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1 대한중환자의학회지 : 제 26 권제 3 호 Vol. 26, No. 3, September, 2011 / DOI: /kjccm 원 저 환기보조받는중환자에서병상머리올림프로토콜적용이임상경과와경장영양공급에미치는효과 연세대학교의과대학마취통증의학교실및마취통증의학연구소, * 세브란스병원영양팀, 내외과계중환자실간호팀 라세희ㆍ이호선 * ㆍ고신옥ㆍ이현심 ㆍ나성원 Implementation of the Head of Bed (HOB) Elevation Protocol on Clinical and Nutritional Outcomes in Critically Ill Patients with Mechanical Ventilator Support Se Hee Na, M.D., Hosun Lee, Ph.D.*, Shin Ok Koh, M.D., Hyun Sim Lee and Sung Won Na, M.D. Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, *Department of Nutrition and Dietetics, Medical/Surgical Intensive Care Unit, Department of Nursing, Severance Hospital, Seoul, Korea Background: 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. Methods: 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. Results: After implementing the protocol, the level of HOB elevation (16.7 ± 9.9 vs ±1 2.9, p < ) and observations of HOB elevation > 30 o increased significantly (34 vs. 151, p < ). 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) Conclusions: Implementation of the protocol for HOB elevation could improve the level of HOB elevation, oxygenation parameter and enteral nutrition delivery. Key Words: enteral nutrition, head of bed elevation, oxygenation, protocol, ventilator-associated pneumonia. 서 위내용물흡인의가장중요한위험요인은비위관과앙와위로유지되는환자의자세라고보고되었으며,[1,2] Torres 논문접수일 :2011 년 1 월 18 일, 수정일 :2011 년 4 월 13 일, 승인일 : 2011 년 6 월 17 일책임저자 : 나성원, 서울시서대문구성산로 250 연세대학교의과대학마취통증의학교실및마취통증의학연구소우편번호 : Tel: , Fax: nswksj@yuhs.ac 론 128 등 [3] 의실험연구에서도반좌위에비해앙와위일때방사성물질을포함한위내용물의기관내흡인율이더높았음을보고했다. 병상머리올림은경장영양공급시흡인의위험을줄임으로써인공호흡기관련폐렴 (ventilator-associated pneumonia, VAP) 의위험을줄일수있는간단한방법으로, 중환자의영양집중지원지침에서는흡인에의한 VAP의예방을위해기관내삽관환자에게경장영양을공급할때는 30 45도로병상머리올린자세를유지하도록권고하였다.[4-6] 한관찰연구에서환기보조받는대다수환자의병상각도가 30도미만이었으며,[7] 혈역동학적불안정을악화시키고, 욕창발생을증가시킬수있다는의료진의부정적

라세희외 4 인 :Implementation of the Head of Bed Elevation Protocol 129 인인식이병상머리올림수행을방해하는요인으로보고되었다.[8] 하지만, 병상머리올린자세를취하였을때경장영양에어떤영향을미치는지, 혈역학적불안정과욕창의발생률을얼마나증가시키는지에대한연구는시행되지않았다.

2 라세희외 4 인 :Implementation of the Head of Bed Elevation Protocol 129 인인식이병상머리올림수행을방해하는요인으로보고되었다.[8] 하지만, 병상머리올린자세를취하였을때경장영양에어떤영향을미치는지, 혈역학적불안정과욕창의발생률을얼마나증가시키는지에대한연구는시행되지않았다. 한편, Helman 등은 [9] 환기보조받는중환자에서침상머리각도에대한표준화된처방을추가하고간호사에대한교육을강화함으로써병상머리올림의평균각도와 30도이상유지되는환자의비율이증가되었음을보고했다. 따라서, 본연구는환기보조받는중환자에서침상머리올림프로토콜을개발하고, 적용전과후에병상머리올림각도와동맥혈산소화를포함한임상경과및경장영양공급시의위잔여량에대한효과를알아보고자하였다. 대상및방법내외과계중환자실 (54 병상 ) 에입원하여환기보조받는성인환자를대상으로시행되었다. 