Pneumonia Evidence Based Problem

Evidence Based Problem: Article Reviews
According to standards of evidence, the highest level of quality (Level 1) is that of a systematic review involving randomized controls to eliminate bias. On a lower level of quality (Level 3), that of systematic reviews of lower-quality studies, different types of methods may be used. In answer to my question regarding the Fowler’s positioning of mechanically-ventilated patients to reduce the risk of pneumonia on medical-surgical units, I first consulted a systematic review of the risks of pneumonia in general for patients. In a Level 4 systematic review conducted by Almirall (et al., 2017) of risk factors for community-acquired pneumonia (CAP), 29 observational studies including cross-sectional, case-control, and cohort studies were reviewed to assess risk factors for adult hospitalized patients for developing pneumonia. The studies all attempted to study different, albeit similar, risk factors.
In the Almirall (et al., 2017) review, the confirmed risk factors included advanced age; being a smoker; a history of environmental exposure to negative toxins; malnutrition; a history of previous CAP; and respiratory complaints like bronchitis, COPD, and asthma. Other exacerbating factors included poor dental health and having being treated with certain kinds of classes of pharmaceuticals, such steroids and gastric-acid or immunosuppressive drugs. This is useful to determine the highest-risk patients and to see which patients might show the greatest benefits from repositioning to preventative care. Other factors which were subject to scrutiny but on which no conclusive evidence emerged include gender, weight, alcohol use, vaccination status, and other chronic ailments such as diabetes and cancers.
Along with a systematic review, another study which was consulted included a Level 4 peer-reviewed single quantitative study by Kubota, Endo, & Kubota, (2013) which involved the positioning of patients in Fowler’s position to reduce the risk of cardiovascular events through improved cardiac regulation. In contrast to a systematic review, which involves multiple studies, this review merely involved a single study. The study hypothesized that slight postural differences would make relatively little difference on the health of patients, based upon the fact that blood volume distribution would not change very much with increases in upper torso flexion. Measurements of 12 patients in the study included respiratory sinus arrhythmia (RSA) and sequence baroreflex sensitivity (sBRS).
The subject population of the study was relatively limited, however, and was healthy rather than had a history of previous complaints. The findings yielded suggested vagal nerve activity was increased in healthy subjects and breathing was facilitated, contrary to the expectation of the researchers. The research study would not be considered of highest quality, merely of Level 3, because of the absence of any control subjects; patients were merely measured in terms of their vital signs before and after positioning. It was primarily observational in nature.
Although the study was very small and solely confined to healthy subjects, its findings thus seemed to support my PICOT hypothesis that Fowler’s position could have a specifically beneficial effect upon the respiratory health of patients at risk for complications. It also speaks to the importance of the already-accepted use of Fowler’s position for a variety of complaints. In contrast to this single study, genuine hospital patients versus healthy subjects would be used. The systematic review would also be useful in enhancing the quality of the to determine what variables to control for that could exacerbate a patient’s risk for developing pneumonia, regardless of patient positioning.
References
Almirall, J., Serra-Prat, M., Bolíbar, I., Balasso, V. (2017). Risk factors for community-acquired pneumonia in adults: A systematic review of observational studies. Respiration, 94:299- 311
Kubota, S., Endo, Y., & Kubota, M. (2013). Effect of upper torso inclination in Fowler’s position
on autonomic cardiovascular regulation. The Journal of Physiological Sciences, 63(5), 369–376. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3751277/