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Comparison of two repositioning schedules for the prevention of pressure ulcers in patients on mechanical ventilation with alternating pressure air mattresses



The objective was to compare the effectiveness of repositioning every 2 or 4 h for preventing pressure ulcer development in patients in intensive care unit under mechanical ventilation (MV).


This was a pragmatic, open-label randomized clinical trial in consecutive patients on an alternating pressure air mattress (APAM) requiring invasive MV for at least 24 h in a university hospital in Spain. Eligible participants were randomly assigned to groups for repositioning every 2 (n = 165) or 4 (n = 164) h. The primary outcome was the incidence of a pressure ulcer of at least grade II during ICU stay.


A pressure ulcer of at least grade II developed in 10.3 % (17/165) of patients turned every 2 h versus 13.4 % (22/164) of those turned every 4 h (hazard ratio [HR] 0.89, 95 % confidence interval [CI] 0.46–1.71, P = 0.73). The composite end point of device-related adverse events was recorded in 47.9 versus 36.6 % (HR 1.50, CI 95 % 1.06–2.11, P = 0.02), unplanned extubation in 11.5 versus 6.7 % (HR 1.77, 95 % CI 0.84–3.75, P = 0. 13), and endotracheal tube obstruction in 36.4 versus 30.5 %, respectively (HR 1.44, 95 % CI 0.98–2.12, P = 0.065). The median (interquartile range) daily nursing workload for manual repositioning was 21 (14–27) versus 11 min/patient (8–15) (P < 0.001).


A strategy aimed at increasing repositioning frequency (2 versus 4 h) in patients under MV and on an APAM did not reduce the incidence of pressure ulcers. However, it did increase device-related adverse events and daily nursing workload.

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We acknowledge the efforts of the Data and Safety Monitoring Board members during the study: José Antonio Ramírez, Miguel Ángel Calleja, Manuela Expósito, Juana de Haro. We also acknowledge all the participants of PUPPAS Study Group: Susana Martínez, Raquel Álvarez-Jiménez, Alicia Jiménez-Pérez, Cristina Garrrido-Colmenero,Vanessa Muñoz, Rafael de la Chica, José Luís Pérez-Quirantes, Samuel Nievas, María Isabel Menéndez, Sonia Ortiz, María Ángeles Carvajal, Juan Alonso Cañadas, María Ángeles Calvo, Gertrudis Sanz, María Mar Marfil, Mª Jesús Machado, Manuel González-Sandoval, Ana de Miguel, Carmen Robles, Ascensión Chamorro, Manuel Baena, María Cruz Medina, Trinidad Jiménez, Olga Erigaray, Mercedes Titos, Arancha González-espigares, Laura Millán, María Mar Aguilar, Juan Talavera, Lourdes Rodríguez, Antonio Escobar, María Dolores Cantero, Clara Rodríguez-Rodríguez, Pilar Toledano, and María Angustias Montijano.

Conflicts of interest

The authors have not disclosed any potential conflicts of interest. This study was sponsored by grants from EFRD (European Fund for Regional Development) and the Spanish Institutes of Health Research (PI10/02923).

Author information

Correspondence to Francisco Manzano or Manuel Colmenero.

Additional information

For the PUPPAS Trial Investigators.

Take-home message:

A schedule of repositioning every 2 h was not superior to every 4 h to prevent pressure ulcers in ICU patients under mechanical ventilation and on modern support surfaces. However, it requires a higher nursing workload and increases the likelihood of an adverse effect.

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Manzano, F., Colmenero, M., Pérez-Pérez, A.M. et al. Comparison of two repositioning schedules for the prevention of pressure ulcers in patients on mechanical ventilation with alternating pressure air mattresses. Intensive Care Med 40, 1679–1687 (2014).

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  • Mechanical ventilation
  • Pressure ulcer
  • Prevention
  • Clinical trial
  • Repositioning
  • Intensive care unit