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Burger-Klepp U, Maleczek M, Ristl R, Kroyer B, Raudner M, Krenn CG, Ullrich R. Using a clinical decision support system to reduce excess driving pressure: the ALARM trial. BMC Med 2025; 23:52. [PMID: 39875856 PMCID: PMC11776331 DOI: 10.1186/s12916-025-03898-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Accepted: 01/23/2025] [Indexed: 01/30/2025] Open
Abstract
BACKGROUND Patients at need for ventilation often are at risk of acute respiratory distress syndrome (ARDS). Although lung-protective ventilation strategies, including low driving pressure settings, are well known to improve outcomes, clinical practice often diverges from these strategies. A clinical decision support (CDS) system can improve adherence to current guidelines; moreover, the potential of a CDS to enhance adherence can possibly be further increased by combination with a nudge type intervention. METHODS A prospective cohort trial was conducted in patients at risk of ARDS admitted to an intensive care unit (ICU). Patients were assigned to control or intervention by their date of admission: First, the control group was included without changing anything in clinical practice. Next, the CDS was activated showing an alert in the patient data management system if driving pressure exceeded recommended values; additionally, data on the performance of the wards were sent to the healthcare professionals as the nudge intervention. The main hypothesis was that this combined intervention would lead to a significant decrease in excess driving pressure. RESULTS The 472 included patients (230 in the control group and 242 in the intervention group) consisted of 33% females. The median age was 64 years; median Sequential Organ Failure Assessment score was 8. There was a significant reduction in excess driving pressure in the augmented ventilation modes (0.28 ± 0.67 mbar vs. 0.14 ± 0.45 mbar, p = 0.012) but not the controlled mode (0.37 ± 0.83 mbar vs. 0.32 ± 0.8 mbar, p = 0.53). However, there was no significant difference between groups in mechanical power, the number of ventilator-free days, or the percentage of patients showing progression to ARDS. Although there was no difference in progression to ARDS, 28-day mortality was higher in the intervention group. Notably, the mean overall driving pressure across both groups was low (12.02 mbar ± 2.77). CONCLUSIONS In a population at risk of ARDS, a combined intervention of a clinical decision support system and a nudge intervention was shown to reduce the excessive driving pressure above 15 mbar in augmented but not in controlled modes of ventilation.
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Affiliation(s)
- Ursula Burger-Klepp
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Mathias Maleczek
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria.
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria.
| | - Robin Ristl
- Center for Medical Data Science, Medical University of Vienna, Vienna, Austria
| | - Bettina Kroyer
- Center for Medical Data Science, Medical University of Vienna, Vienna, Austria
| | - Marcus Raudner
- Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - Claus G Krenn
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Roman Ullrich
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
- AUVA Trauma Center Vienna, Vienna, Austria
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Harriman A, Butler K, Parekh D, Weblin J. Quality improvement project to improve adherence to lung protective ventilation guidelines. BMJ Open Qual 2024; 13:e002638. [PMID: 38789280 PMCID: PMC11129028 DOI: 10.1136/bmjoq-2023-002638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 02/12/2024] [Indexed: 05/26/2024] Open
Abstract
INTRODUCTION Lung protective ventilation (LPV) is advocated for all patients requiring mechanical ventilation (MV), for any duration of time, to prevent worsening lung injury. Previous studies proved simple interventions can increase awareness of LPV and disease pathophysiology as well as improve adherence to LPV guidelines. OBJECTIVE To assess the impact of a multi-component LPV quality improvement project (QIP) on adherence to LPV guidelines. METHODS Tidal volume data for all patients requiring MV at a large, tertiary UK critical care unit were collected retrospectively over 3, 6 months, Plan-Do-Study-Act cycles between September 2019 and August 2022. These cycles included the sequential implementation of LPV reports, bedside whiteboards and targeted education led by a multispecialty working group. MAIN OUTCOME MEASURE Adherence against predetermined targets of <5% of MV hours spent at >10 mL/kg predicted body weight (PBW) and >75% of MV hours spent <8 mL/kg PBW for all patients requiring MV. RESULTS 408 949 hours (17 040 days) of MV data were analysed. Improved LPV adherence was demonstrated throughout the QIP. During mandated MV, time spent >10 mL/kg PBW reduced from 7.65% of MV hours to 4.04% and time spent <8 mL/kg PBW improved from 68.86% of MV hours to 71.87% following the QIP. During spontaneous MV, adherence improved with a reduction in time spent >10 mL/kg PBW from baseline to completion (13.2% vs 6.75%) with increased time spent <8 mL/kg PBW (62.74% vs 72.25%). Despite demonstrating improvements in adherence, we were unable to achieve success in all our predetermined targets. CONCLUSION This multicomponent intervention including the use of LPV reports, bedside whiteboards and education improves adherence to LPV guidelines. More robust data analysis of reasons for non-adherence to our predetermined targets is required to guide future interventions that may allow further improvement in adherence to LPV guidelines.