수술로인하여병상머리올림이제한적인환자, 즉척추수술, 전대퇴골관절수술환자이거나골반손상, 척추손상환자및시술후절대안정을요하는환자들 ( 기관절개술후 12시간이내, 혈관조영술후 3시간이내, 뇌척수액검사후 4시간이내등 ) 은측정대상에서제외했다. 병상머리올림각도측정은프로토콜적용전과적용 4 주후에각각 5주간실시하였으며, 매주마다 2일을임의로선택하고선택된날에임의로 2회측정했다. 동일환자에대해서도하루중측정시간에따라병상머리올림각도가 달라질수있으나 24시간동안지속적으로측정이불가능하므로가능한선택된요일의배분과하루중측정시간이다양하도록측정시점을임의적으로정했다. 병상머리올림각도측정시마다수축기혈압과이완기혈압, 평균동맥압, 혈역학적안정유지를위한혈역학약물의사용여부및투여량, 진정제와진통제의사용여부및투여량, 경장영양공급여부와공급량, 욕창유무를관찰혹은전자의무기록을통해수집했다. 측정시점에앙와위를취하고있는환자의경우에는사유를기록했다. 인공호흡기관련폐렴 (ventilator-associated pneumonia, VAP) 은미국질병관리센터 (CDC 2003년 ) 의병원감염진단기준에의해진단했다.[6,10] 프로토콜은인공호흡기관련폐렴과관련된문헌고찰을통해병상머리올림각도를 30도이상으로유지하는것을목표로했다. 주요내용은중환자실에처음입실하는환자의병상머리올림에대한의사결정의흐름과검사나시술종료후, 욕창예방을위한환자의자세와위치변경후등중환자실치료중에환자가이동하거나자세가반좌위에서앙와위로변경된후다시반좌위로변경하는것을잊기쉬운시점에서의병상머리올림을확인하도록했다 (Fig. 1). 개발된병상머리올림프로토콜내용은내외과중환자실간호사를대상으로 2주간 4회의집담회와 1회의집단교육을통해교육했다. 프로토콜내용을수시로기억할수있도록침상머리올림관련표어를중환자실각침상머리위벽면에게시하고, 프로토콜내용은각침상옆에비치된간호사용차트안쪽면, 눈에쉽게띄는곳에비치했다. 측정한모든결과는평균 ± 표준편차로표시했으며, SP- SS for Windows ver (SPSS Inc., Chicago, IL, USA) 을 Fig. 1. Head of bed elevation protocol. MBP: mean arterial pressure; CVP: central venous pressure.

3 130 대한중환자의학회지 : 제 26 권제 3 호 2011 이용하여분석하였다. 프로토콜적용전후의평균침상각도, 평균동맥압, 심혈관계약물및진정제투여량, 경장영양을통한열량공급량에차이가있는지 Student t-test로분석했고, 침상각도가 30도이상측정된비율, 혈역학약물과진정제사용여부, 인공호흡기관련폐렴과욕창발생률에차이가있는지 chi-square test로분석했다. p < 0.05인경우통계적으로유의한것으로해석했다. 결 프로토콜적용전 5주간은 35명대해총 251회, 적용 1개월후 5주동안 66명을대상으로총 467회병상머리올림각도를측정했다. 프로토콜적용전과후의대상환자의연령, APACHE II 점수, 인공호흡기치료기간, 중환자실재실기간및사망률은프로토콜적용전후에통계적으로의미있는차이를보이지않았다. 인공호흡기관련폐렴발생률 Table 1. Demographic Characteristics (n = 35) (n = 66) Age (year old) 65.5 ± ± Gender (M/F) 20/15 39/27 (57%/43%) (59%/41%) APACHE II score 20.9 ± Diagnosis Respiratory Renal/Gastrointestinal 7 9 Oncology 1 11 Cardiovascular 1 7 Infectious 2 10 Postoperative care 4 2 Neurology 5 7 Others 0 2 Values are mean ± SD or number of patients. APACHE: acute physiology and chronic health evaluation. 과 은프로토콜적용전에 5.7%, 적용후에 3.0% 로감소하였으나통계적으로유의한차이가없었다. 욕창발생률도프로토콜적용전과후에각각 31.4% 와 27.3% 로차이가없었다 (Table 1, 2). 병상머리올림각도는프로토콜적용전에 16.7 ± 9.9도에서적용후에 23.6 ± 12.9도로통계적으로의미있는증가를보였으며 (p = ), 전체측정횟수중 30도이상측정된횟수의비율도프로토콜적용전 13.5% 에서적용후 32.3% 로증가되었다 (p < ). 산소화지표인흡인산소분률에대한동맥혈산소분압의비율 (PaO 2/FiO 2 ratio) 은프로토콜적용후에통계적으로의미있는증가를보였다 (p = 0.02). 병상머리올림각도측정에포함된환자중경장영양을공급받은환자수는프로토콜적용전과후에각각 65.7% 와 43.9% 로차이가없었으나, 전체측정횟수중경장영양이공급된비율은프로토콜적용전, 39.0% 에서적용후에 47.8% 로통계적으로의미있는증가를보였고 (p = 0.021), 경장영양공급량도프로토콜적용후에의미있게증가되었다. 평균위잔여량은프로토콜적용전후에차이가없었으나위잔여량이 100 ml 이상으로높게측정된건수는프로토콜적용후에유의적으로감소했다 (50% vs 17%, p = 0.001) (Table 3). 프로토콜적용후의수축기혈압과이완기혈압, 평균동맥압은적용전에비해유의적으로감소했으나두군모두에서정상범위이내였다. 