Clinical question
Should air fluidized full body support surfaces versus any other full body support surfaces with pressure management properties be used to promote healing in individuals with Category/Stage 2-4 or unstageable pressure injuries?
Should air fluidized full body support surfaces versus any other full body support surfaces with pressure management properties be used to promote healing in individuals with deep tissue pressure injuries (DTPI)?
Context
Population:
Intervention:
Comparison:
Main Outcomes:
Setting:
Conflicts of Interest:
Individuals who have a pressure injury or who have a deep tissue pressure injury (DTPI)
Air fluidized full body support surfaces
Any full body support surface with pressure management properties
Any clinical setting
Hierarchy of outcome measures for Category/Stage 2-4 or unstageable PI:
Outcome 1: Time to healing
Outcome 2: Complete healing (total/percent healed)
Outcome 3: Change in wound size (% change)
Outcome 4: Pain
Outcome 5: If infected at baseline, changes in signs and symptoms of infection
Hierarchy of outcome measures for closed pressure injuries (Category/Stage 1 and DTPI):
Outcome 1: Percent fully resolved
Outcome 2: Change in injury size (cm2)
Outcome 3: Pain
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
Small for PIs, Don’t know for DTPI
Small for PIs; Moderate for DTPI
Very low
No important uncertainty or variability
Don’t know
Don’t know
No included studies
No included studies
Probably increased
Probably yes or varies
Varies
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
Small (open PI)
Moderate (DTPI)
Large
Varies
Don’t Know
RESEARCH EVIDENCE
| Outcome | Air fluidized support surfaces | Any support surface with pressure management properties | Difference | Relative effect |
|---|---|---|---|---|
| Complete PI healing | 20/36 (55.6%) | 15/36 (41.7%) | 138 more PIs healed per 1,000 (from 75 fewer to 483 more) |
RR 1.33 (0.872 to 2.16) |
| Decrease in wound size (cm2) | –1.2cm2 (–38 to 15.5) | 0.5 cm2 (–55.1 to 94.7) | -- | 0.7cm2 |
| Change in deep tissue pressure injury surface area (cm2) | –7.4 cm2 (–16.5 to –3.7) | 5.1 cm2 (1.85 to 25.8) | --- | 12.5 cm2 |
Outcomes for open PIs: Complete PI healing and decrease in PI size (cm2)
The forest plot conducted by the GGG representing the data from one RCT (Allman, Walker et al. 1987) showed the effectiveness of air fluidized support surfaces for supporting PIs to completely heal compared with any other type of support surface with pressure management properties.** The comparator surface in the included study was a vinyl air mattress that was manufactured with a 0.75 inch (19mm) foam pad cover. The study was conducted in individuals in a primary care medical center with Category/Stage 2-4 PIs who were repositioned two hourly for the study duration of 13 days (Allman, Walker et al. 1987). The analysis showed there was no statistically significant difference between the two different support surfaces for achieving complete healing of PIs (55.60% versus 41.70%, risk ratio [RR] 1.33, 95% confidence interval [CI] 0.82 to 2.16, p = 0.24). This translated to 138 more PIs per 1,000 healing with an air fluidized support surface. However, there is very little confidence in this estimate; the true effect may be substantially different (from 75 fewer to 483 more PIs healing). This evidence was downgraded once for risk of bias and downgraded once for imprecision. Additionally, this study (Allman, Walker et al. 1987) reported a mean decrease of 1.2 cm2 (–38 to 15.5) for pressure injuries in individuals on an air-fluidized bed, while the control group had a mean increase in PI size of 0.5cm2 (–55.1 to 94.2). The effect size was inestimable and there was low certainty in the result (downgraded once for risk of bias and once for imprecision).
Another study also reported improvements in healing of Category/Stage 3—4 PIs for individuals in a nursing home who used an air fluidized support surface. The PIs healed at a faster rate (mean 3.1 cm2/week) compared to PIs for individuals using static overlays and replacement mattresses (mean = 0.6 cm2/week) or compared to individuals who used low air loss or alternating pressure air (active) full body support surfaces (mean = 0.7 cm2/week).