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Affiliation(s)
- Adam Harriman
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Katrina Butler
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Dhruv Parekh
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Birmingham Acute Care Research Group, University of Birmingham Institute of Inflammation and Ageing, Birmingham, UK
| | - Jonathan Weblin
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Piriyapatsom A, Trisukhonth A, Chintabanyat O, Chaiwat O, Kongsayreepong S, Thanakiattiwibun C. Adherence to lung protective mechanical ventilation in patients admitted to a surgical intensive care unit and the associated increased mortality. Heliyon 2024; 10:e26220. [PMID: 38404779 PMCID: PMC10884462 DOI: 10.1016/j.heliyon.2024.e26220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 02/05/2024] [Accepted: 02/08/2024] [Indexed: 02/27/2024] Open
Abstract
Background The adherence rate to the lung protective ventilation (LPV) strategy, which is generally accepted as a standard practice in mechanically ventilated patients, reported in the literature is approximately 40%. This study aimed to determine the adherence rate to the LPV strategy, factors associated with this adherence, and related clinical outcomes in mechanically ventilated patients admitted to the surgical intensive care unit (SICU). Methods This prospective observational study was conducted in the SICU of a tertiary university-based hospital between April 2018 and February 2019. Three hundred and six adult patients admitted to the SICU who required mechanical ventilation support for more than 12 h were included. Ventilator parameters at the initiation of mechanical ventilation support in the SICU were recorded. The LPV strategy was defined as ventilation with a tidal volume of equal or less than 8 ml/kg of predicted body weight plus positive end-expiratory pressure of at least 5 cm H2O. Demographic and clinical data were recorded and analyzed. Results There were 306 patients included in this study. The adherence rate to the LPV strategy was 36.9%. Height was the only factor associated with adherence to the LPV strategy (odds ratio for each cm, 1.10; 95% confidence interval (CI), 1.06-1.15). Cox regression analysis showed that the LPV strategy was associated with increased 90-day mortality (hazard ratio, 1.73; 95% CI, 1.02-2.94). Conclusion The adherence rate to the LPV strategy among patients admitted to the SICU was modest. Further studies are warranted to explore whether the application of the LPV strategy is simply a marker of disease severity or a causative factor for increased mortality.
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Affiliation(s)
- Annop Piriyapatsom
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700, Thailand
| | - Ajana Trisukhonth
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700, Thailand
| | - Ornin Chintabanyat
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700, Thailand
| | - Onuma Chaiwat
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700, Thailand
| | - Suneerat Kongsayreepong
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700, Thailand
| | - Chayanan Thanakiattiwibun
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 10700, Thailand
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LeSieur MN, Bosch NA, Walkey AJ. Hospital Variation in Mortality and Ventilator Management among Mechanically Ventilated Patients with ARDS. J Intensive Care Med 2023; 38:179-187. [PMID: 35786134 DOI: 10.1177/08850666221111748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
RATIONALE Acute Respiratory Distress Syndrome (ARDS) is associated with significant mortality. Despite the mortality benefits of lung protective ventilation, adherence rates to evidence-based ventilator practice have remained low and ARDS mortality has remained high. OBJECTIVE Determine variation in ARDS mortality and adherence to low tidal volume ventilation (LTV) across US hospitals. MATERIALS AND METHODS We identified mechanically ventilated patients with ARDS using data from Philips eICU (2014-2015). We then used multi-variable hierarchical logistic regression models with hospital site as the random effect and patient and hospital level factors as fixed effects to assess the hospital risk adjusted mortality rate and median odds ratio for the association between mortality and hospital site. We then assessed associations between adherence to LTV (defined as 4-8 mL/kg PBW) and hospital risk adjusted mortality rates using Spearman correlation. RESULTS Among 4441 patients admitted at 110 hospitals with ARDS, the hospital risk-adjusted mortality rate ranged from 19% to 39%, and the MOR for hospital of admission was 1.33 (95% CI 1.25-1.41). Among 3070 patients at 72 hospitals with available ventilator data, 73% of patients had a median set Vt between 4 to 8 mL/kg PBW; hospital adherence rates to LTV ranged from 13% to 95%. There was no association between hospital adherence to LTV and risk-adjusted mortality rate (spearman correlation coefficient -0.01, p = .93). Similarly, among 956 patients who started with a Vt > 8 mL/kg PBW, there was no association between the percent of patients at each hospital whose Vt was decreased to ≤ 8 mL/kg PBW and risk adjusted mortality rate (spearman correlation coefficient .05, p = .73). CONCLUSION Risk adjusted mortality and use of LTV for patients with ARDS varied widely across hospitals. However, hospital adherence to LTV was not associated with ARDS mortality rates. Further evaluation of hospital practices associated with lower ARDS mortality are warranted.