병상머리올림각 Table 2. Clinical Outcomes (n = 35) (n = 66) Sore incidence (n, %) 11 (31.4) 18 (27.3) VAP incidence (n, %) 2 (5.7) 2 (3.0) ICU length of stay (day) 16.9 ± ± Mortality (n, %) 8 (22.9) 18 (27.3) Values are mean ± SD or number of patients. VAP: ventilator associated pneumonia; ICU: intensive care unit. Table 3. The Level of Head of Bed (HOB) Elevation, Oxygenation and Nutritional Outcomes Pre-implementation (n = 251) Post-implementation (n = 467) Degree of HOB elevation ( o ) 16.7 ± ± 12.9 < Patients of HOB degree >30 o (n, %) 34 (13.5) 151 (32.3) < P/F ratio (mmhg) 229 ± ± Number of tube feeding incidences when monitoring the HOB elevation (n, %) 98 (39.1%) 186 (47.8%) Days to start tube feeding from ICU admission 4.9 ± ± Days to reach feeding target from ICU admission 7.7 ± ± Calorie intake from tube feeding (kcal) 672 ± ± Mean GRV (ml) 29 ± ± Events of high GRV (n, %) 26/52 (50) 8/47 (17) Values are mean ± SD. P/F ratio: PaO 2/FiO 2; GRV: gastric residual volume.

4 라세희외 4 인 :Implementation of the Head of Bed Elevation Protocol 131 Table 4. Hemodynamic Variables and Use of Vasoactive Drugs (n = 251) (n = 467) Hemodynamics Systolic BP (mmhg) 138 ± ± 19 < Diastolic BP (mmhg) 71 ± ± 12 < Mean BP (mmhg) 94 ± ± 12 < Vasoactive drugs Patients who needed 77 (30.7) 125 (26.8) vasoactive drugs (n, %) Norepinephrine (μg/kg/min) 1.0 ± ± Dopamine (μg/kg/min) 5.1 ± ± Dobutamine (μg/kg/min) 7.7 ± ± Values are mean ± SD or number of patients. BP: blood pressure. Table 5. The Use of Sedatives and Analgesics (n = 251) (n = 467) Patient with sedatives (n, %) 99 (39.4) 208 (44.6) Ramsay score 4.9 ± ± Sedatives and analgesics Midazolam (μg/kg/min) 1.6 ± ± 1.2 < Ketamine (μg/kg/min) 15.6 ± ± Lorazepam (μg/kg/min) 0.7 ± ± 0.7 < Alfentanil (μg/kg/min) 0.3 ± ± Values are mean ± SD or number of patients. 도측정시점에혈역동학안정을위한혈역학약물사용률은프로토콜적용전과후에차이가없었으나, 약물종류별로보았을때노르에피네프린 (norepinephrine) 의주입량은프로토콜적용전과후에차이가없었으나도파민 (dopamine) 주입량은프로토콜적용후에통계적으로의미있는증가를, 도부타민 (dobutamine) 은감소를보였다 (Table 4). 침상각도측정시점에진정제가주입되고있는경우와진정척도인 Ramsay 점수는프로토콜적용전, 후에차이가없었으나미다졸람 (midazolam) 과로라제팜 (lorazepam) 투여량은프로토콜적용후높았고, 케타민 (ketamine) 과알펜타닐 (alfentanil) 투여량은차이가없었다 (Table 5). 병상머리올림을하지않고앙와위를유지한사유로는혈역동학적불안정이 35.4% 로가장많았고, 수술과기관절개, 지속적신대체요법등의시술이각각 25.3% 와 9.1% 였으며, 사유를알수없는경우가 30.3% 였다 (Table 6). 혈압불안정을사유로앙와위를유지하고있던 35건중 21건에서만평균동맥압이 70 mmhg 미만이었으며, 나머지 14건에서는 70 mmhg 이상이었다. Table 6. Reasons to Limit the HOB Elevation n = 99 Hemodynamic unstable (n, %) 35 (35.4) Operation (n, %) 25 (25.3) Tracheotomy or CRRT (n, %) 9 (9.1) Unknown 30 (30.3) Values are number of events. CRRT: continuous renal replacement therapy. 