Outcomes for DTPI: Change in deep tissue pressure injury surface area (cm²)
The data from one non-randomized comparative study10 showed the effectiveness of air fluidized support surfaces compared with any other type of support surface with pressure management properties# to promote resolution of torso DTPI (heel DTPIs were excluded). The comparator in the study was a low air loss support surface. The study reported a retrospective cohort analysis using data from medical records over three years in a trauma center, with the primary outcome being mean change in the DTPI surface area (cm2), calculated as the final size minus the initial size. The analysis showed there a statistically significant mean difference in DTPI surface area change of 12.5cm2, favoring the air fluidized support surface (p=0.0178).10 However, there is very little confidence in this estimate. The evidence was downgraded twice for risk of bias and downgraded twice for imprecision, noting this was a very small study (n=18 total participants) and excluded DTPI of the heel.
** Support surfaces are described in the data extraction tables. Product names may have changed, both studies conducted more than 20 years ago.
# Support surfaces are described in the data extraction tables. Product names may have changed.
3. Undesirable Effects:
How substantial are the undesirable anticipated effects?
JUDGEMENT
Trivial
Small (for open PI)
Moderate
Large
Varies
Don’t Know (for DTPI)
RESEARCH EVIDENCE
In the study exploring PI healing (Allman, Walker et al. 1987), the death rate, and the proportion of individuals developing pneumonia, urinary tract infection and hypernatremia did not differ based on whether they used an air fluidized or conventional (combined air/foam mattress) support surface.
There were no studies exploring reduction in DTPI that reported adverse events.
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 |
|---|---|---|
| Complete PI healing | CRITICAL | VERY LOW |
There is no core outcome set specific to pressure injury healing. To determine the relative importance of outcome measures, the GGG reviewed literature(Gottrup, Apelqvist et al. 2010, Augustin, Schmitt et al. 2014, Driver, Gould et al. 2017, Driver, Gould et al. 2019, Miranda, Deonizio et al. 2021, Raepsaet, Alves et al. 2023, Gupta, Goldstone et al. 2024, Zhang, Zhang et al. 2024) on PI and wound healing outcome measures and, in 2021, undertook a survey of stakeholders regarding their perspective on the importance of commonly reported wound healing outcomes. Based on the review and survey, the GGG prioritized consideration of the following five outcome measures of interest when evaluating evidence for interventions to support PI healing (see below). These clinical outcomes were supported by all surveyed stakeholder groups as critically important to making decisions about the evidence, and are wound agnostic(Gupta, Goldstone et al. 2024), frequently reported in PI research,(Miranda, Deonizio et al. 2021) and relevant to both clinical practice and quality of life for individuals with a PI.(Driver, Gould et al. 2017, Driver, Gould et al. 2019)
Selected outcome measures for open PIs::
Outcome 1: Time to healing
Outcome 2: Complete healing (total/percent healed)
Outcome 3: Change in wound size (% change)
Outcome 4: Pain
Outcome 5: If infected at baseline, changes in signs and symptoms of infection.
Selected outcome measures for closed pressure injuries (Category/Stage 1 and DTPI):
Outcome 1: Percent fully resolved
Outcome 2: Change in injury size (cm2)
Outcome 3: Pain
Certainty of evidence for outcome measures
Certainty of evidence for complete PI healing was very low. The evidence was downgraded once for risk of bias due to unclear risk of bias in two domains and downgraded once for imprecision due to the confidence interval crossing the range between recommending and not recommending the treatment. The evidence was also downgraded for directness because the comparator intervention is unlikely to reflect contemporary support surface options.
Certainty of evidence for complete PI healing was very low. The evidence was downgraded twice for risk of bias due to non-randomized design, lack of blinding, missing data, and potential confounding. The evidence was downgraded twice for imprecision due to the small sample size and absence of confidence intervals for median differences.
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 GGG determined that the balance of effects were unclear.
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
No evidence was available.
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
Don’t know
RESEARCH EVIDENCE
No included studies.