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Affiliation(s)
- Mallory N LeSieur
- Department of Medicine, Pulmonary Center, 12259Boston University School of Medicine, Boston, MA, USA
| | - Nicholas A Bosch
- Department of Medicine, Pulmonary Center, 12259Boston University School of Medicine, Boston, MA, USA
| | - Allan J Walkey
- Department of Medicine, Pulmonary Center, 12259Boston University School of Medicine, Boston, MA, USA
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Intermediate tidal volume is an acceptable option for ventilated patients with acute respiratory distress syndrome. Med Intensiva 2022; 46:609-618. [PMID: 36313965 PMCID: PMC9597521 DOI: 10.1016/j.medin.2022.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/25/2022] [Indexed: 01/05/2023]
Abstract
Objective Evidence only proves low surpasses high tidal volume (V T) for acute respiratory distress syndrome (ARDS). Intermediate V T is a common setting for ARDS patients and has been demonstrated as effective as low V T in non-ARDS patients. The effectiveness of intermediate V T in ARDS has not been studied and is the objective of this study. Design A retrospective cohort study. Setting Five ICUs with their totally 130 beds in Taiwan. Patients or participants ARDS patients under invasive ventilation. Interventions No. Main variables of interest 28-D mortality. Result Totally 382 patients, with 6958 ventilator settings eligible for lung protection, were classified into low (mean V T = 6.7 ml/kg), intermediate (mean V T = 8.9 ml/kg) and high (mean V T = 11.2 ml/kg) V T groups. With similar baseline ARDS and ICU severities, intermediate and low V T groups did not differ in 28-D mortality (47% vs. 63%, P = 0.06) or other outcomes such as 90-D mortality, ventilator-free days, ventilator-dependence rate. Multivariate analysis revealed high V T was independently associated with 28-D and 90-D mortality, but intermediate V T was not significantly associated with 28-D mortality (HR 1.34, CI 0.92-1.97, P = 0.13) or 90-D mortality. When the intermediate and low V T groups were matched in propensity scores (n = 66 for each group), their outcomes were also not significantly different. Conclusion Intermediate V T, with its outcomes similar to small V T, is an acceptable option for ventilated ARDS patients. This conclusion needs verification through clinical trials.