고 본연구결과, 병상머리올림프로토콜적용으로환기보조받는환자의병상머리올림각도와 30도이상으로측정된비율이유의적으로증가되어병상머리올림수행도가개선되었다. 경장영양을통한영양공급량역시증가되었고, 위잔여량증가횟수는감소했다. 병상머리올림각도가 30 도미만인경우에흡인의위험이증가되며, 흡인의증가가폐렴발생의위험요인으로보고되었다.[2,11] 여러연구들에서앙와위보다병상머리를 30 45도로올린반좌위를취했을때위내용물의흡인량이적었고,[1,3] 임상증상이나미생물학적으로확인된폐렴발생률이감소하였다.[12] 중환자의경장영양이나호흡기관련학회의지침들에서도인공호흡기관련폐렴 (VAP) 의예방을위해인공호흡기치료와경장영양공급받는환자의병상머리올림각도를 30 45도정도로유지하도록권고하였다.[4-6] 이처럼 30 45도의병상머리올림이흡인의위험을막고 VAP를예방할수있는비교적간단하고비용효과적인방법임에도불구하고, 중환자실에서 30도이상병상머리올림의수행율은 28 38% 로낮았다.[7,11,13] 본연구에서는프로토콜적용전병상머리올림각도가 30도이상인측정건수의비율이 13.5% 에불과했으며, 프로토콜적용후통계적으로의미있게증가하였으나, 32.3% 로다른연구와비슷한수준이었다. Cook 등은 [8] 중환자치료에관여하는의료진의반좌위에대한이해도와의사결정에관여하는요인을알아보기위해중환자치료에관여하는의사, 간호사, 호흡치료사, 물리치료사, 영양사, 중환자실전임의등을대상으로면담한결과, 중환자실전담의와영양사만이반좌위가폐렴의위험을예방하기위한전략의일환임을이해하고있었다고보고하였다. 중환자실간호사는의사의처방이있는경우에만반좌위를취한다고답한반면, 의사는간호사의선호도에의해결정된다고했으며, 병상머리올림수행도개선을위해교육, 지침, 감시와피드백, 의무기록, 질개선활동등이필요하다고했다. 간호사를대상으로교육효과에대한연구에서 Helman 등은 [9] 병상머리올림에대한표준화된처방과간호사교육후병상머리올림각도가 24도에서 35도로증가되었음을보고했고, Zack 등은 [14] VAP 예방을위한간 찰

5 132 대한중환자의학회지 : 제 26 권제 3 호 2011 호사와호흡치료사대상의집중교육과정을통해 VAP 발생률을 57.6% 감소시켰다고했다. 본연구에서프로토콜적용전, 후병상머리올림수행도는개선되었으나 VAP의발생률은차이가없었다. 이는본연구에서프로토콜적용전 VAP의발생률이 5.7% 로, 다른연구들에서보고한 8 28% 보다낮았기때문으로생각되었다.[15,16] VAP는환기보조시작 48시간후에발생하는폐렴으로정의하는데, 실제로환기보조위해중환자실에입실하는환자들의상당수가이미폐렴을진단받은경우가많아환기보조시작후새롭게발생하는폐렴발생빈도는상대적으로낮게측정될수있다. 본연구대상에서도 30.7% 가중환자실입실시호흡기관련진단을받은환자들이었다. 또한, 연구의기획이병상머리올림을시행한환자와시행하지않은환자군을대조한것이아니고, 프로토콜을통한병상머리올림의수행도에따른 VAP의발생률을관찰한것이므로, 다른연구에서보여지는병상머리올림과 VAP 발생률사이의유의한관계와는다르게통계적으로의미있는차이를보이지않은것이라생각이된다. 본원중환자실의경장영양프로토콜은하루 18시간동안지속적인공급방법을적용하고, 6시간마다위잔여량을측정하여 100 ml 이상측정되는경우, 2시간동안경장영양공급을중단한다. 2시간후재측정하여 100 ml 미만이면경장영양공급을지속하고, 다시 100 ml 이상측정되면당일은금식하고다음날다시경장영양공급을시작한다. 프로토콜적용전, 후에위잔여량의평균은차이가없었으나, 프로토콜적용전에비해적용후에경장영양을통한영양공급량은유의적으로증가했고 (672 ± 649 vs 798 ± 670, p = 0.021), 본원중환자실경장영양프로토콜에서위잔여량증가에대한중재가시작되는지표인 100 ml 이상측정된건수의비율은프로토콜적용후유의적으로감소했다. 흡인이 VAP의주요원인임을고려하면,[15,16] 병상머리올림프로토콜을통한위잔여량증가횟수의감소가 VAP 발생예방에기여할수있을것으로생각된다. 경장영양을통한영양공급량증가가환자의영양상태개선에기여했는지에대해서는본연구내용에는포함되지않았으나추가적인연구가필요할것이다. 병상머리올림의수행을방해하는요인으로혈역동학불안정, 욕창발생, 자세유지의어려움등의부정적인측면에대한의료진의인식이기여한다.[8,17] 본연구에서프로토콜적용전에비해적용후에수축기혈압과이완기혈압및평균동맥압이각각유의적인감소를보였으나모두정상범위였고, 도파민의투여량이통계적으로의미있는증가를보였으나, 혈압안정을위해혈역학약물투여받은환자비율은차이가없어서병상머리올림이혈역동학불안정을악화시키지않은것으로생각되었다. 진정제와진통제를투여받은환자비율은프로토콜적용전, 후차이가없 었으나미다졸람과로라제팜의투여량이적용후환자에서의미있게증가되어진정제와진통제를증량한것이혈압저하에기여했을가능성이있다. 반좌위자세를유지하기위해서더많은용량의진정제가투여됐을것으로예상되기는하지만미다졸람과로라제팜의증량시각각의사유를기록하지는않아정확한연관성은알아볼수없었으며추후연구가필요할것으로생각된다. 병상머리올림을시행하지못한사유로혈역동학불안정이가장많았으나이중 60% 에서만측정당시실제평균동맥압이 70 mmhg 미만이였으며, 저혈압으로앙와위를취한후언제다시반좌위로회복시킬것인지에대한지침이필요할것이다. 