Clinical question
Should alternating pressure (active) air full body support surfaces vs. air (reactive) full body support surfaces be used to prevent PI occurrence in people at risk?
Context
Population:
Intervention:
Comparison:
Main Outcomes:
Setting:
Conflicts on Interest:
Individuals at risk of pressure injuries
Alternating pressure (active) air full body support surfaces
Air (reactive) full body support surfaces
Any clinical setting
Pressure Injury occurrence
No Guideline Governance Group members or Core Review Group members had a conflict of interest
Evidence to Decision Framework
(Click on the individual judgements for more information)
Summary of Judgements
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Yes
Don’t know
Trivial (favors the comparator air reactive)
Very low
No important uncertainty or variability
Don’t know
Varies
No included studies
No included studies
Probably increased
Probably yes
Probably yes
1. Problem:
Is the problem (pressure injuries) a priority?
JUDGEMENT
No
Probably No
Probably Yes
Yes
Varies
Don’t Know
RESEARCH EVIDENCE
The problem of preventing pressure injuries is a significant priority to healthcare in most clinical settings. In a stakeholder survey conducted by the Guideline Governance Group in 2021, the target audiences for the guideline, including individuals with or at risk of PIs, their informal carers and health professionals, all identified that receiving clinical guidance on selection of support surfaces is of the highest priority (median ranking 5/5).
In an earlier survey conducted by the International Pressure Injury Guideline, Guideline Governance Group (Haesler, Pittman et al. 2022), 68.6% (263/383) of individuals with or at risk of PIs and 61.5% (523/850) of informal carers rated receiving information on support surfaces to use as important or very important. The median priority ranking for receiving information on support surfaces was 4/5 for both individuals with or at risk of PIs of informal carers (Haesler, Pittman et al. 2022).
2. Desirable Effects:
How substantial are the desirable anticipated effects?
JUDGEMENT
Trivial (favors air reactive)
Small
Moderate
Large
Varies
Don’t Know
RESEARCH EVIDENCE
| Outcome | Pressure redistribution foam (reactive) full body support surfaces | Standard mattresses/non-pressure redistribution foam (reactive) full body support surface | Difference | Relative effect |
|---|---|---|---|---|
| PI occurrence | 32/780 (4.1%) | 19/828 (2.3%) | 19 fewer PIs per 1,000 (from 0 fewer to 52 more) |
RR 1.81 (1.00-3.27) |
Outcome 1: Reduction in PI Occurrence
A meta-analysis of five RCTs (Sideranko, Quinn et al. 1992, Price, Bale et al. 1999, Cavicchioli and Carella 2007, Malbrain, Hendriks et al. 2010, Jiang, Li et al. 2014, Beeckman, Serraes et al. 2019) compared alternating pressure (active) air surfaces with air (reactive) surfaces.** The meta-analysis showed that alternating pressure air (active) surfaces are associated with a higher rate of PI occurrence (RR = 1.81, 95% CI 1.00 to 3.27, p = 0.05). Using an air (reactive) support surface might reduce the proportion of people who develop a new PI compared to alternating pressure (active) air surfaces, but the evidence is very uncertain.
** Support surfaces reported in the research were considered in this Guideline based on their categorization by the researchers (at the time the research was undertaken). Where available, the product name and characteristics were included in the data extraction tables. Product names/technology may have changed. Due to advances in technology, currently available support surfaces in the same category may have different performance characteristics.
3. Undesirable Effects:
How substantial are the undesirable anticipated effects?
JUDGEMENT
Trivial
Small
Moderate
Large
Varies
Don’t Know
RESEARCH EVIDENCE
| Outcome | alternating pressure (active) air support surfaces | air (reactive) support surfaces | Difference | Relative effect |
|---|---|---|---|---|
| Discomfort (Price, Bale et al. 1999, Cavicchioli and Carella 2007, Malbrain, Hendriks et al. 2010, Jiang, Li et al. 2014) | Explored, but precise rate of events was not reported | Explored, but precise rate of events was not reported | Reported to be not different between groups but precise statistical analysis not reported | Not calcuable |
The studies in the meta-analysis did not report on adverse effects. The Consumer Panel Group noted that deflation of support surfaces is a risk that can lead to developing a PI. Vigilance is required to ensure that deflation of a support surface is identified and addressed promptly.