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Intermediate tidal volume is an acceptable option for ventilated patients with acute respiratory distress syndrome. MEDICINA INTENSIVA (ENGLISH EDITION) 2022; 46:609-618. [PMCID: PMC9633924 DOI: 10.1016/j.medine.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/25/2022] [Indexed: 11/06/2022]
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McCrory MC, Woodruff AG, Saha AK, Evans JK, Halvorson EE, Bass AL. Nonadherence to appropriate tidal volume and PEEP in children with pARDS at a single center. Pediatr Pulmonol 2022; 57:2464-2473. [PMID: 35778788 PMCID: PMC9489656 DOI: 10.1002/ppul.26060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/22/2022] [Accepted: 06/26/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Low tidal volume and adequate positive end-expiratory pressure (PEEP) are evidence-based approaches for pediatric acute respiratory distress syndrome (pARDS), however, data are limited regarding their use since pARDS guidelines were revised in 2015. OBJECTIVE To identify prevalence of, and factors associated with, nonadherence to appropriate tidal volume and PEEP in children with pARDS. METHODS Retrospective cohort study of children 1 month to <18 years with pARDS who received invasive mechanical ventilation from 2016 to 2018 in a single pediatric intensive care unit (PICU). RESULTS At 24 h after meeting pARDS criteria, 48/86 (56%) patients received tidal volume ≤8 ml/kg of ideal body weight and 45/86 (52%) received appropriate PEEP, with 22/86 (26%) receiving both. Among patients ≥2 years of age, a lower proportion of patients with overweight/obesity (9/25, 36%) had appropriate tidal volume versus those in the normal or underweight category (16/22, 73%, p = 0.02). When FIO2 was ≥50%, PEEP was appropriate in 19/60 (32%) cases versus 26/26 (100%) with FIO2 < 50% (p < 0.0001). pARDS was documented in the progress note in 7/86 (8%) patients at 24 h. Severity of pARDS, documentation in the progress note, and other clinical factors were not significantly associated with use of appropriate tidal volume and PEEP, however pARDS was documented more commonly in patients with severe pARDS. CONCLUSIONS In a single PICU in the United States, children with pARDS did not receive appropriate tidal volume for ideal body weight nor PEEP. Targets for improving tidal volume and PEEP adherence may include overweight patients and those receiving FIO2 ≥ 50%, respectively.
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Affiliation(s)
- Michael C. McCrory
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC
| | - Alan G. Woodruff
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC
- Center for Redox in Biology and Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Amit K. Saha
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Joni K. Evans
- Department of Biostatistics; Wake Forest School of Medicine, Winston-Salem, NC
| | | | - Andora L Bass
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC
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Creation of an International Interprofessional Simulation-enhanced Mechanical Ventilation Course. ATS Sch 2022; 3:270-284. [PMID: 35924195 PMCID: PMC9341493 DOI: 10.34197/ats-scholar.2021-0102oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 03/25/2022] [Indexed: 11/30/2022] Open
Abstract
Background Evidence shows poor adherence to strategies for reducing morbidity and mortality in intensive care unit (ICU) patients receiving mechanical ventilation globally. Best practice management relies on training all members of the interprofessional ICU team, each with complementary roles in patient management. Objectives To develop and evaluate a novel two-phase, train-the-trainer, interprofessional and multicultural “Best Practice Management of the Ventilated ICU Patient” multimodality, simulation-enhanced curriculum for Thai education leaders in critical care. Methods In phase 1 (Oregon Health and Science University cohort), two groups of nine ICU nurses and one critical care physician representing experts in critical care and education from a large hospital system in Thailand participated in a weeklong, immersive course consisting of didactic, simulation, and in situ immersive sessions focused on best practice management of mechanically ventilated ICU patients, as well as training in our educational techniques. Outcomes were assessed with pre- and postcourse knowledge assessments and overall course evaluation. In phase 2 (Thai cohort), participants from phase 1 returned to Thailand and implemented a lower fidelity curriculum in two hospitals, using the same pre- and posttest knowledge assessment in 41 participants, before the onset of the coronavirus disease (COVID-19) 6 pandemic. Results In the Oregon Health and Science University cohort, the mean pretest knowledge score was 58.4 ± 13.2%, with a mean improvement to 82.5 ± 11.6% after completion of the course (P , 0.05). The greatest improvements were seen in respiratory physiology and advanced/disease-specific concepts, which demonstrated absolute improvements of 30.4% and 30.6%, respectively (P < 0.05). Participants had a high degree of satisfaction, with 90% rating the course as “excellent” and .90% reporting that the course “greatly improved” their understanding of best practices and comfort in managing mechanical ventilation. The Thai cohort had a mean baseline score of 45.4 ± 15.0% and a mean improvement to 70.3 ± 19.1% after training (P < 0.05). This cohort also saw the greatest improvement in respiratory physiology and advanced/disease-specific concepts, with 26.2% and 26.3% absolute improvements, respectively (P < 0.05). Conclusion A novel, two-phase, interprofessional, multicultural, simulation-enhanced train-the-trainer curriculum was feasible and effective in improving education in best practice management of mechanically ventilated patients and may be a useful model for improving the care of ICU patients across the world.