병상머리올림을시행하지못한경우 30.3% 는뚜렷한이유없이앙와위를취하고있었는데, 이는다른연구결과와유사했다.[7,17,18] 욕창과같은피부상태변화에대한우려가간호사가병상머리올림을시행하지못한이유중하나였으나 [8,9,19] 본연구에서욕창발생률은프로토콜적용전후에차이가없었다 (31.4% vs 27.3%). 동맥혈산소분압 / 흡입산소농도비율은교육후의미있게증가하였으나, 중환자실재원일또는사망률을감소시키지못했다. Chan과 Jensen,[20] Yeaw의 [21] 연구에서중환자에서체위변경은가스교환호전, 특히동맥혈산소화를호전시킴으로써예후를개선하고, 중환자실재원기간을감소시키며, 가스 / 관류불일치를개선하고, 적절한산소화를유도하는비용효과적인방법임을보고했다. 고령환자에서누운자세보다앉은자세에서산소화가호전되었으며,[22] 비만이나복수로복부둘레가증가된환자에서 [23] 환기보조동안앙와위보다는병상머리각도를 45도로유지하는것이환기 / 관류일치와동맥혈산소화를개선에기여하여호흡수감소와일회호흡량이증가하여환기보조이탈에유리하였다. 본연구결과는다음과같은제한점이있다. 첫째, 병상머리올림각도를간헐적으로측정했다는점이다. 병상머리올림각도는하루중시간에따라달라질수있으나 24시간지속적인측정이현실적으로불가능하므로가능한선택된요일의배분과하루중측정시간이다양하도록측정시점을정하였다. 또한간호사근무시간에따라병상머리올림각도가달랐던다른연구와는 [7] 달리요일간이나간호사의근무시간별병상올림각도는통계적으로의미있는차이가없었다. 둘째, 본연구는 1개병원내외과계중환자실에서이루어진결과로모든병원에일반화하기에는한계가있다. 셋째, 무작위배정연구가아닌프로토콜적용전과후를비교한관찰연구이며, 모든중환자실간호사와의료진에게완전히맹검화되지못한한계가있다. 따라서, 의료진과간호사, 그외중환자치료에관여하는인력의행위에영향을주었을가능성이있다. 이와같은제한점에도불구하고, 본연구에서환기보조와경장영양을지원받는중환자의병상머리올림프로토콜의

6 라세희외 4 인 :Implementation of the Head of Bed Elevation Protocol 133 적용을통해병상머리올림에대한수행도가개선되었으며, 혈역동학안정이나욕창발생률을악화시키지않으면서경장영양공급량을증가시키고, 위잔여량이높게측정되는횟수를감소시켰다. 인공호흡기관련폐렴발생빈도에는차이가없었으나, 향후에병상머리올림프로토콜에대한순응도를개선하고, 이를장기적으로유지할수있는전략및그효과에대한전향적인연구가필요할것으로생각된다. 참고문헌 1) Ibañez J, Peñafiel A, Raurich JM, Marse P, Jorda R, Mata F: Gastroesophageal reflux in intubated patients receiving enteral nutrition: effect of supine and semirecumbent positions. JPEN J Parenter Enteral Nutr 1992; 16: ) Heyland DK, Cook DJ, Griffith L, Keenan SP, Brun-Buisson C: The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. The Canadian Critical Trials Group. Am J Respir Crit Care Med 1999; 159: ) Torres A, Serra-Batlles J, Ros E, Piera C, Puig de la Bellacasa J, Cobos A, et al: Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med 1992; 116: ) Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P; Canadian Critical Care Clinical Practice Guidelines Committee: Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr 2003; 27: ) McClave SA, Martindale RG, Vanek VW, McCarthy M, Roverts P, Taylor B, et al; Society of Critical Care Medicine: Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 2009; 33: ) American Thoracic Society; Infectious Diseases Society of America: Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171: ) Grap MJ, Cantley M, Munro CL, Corley MC: Use of backrest elevation in critical care: a pilot study. Am J Crit Care 1999; 8: ) Cook DJ, Meade MO, Hand LE, McMullin JP: Toward understanding evidence uptake: semirecumbency for pneumonia