Korean J Crit Care Med.  2011 Sep;26(3):128-133. 10.4266/kjccm.2011.26.3.128.

Implementation of the Head of Bed (HOB) Elevation Protocol on Clinical and Nutritional Outcomes in Critically Ill Patients with Mechanical Ventilator Support

  • 1Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea. nswksj@yuhs.ac
  • 2Department of Nutrition and Dietetics, Severance Hospital, Seoul, Korea.
  • 3Medical/Surgical Intensive Care Unit, Department of Nursing, Severance Hospital, Seoul, Korea.


Although head of bed (HOB) elevation is an important strategy to prevent ventilator associated pneumonia (VAP), some observational studies have reported that the application of the semi-recumbent position was lower in patients receiving mechanical ventilator support. We performed this study to assess the effect of implementation of the HOB elevation protocol in the intensive care unit (ICU) on clinical and nutritional outcomes.
We developed a HOB elevation protocol including a flow chart to determine whether the HOB of newly admitted patients to ICU could be elevated. We measured the level of HOB elevation in patients with mechanical ventilator twice a day and 2 days a week for 5 weeks before and after the implementation of the protocol, respectively. Hemodynamic, respiratory and nutritional data were also collected, resulting in 251 observations from 35 patients and 467 observations from 66 patients before and after implementation.
After implementing the protocol, the level of HOB elevation (16.7 +/- 9.9 vs. 23.6 +/-1 2.9, p < 0.0001) and observations of HOB elevation > 30degrees increased significantly (34 vs. 151, p < 0.0001). There was no significant difference in the incidence of VAP. Arterial oxygen tension/fraction of inspired oxygen ratio improved (229 +/- 115 vs. 262 +/- 129, p = 0.02). Mean arterial blood pressure decreased after the implementation of the protocol, but remained within the normal limits. Calorie intake from tube feeding increased significantly (672 +/- 649 vs. 798 +/- 670, p = 0.021) and the events of high gastric residual volume (> 100 ml) occurred less frequently after implementing the protocol (50% vs. 17%, p = 0.001)
Implementation of the protocol for HOB elevation could improve the level of HOB elevation, oxygenation parameter and enteral nutrition delivery.


enteral nutrition; head of bed elevation; oxygenation; protocol; ventilator-associated pneumonia

MeSH Terms

Arterial Pressure
Critical Illness
Enteral Nutrition
Intensive Care Units
Pneumonia, Ventilator-Associated
Residual Volume
Ventilators, Mechanical
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