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Bechel M, Pah AR, Persell SD, Weiss CH, Nunes Amaral LA. The first step is recognizing there is a problem: a methodology for adjusting for variability in disease severity when estimating clinician performance. BMC Med Res Methodol 2022; 22:69. [PMID: 35296240 PMCID: PMC8924737 DOI: 10.1186/s12874-022-01543-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 02/11/2022] [Indexed: 11/28/2022] Open
Abstract
Background Adoption of innovations in the field of medicine is frequently hindered by a failure to recognize the condition targeted by the innovation. This is particularly true in cases where recognition requires integration of patient information from different sources, or where disease presentation can be heterogeneous and the recognition step may be easier for some patients than for others. Methods We propose a general data-driven metric for clinician recognition that accounts for the variability in patient disease severity and for institutional standards. As a case study, we evaluate the ventilatory management of 362 patients with acute respiratory distress syndrome (ARDS) at a large academic hospital, because clinician recognition of ARDS has been identified as a major barrier to adoption to evidence-based ventilatory management. We calculate our metric for the 48 critical care physicians caring for these patients and examine the relationships between differences in ARDS recognition performance from overall institutional levels and provider characteristics such as demographics, social network position, and self-reported barriers and opinions. Results Our metric was found to be robust to patient characteristics previously demonstrated to affect ARDS recognition, such as disease severity and patient height. Training background was the only factor in this study that showed an association with physician recognition. Pulmonary and critical care medicine (PCCM) training was associated with higher recognition (β = 0.63, 95% confidence interval 0.46–0.80, p < 7 × 10− 5). Non-PCCM physicians recognized ARDS cases less frequently and expressed greater satisfaction with the ability to get the information needed for making an ARDS diagnosis (p < 5 × 10− 4), suggesting that lower performing clinicians may be less aware of institutional barriers. Conclusions We present a data-driven metric of clinician disease recognition that accounts for variability in patient disease severity and for institutional standards. Using this metric, we identify two unique physician populations with different intervention needs. One population consistently recognizes ARDS and reports barriers vs one does not and reports fewer barriers. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-022-01543-7.
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Affiliation(s)
- Meagan Bechel
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Adam R Pah
- Northwestern Institute on Complex Systems, Northwestern University, 2145 Sheridan Road (Room E136), Evanston, IL, 60208, USA.,Kellogg School of Management, Northwestern University, Evanston, IL, USA
| | - Stephen D Persell
- Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Curtis H Weiss
- Division of Pulmonary, Critical Care, Allergy, and Immunology, NorthShore University HealthSystem, 1001 University Place, Suite 162, Evanston, IL, 60201, USA.
| | - Luís A Nunes Amaral
- Northwestern Institute on Complex Systems, Northwestern University, 2145 Sheridan Road (Room E136), Evanston, IL, 60208, USA. .,Department of Chemical and Biological Engineering, Northwestern University, Evanston, IL, USA. .,Department of Physics and Astronomy, Northwestern University, Evanston, IL, USA.