Discomfort
Three RCTs (Price, Bale et al. 1999, Cavicchioli and Carella 2007, Jiang, Li et al. 2014) reported that there was no on differences in comfort levels between using an air (reactive) surfaces or using an alternating pressure (active) air surface. The evidence from these RCTs had very low certainty (Shi, Dumville et al. 2021).
The GGG considered the low rate of serious adverse events reported in trials comparing alternating pressure air (active) support surfaces to high specification foam (reactive) surfaces. (Nixon, Brown et al. 2019, Shi, Dumville et al. 2021) Together with their clinical experience, the GGG considered adverse events associated with alternating pressure air (active) support surfaces are likely to be small.
4. Overall certainty of evidence: What is the overall certainty of the evidence of effects?
JUDGEMENT
Very low
Low
Moderate
High
No included studies
RESEARCH EVIDENCE
| Outcome | Relative Importance | Certainty of Evidence |
|---|---|---|
| PI occurrence | CRITICAL | LOW |
Outcome 1: PI occurrence
In a Delphi survey (Lechner, Coleman et al. 2022) that developed a core outcomes et for PI prevention trials, the outcome of PI occurrence was rated as being of critical importance (score of 7-9).
The evidence was of low certainty. The evidence was downgraded twice for risk of bias based on critical appraisal in an existing review (McInnes, Jammali-Blasi et al. 2015). Five of the studies in the analysis had high or unclear risk of performance and detection bias. Certainty was also downgraded for inconsistency.
5. Values:
Is there important uncertainty about or variability in how much people value the main outcomes?
JUDGEMENT
Important uncertainty or variability
Possibly important uncertainty or variability
Probably no important uncertainty or variability
No important uncertainty or variability
RESEARCH EVIDENCE
In a Delphi survey (Lechner, Coleman et al. 2022) that developed a core outcomes et for PI prevention trials, the outcome of PI occurrence was rated as being of critical important (score of 7-9) by all types of stakeholders (health professionals, people with or at risk of a PI and their informal carers, industry representatives and researchers). Greater than 90% of the 158 participants rated this outcome measure as critically important (Lechner, Coleman et al. 2022).
6. Balance of Effects:
Does the balance between desirable and undesirable effects favour the intervention or the comparison?
JUDGEMENT
Favors the comparison
Probably favors the comparison
Does not favor either the intervention or the comparison
Probably favors the intervention
Favors the intervention
Varies
Don’t know
RESEARCH EVIDENCE
The evidence on desirable and desirable effects is very low certainty.
7. Resources Required:
How large are resource requirements (costs) of the intervention?
JUDGEMENT
Large costs
Moderate costs
Negligible costs and savings
Moderate savings
Large savings
Varies
Don’t know
RESEARCH EVIDENCE
All powered support surfaces require a reliable and affordable power source that may not be accessible in many settings.
In the Panel Group’s expert opinion, a powered (reactive) air surface can increase the time health workers and informal carers spend managing and maintaining support surfaces (e.g. checking power, settings and inspecting the integrity of the surface).
Alternating pressure (active) air surfaces and unpowered (reactive) air surfaces may require less management but will still require inspection and maintenance.
The GGG considered the wide variation in clinical and geographic context and determined that resource requirements vary.
8. Certainty of evidence of required resources:
What is the certainty of evidence of resource requirements (costs) of the intervention?
JUDGEMENT
Very low
Low
Moderate
High
No included studies
RESEARCH EVIDENCE
There was no evidence on the costs of required resources.
9. Cost Effectiveness: Does the cost-effectiveness of the intervention favour the intervention or the comparison?
JUDGEMENT
Favors the comparison
Probably favors the comparison
Does not favor either the intervention or the comparison
Probably favors the intervention
Varies
No included studies
RESEARCH EVIDENCE
There was no evidence on cost-effectiveness of the options.
