depth analysis will be provided.



Craven, D.E., Kunches, L.M., Kilinsky, V., Lichtenberg, D.A., Make, B.J., and McCabe, W.R. (1986). Risk factors for pneumonia and fatality in patients receiving continuous mechanical ventilation. Am Rev Respir Dis., 133, 792-796.

Craven, .D.E., Steger, K.A., Barber, T.W. (1991). Preventing nosocomial pneumonia: state of the art and perspectives for the 1990s. Am J Med, 91, 44S-53S


Gould, M.K. et al (2003). Variability in Antibiotic Prescribing Patterns and Outcomes in Patients With Clinically Suspected Ventilator-Associated Pneumonia. Chest, 123, 835 - 844.


Grap, M.J. et al (2005). Effect of Backrest Elevation on the Development of Ventilator-Associated Pneumonia. American Journal of Critical Care, 14(4), 325-332

Grap, M.J., Dillon, A. and Munro, C.L. (2002). Nurses' Accuracy in Estimating Backrest Elevation. American Journal of Critical Care, 11, 34-37

Johanson, W.G. Jr, Pierce, A.K., Sanford, J.P., and Thomas, G.D. (1972). Nosocomial respiratory infections with gram-negative bacilli. The significance of colonization of the respiratory tract. Ann Intern Med 77, 701-6.

Kollef, M.H. (1993).Ventilator-associated pneumonia: a multivariate analysis. JAMA, 270,1965-1970.

Kollef MH. (1995). The identification of ICU-specific outcome predictors: a comparison of medical, surgical, and cardiothoracic ICUs from a single institution. Heart Lung, 24, 60-66.

Mayhall, G.C. (2001). Ventilator-Associated Pneumonia or Not? Contemporary Diagnosis. Emerging Infectious Disease, 7(2), 200-204.


Sole-Violan, J. et al (2001). International Conference for the Development of Consensus on the Diagnosis and Treatment of Ventilator-Associated Pneumonia, Chest, 120, 955 - 970.


Torres, A, Serra-Batlles, J., Ros, E., et al (1992). Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med, 116, 540-543.



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