• Gianluigi Li Bassi, Mauro Panigada, Otavio T Ranzani, Alberto Zanella, Lorenzo Berra, Massimo Cressoni, Vieri Parrini, Hassan Kandil, Giovanni Salati, Paola Selvaggi, Alessandro Amatu, Miquel Sanz-Moncosi, Emanuela Biagioni, Fernanda Tagliaferri, Mirella Furia, Giovanna Mercurio, Antonietta Costa, Tullio Manca, Simone Lindau, Jaksa Babel, Marco Cavana, Chiara Chiurazzi, Joan-Daniel Marti, Dario Consonni, Luciano Gattinoni, Antonio Pesenti, Janine Wiener-Kronish, Cecilia Bruschi, Andrea Ballotta, Pierpaolo Salsi, Sergio Livigni, Giorgio Iotti, Javier Fernandez, Massimo Girardis, Maria Barbagallo, Gabriella Moise, Massimo Antonelli, Maria Luisa Caspani, Antonella Vezzani, Patrick Meybohm, Vladimir Gasparovic, Edoardo Geat, Marcelo Amato, Michael Niederman, Theodor Kolobow, Antoni Torres, and Gravity-VAP Network.
• Department of Pulmonary and Critical Care Medicine, Hospital Clinic, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain. glibassi@clinic.cat.
• Intensive Care Med. 2017 Nov 1; 43 (11): 1572-1584.

PurposeThe lateral Trendelenburg position (LTP) may hinder the primary pathophysiologic mechanism of ventilator-associated pneumonia (VAP). We investigated whether placing patients in the LTP would reduce the incidence of VAP in comparison with the semirecumbent position (SRP).MethodsThis was a randomized, multicenter, controlled study in invasively ventilated critically ill patients. Two preplanned interim analyses were performed. Patients were randomized to be placed in the LTP or the SRP. The primary outcome, assessed by intention-to-treat analysis, was incidence of microbiologically confirmed VAP. Major secondary outcomes included mortality, duration of mechanical ventilation, and intensive care unit length of stay.ResultsAt the second interim analysis, the trial was stopped because of low incidence of VAP, lack of benefit in secondary outcomes, and occurrence of adverse events. A total of 194 patients in the LTP group and 201 in the SRP group were included in the final intention-to-treat analysis. The incidence of microbiologically confirmed VAP was 0.5% (1/194) and 4.0% (8/201) in LTP and SRP patients, respectively (relative risk 0.13, 95% CI 0.02-1.03, p = 0.04). The 28-day mortality was 30.9% (60/194) and 26.4% (53/201) in LTP and SRP patients, respectively (relative risk 1.17, 95% CI 0.86-1.60, p = 0.32). Likewise, no differences were found in other secondary outcomes. Six serious adverse events were described in LTP patients (p = 0.01 vs. SRP).ConclusionsThe LTP slightly decreased the incidence of microbiologically confirmed VAP. Nevertheless, given the early termination of the trial, the low incidence of VAP, and the adverse events associated with the LTP, the study failed to prove any significant benefit. Further clinical investigation is strongly warranted; however, at this time, the LTP cannot be recommended as a VAP preventive measure. CLINICALTRIALS.Gov IdentifierNCT01138540.

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