prevention. Crit Care Med 2002; 30: ) Helman DL Jr, Sherner JH 3rd, Fitzpatrick TM, Callender ME, Shorr AF: Effect of standardized orders and provider education on head-of-bed positioning in mechanically ventilated patients. Crit Care Med 2003; 31: ) Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjen R: Guidelines for preventing health- care-associated pneumonia, 2003: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 2004; 53(RR-3): ) Metheny NA, Clouse RE, Chang YH, Stewart BJ, Oliver DA, Kollef MH: Tracheobronchial aspiration of gastric contents in critically ill tube-fed patients: frequency, outcomes, and risk factors. Crit Care Med 2006; 34: ) Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogué S, Ferrer M: Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet 1999; 354: ) Grap MJ, Munro CL, Hummel RS 3rd, Elswick RK Jr, McKinney JL, Sessler CN: Effect of backrest elevation on the development of ventilator-associated pneumonia. Am J Crit Care 2005; 14: ) Zack JE, Garrison T, Trovillion E, Clinkscale D, Coopersmith CM, Fraser VJ, et al: Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia. Crit Care Med 2002; 30: ) Chastre J, Fagon JY: Ventilator-associated pneumonia. Am J Respir Crit Care Med 2002; 165: ) Shaw MJ: Ventilator-associated pneumonia. Curr Opin Pulm Med 2005; 11: ) Miller CA, Grossman S, Hindley E, MacGarvie D, Madill J: Are enterally fed ICU patients meeting clinical practice guidelines? Nutr Clin Pract 2008; 23: ) Kollef MH: Ventilator-associated pneumonia. A multivariate analysis. JAMA 1993; 270: ) Griffiths H, Gallimore D: Positioning critically ill patients in hospital. Nurs Stand 2005; 19: 56-64; quiz 6. 20) Chan M, Jensen L: Positioning effects on arterial oxygen and relative pulmonary shunt in patients receiving mechanical ventilation after CABG. Heart Lung 1992; 21: ) Yeaw EM: How position affects oxygenation. Good lung down? Am J Nurs 1992; 92: ) Marklew A: Body positioning and its effect on oxygenation--a literature review. Nurs Crit Care 2006; 11: ) Burns SM, Egloff MB, Ryan B, Carpenter R, Burns JE: Effect of body position on spontaneous respiratory rate and tidal volume in patients with obesity, abdominal distension and ascites. Am J Crit Care 1994; 3:

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1.. Volume 12, Number 1, 6~16, Factors influencing consultation time and waiting time of ambulatory patients in a tertiary teaching hospital Jee-In Hwang College of Nursing Science, Kyung Hee University :