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Copyright: Copyright © 2017, Iranian Red Crescent Medical Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.
1. Background
Ventilator-associated pneumonia (VAP) is the most common nosocomial infection that affects 28% of patients hospitalized in the intensive care unit (ICU) (1). VAP is the second most common healthcare-associated infection in the United States (2). VAP occurs in patients who are receiving mechanical ventilation for more than 48 hours (3). VAP is the most common nosocomial infection in critically ill patients and in patients under mechanical ventilation (4). It increases the duration of mechanical ventilation, hospital stay, and patient’s mortality (5). Risk factors for VAP are the prescription of proton pump inhibitors’ medications, sedatives, neuromuscular paralyzing agents, blood transfusions more than 4 units, monitoring the intracranial pressure, mechanical ventilation for more than 2 days, positive end expiratory pressure (PEEP), inserting the endotracheal and nasogastric feeding tubes, sleeping in the supine position, hospitalization in the ICU, and previous treatment with antibiotics (6). Other risk factors for VAP are endotracheal intubation and tracheostomy. Endotracheal tube significantly disturbs the mechanism for airway protection and causes local inflammation (7). Therefore, the prevention of VAP would be a major challenge and priority in the care of critically ill patients (2, 8).
Raising HOB, rinsing with Chlorhexidine, prophylactic medications for deep venous thrombosis, prevention of aspiration, hand washing, less use of sedatives, and early weaning of mechanical ventilation reduces VAP (9). The prevention of VAP reduces the duration of mechanical ventilation, length of hospital stay, mortality, and healthcare costs (10). Another preventive method in patients undergoing mechanical ventilation is raising HOB to 30 degrees or more (11). According to clinical guidelines related to the prevention of pneumonia and aspiration, HOB should be elevated to 30 - 45 degrees among mechanically ventilated patients (12). Clinical guidelines also recommend that HOB should not be raised to more than 30 degrees for the prevention of pressure ulcers (13). Raising HOB to more than 30 degrees increases the shear stress and causes pressure ulcers. For the prevention of pressure ulcers in the sacral area, clinical guidelines recommend that...