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 air fluidized support surfaces is highly variable depending upon geographic and clinical context. 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
One study (Allman, Walker et al. 1987) explored pain and comfort associated with using an air fluidized support surface. 8/13 (61.5%) participants with PIs experienced decreased pain and the remainder (38.5%) experienced no change in their pain when using an air fluidized support surface. However, these individuals had open ulcers and their pain experience may not be directly transferable to individuals with DTPIs.
12. Feasibility:
Is the intervention feasible to implement?
JUDGEMENT
No
Probably no
Probably yes
Yes
Varies
Don’t know
RESEARCH EVIDENCE
In one RCT, (Allman, Walker et al. 1987) 4/14 (28.6%) participants with PIs were withdrawn from the study due to difficulties transferring in an out of bed and maintaining a side-lying position when using the air fluidized support surface.
References
Allman, R. M., J. M. Walker, M. K. Hart, C. A. Laprade, L. B. Noel and C. R. Smith (1987). "Air-fluidized beds or conventional therapy for pressure sores. A randomized trial." Ann Intern Med 107(5): 641–648.
Augustin, M., J. Schmitt, K. Herberger, L. Goepel, K. Heyer, J. Dissemond, A. Mayer, R. Aschoff, F. Beikert, M. Bischoff, C. Blome, J. Bunse, H. Diener, T. Eberlein, S. Eming, H. Fansa, F. Flesch, F. Gaiser, S. Gartner, S. Gass, V. Gerber, S. Glau, T. Goerge, V. Großkopf, C. Hampel-Kalthoff, B. Hartmann, J. Helfrich, T. Hirsch, D. Hochlenert, T. Horn, U. Imkamp, C. Janetzko, J. O. Jost, M. Jünger, R. Kaufmann, F. Kamperhoff, B. Lange-Asschenfeldt, S. Langer, M. May, K. C. Münter, R. Nagel, A. Nast, T. R. Neubert, A. D. Niederbichler, R. U. Peter, T. Petzold, K. Protz, A. Risse, E. Schäfer, K. Scharffetter-Kochanek, M. Schindzielorz, M. Schmidt, H. Schuster, A. Sindrilaru, M. Storck, W. Tigges, C. Tonn, E. Valesky, C. van Montfrans, W. Vanscheidt, A. von Lienen, K. Waldvogel-Röcker, T. Wild, C. C. Zouboulis and E. S. Debus (2014). "The German national consensus on wound documentation and outcomes: Rationale, working programme and current status." Wound Medicine 7: 8-13.
Driver, V. R., L. J. Gould, P. Dotson, L. L. Allen, M. J. Carter and L. L. Bolton (2019). "Evidence supporting wound care end points relevant to clinical practice and patients' lives. Part 2. Literature survey." Wound Repair Regen 27(1): 80-89.
Driver, V. R., L. J. Gould, P. Dotson, G. W. Gibbons, W. W. Li, W. J. Ennis, R. S. Kirsner, W. H. Eaglstein, L. L. Bolton and M. J. Carter (2017). "Identification and content validation of wound therapy clinical endpoints relevant to clinical practice and patient values for FDA approval. Part 1. Survey of the wound care community." Wound Repair Regen 25(3): 454-465.
Gottrup, F., J. Apelqvist and P. Price (2010). "Outcomes in controlled and comparative studies on non-healing wounds: recommendations to improve the quality of evidence in wound management." J Wound Care 19(6): 237-268.
Gupta, R., L. Goldstone, S. Eisen, D. Ramachandram, A. Cassata, R. D. J. Fraser, J. L. Ramirez-GarciaLuna, R. Bartlett and J. Allport (2024). "Towards an AI-based objective prognostic model for quantifying wound healing." IEEE J Biomed Health Inform 28(2): 666-677.
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.
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.
McIntosh, M., H. Cervantes, L. Oakes and C. Garvan (2025). "Wound progression and healing in patients with deep tissue pressure injuries when placed on air-fluidized therapy versus low air loss support surface beds." J Wound Ostomy Continence Nurs 52(4): 279-284.
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Ochs, R. F., S. D. Horn, L. van Rijswijk, C. Pietsch and R. J. Smout (2005). "Comparison of air-fluidized therapy with other support surfaces used to treat pressure ulcers in nursing home residents." Ostomy Wound Management 51(2): 38-68.
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