10. Inequity:
What would be the impact of recommending the intervention on health inequity?
JUDGEMENT
Reduced
Probably reduced
Probably no impact
Probably increased
Increased
Varies
Don’t know
RESEARCH EVIDENCE
In the Panel Group’s expert opinion, accessibility of alternating pressure (active) air surfaces is highly variable depending upon geographic and clinical context. In high resource countries, alternating pressure (active) air surfaces may be accessible in in-patient and community settings and might be funded through government disability or veteran schemes for people at higher risk of PIs. The Panel Group noted that people from low economic backgrounds in all geographic regions, including people who are homeless, have reduced access to support surfaces. The Panel Group noted that the rising costs of power could increase the costs of using powered support surfaces and reduce access.
11. Acceptability:
Is the intervention acceptable to key stakeholders?
JUDGEMENT
No
Probably no
Probably yes
yes
Varies
Don’t know
RESEARCH EVIDENCE
There is no evidence on how acceptable alternating pressure (active) air surfaces are to key stakeholders. Comfort was not different between alternating pressure air (active) support surfaces and air (reactive) surfaces. In the GGG’s expert clinical experience an alternating pressure (active) support surface is generally accepted by people at high PI risk.
12. Feasibility:
Is the intervention feasible to implement?
JUDGEMENT
No
Probably no
Probably yes
Yes
Varies
Don’t know
RESEARCH EVIDENCE
Both support surface options require ongoing maintenance, function inspection and an electrical supply.
There is no evidence on how feasible alternating pressure air (active) surfaces are to implement. Repositioning and egress from bed were reported as easy with air (reactive) surface. (Zwaenepoel, Van Hecke et al. 2020; Raepsaet, Zwaenepoel et al. 2021)
In the Panel Group’s expert opinion, some health services have ceased using air (reactive) surfaces because of the risk of undetected deflation of the product.
References
Bennett, R., P. Baran, L. DeVone, H. Bacetti, B. Kristo, M. Tayback and W. r. Greenough (1998). "Low airloss hydrotherapy versus standard care for incontinent hospitalized patients." J Am Geriatr Soc 46(5): 569-576.
Haesler, E., J. Pittman, J. Cuddigan, S. Law, Y. Y. Chang, K. Balzer, D. Berlowitz, K. Carville, J. Kottner, M. Litchford, Z. Moore, P. Mitchell and D. Sigaudo-Roussel (2022). "An exploration of the perspectives of individuals and their caregivers on pressure ulcer/injury prevention and management to inform the development of a clinical guideline." J Tissue Viability 31(1): 1-10.
Inman, K. J., W. J. Sibbald, F. S. Rutledge and B. J. Clark (1993). "Clinical utility and cost-effectiveness of an air suspension bed in the prevention of pressure ulcers." JAMA 269(9): 1139-1143.
Lechner, A., S. Coleman, K. Balzer, J. J. Kirkham, D. Muir, J. Nixon and J. Kottner (2022). "Core outcomes for pressure ulcer prevention trials: results of an international consensus study." Br J Dermatol 187(5): 743-752.
Rosenthal, M. J., R. M. Felton, A. E. Nastasi, B. D. Naliboff, J. Harker and J. H. Navach (2003). "Healing of advanced pressure ulcers by a generic total contact seat: 2 randomized comparisons with low air loss bed treatments." Arch Phys Med Rehabil 84(12): 1733-1742.
Shi, C., J. C. Dumville, N. Cullum, S. Rhodes, A. Jammali-Blasi and E. McInnes (2021). "Alternating pressure (active) air surfaces for preventing pressure ulcers." Cochrane Database Syst Rev 5: CD013620.
Shi, C., J. C. Dumville, N. Cullum, S. Rhodes, V. Leung and E. McInnes (2021). "Reactive air surfaces for preventing pressure ulcers." Cochrane Database Syst Rev 5: CD013622.