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Adherence to Lung-Protective Ventilation in Pediatric Acute Respiratory Distress Syndrome: Principles Versus Explicit Targets. Crit Care Med 2021; 49:1836-1839. [PMID: 34529616 DOI: 10.1097/ccm.0000000000005108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Barr J, Paulson SS, Kamdar B, Ervin JN, Lane-Fall M, Liu V, Kleinpell R. The Coming of Age of Implementation Science and Research in Critical Care Medicine. Crit Care Med 2021; 49:1254-1275. [PMID: 34261925 PMCID: PMC8549627 DOI: 10.1097/ccm.0000000000005131] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Juliana Barr
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, CA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Shirley S Paulson
- Regional Adult Patient Care Services, Kaiser Permanente, Northern California, Oakland, CA
| | - Biren Kamdar
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California, San Diego School of Medicine, La Jolla, CA
| | - Jennifer N Ervin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Meghan Lane-Fall
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Vincent Liu
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, CA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
- Regional Adult Patient Care Services, Kaiser Permanente, Northern California, Oakland, CA
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California, San Diego School of Medicine, La Jolla, CA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Division of Research, Kaiser Permanente Northern California, Santa Clara, CA
- Kaiser Permanente Medical Center, Santa Clara, CA
- Stanford University, Stanford, CA
- Hospital Advanced Analytics, Kaiser Permanente Northern California, Santa Clara, CA
- Vanderbilt University School of Nursing, Nashville, TN
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Short B, Serra A, Tariq A, Moitra V, Brodie D, Patel S, Baldwin MR, Yip NH. Implementation of lung protective ventilation order to improve adherence to low tidal volume ventilation: A RE-AIM evaluation. J Crit Care 2021; 63:167-174. [PMID: 33004237 PMCID: PMC7979571 DOI: 10.1016/j.jcrc.2020.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 08/27/2020] [Accepted: 09/15/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE Lung protective ventilation (LPV), defined as a tidal volume (Vt) ≤8 cc/kg of predicted body weight, reduces ventilator-induced lung injury but is applied inconsistently. MATERIALS AND METHODS We conducted a prospective, quasi-experimental, cohort study of adults mechanically ventilated admitted to intensive care units (ICU) in the year before, year after, and second year after implementation of an electronic medical record based LPV order, and a cross-sectional qualitative study of ICU providers regarding their perceptions of the order. We applied the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate the implementation. RESULTS There were 1405, 1424, and 1342 in the control, adoption, and maintenance cohorts, representing 95% of mechanically ventilated adult ICU patients. The overall prevalence of LPV increased from 65% to 73% (p < 0.001, adjusted-OR for LPV adherence: 1.9, 95% CI 1.5-2.3), but LPV adherence in women was approximately 30% worse than in men (women: 44% to 56% [p < 0.001],men: 79% to 86% [p < 0.001]). ICU providers noted difficulty obtaining an accurate height measurement and mistrust of the Vt calculation as barriers to implementation. LPV adherence increased further in the second year post implementation. CONCLUSION We designed and implemented an LPV order that sustainably improved LPV adherence across diverse ICUs.
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Affiliation(s)
- Briana Short
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Vagelos College of Physicians & Surgeons/NewYork-Presbyterian Hospital, New York, NY, United States of America.
| | - Alexis Serra
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Vagelos College of Physicians & Surgeons/NewYork-Presbyterian Hospital, New York, NY, United States of America
| | - Abdul Tariq
- The Value Institute at NewYork-Presbyterian Hospital, New York, NY, United States of America
| | - Vivek Moitra
- Department of Anesthesia, Columbia University Vagelos College of Physicians & Surgeons/NewYork-Presbyterian Hospital, New York, NY, United States of America
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Vagelos College of Physicians & Surgeons/NewYork-Presbyterian Hospital, New York, NY, United States of America
| | - Sapana Patel
- The New York State Psychiatric Institute, Research Foundation for Mental Hygiene, New York, NY, United States of America; Department of Psychiatry, Columbia University Vagelos College of Physicians & Surgeons, New York, NY, United States of America
| | - Matthew R Baldwin
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Vagelos College of Physicians & Surgeons/NewYork-Presbyterian Hospital, New York, NY, United States of America
| | - Natalie H Yip
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Vagelos College of Physicians & Surgeons/NewYork-Presbyterian Hospital, New York, NY, United States of America
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Development and Content Validation of a Multidisciplinary Standardized Management Pathway for Hypoxemic Respiratory Failure and Acute Respiratory Distress Syndrome. Crit Care Explor 2021; 3:e0428. [PMID: 34036279 PMCID: PMC8133138 DOI: 10.1097/cce.0000000000000428] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Supplemental Digital Content is available in the text. Objectives: Treatment of hypoxemic respiratory failure and acute respiratory distress syndrome is complex. Evidence-based therapies that can improve survival and guidelines advocating their use exist; however, implementation is inconsistent. Our objective was to develop and validate an evidence-based, stakeholder-informed standardized management pathway for hypoxemic respiratory failure and acute respiratory distress syndrome to improve adherence to best practice. Design: A standardized management pathway was developed using a modified Delphi consensus process with a multidisciplinary group of ICU clinicians. The proposed pathway was externally validated with a survey involving multidisciplinary stakeholders and clinicians. Setting: In-person meeting and web-based surveys of ICU clinicians from 17 adult ICUs in the province of Alberta, Canada. Intervention: Not applicable. Measurements and Main Results: The consensus panel was comprised of 30 ICU clinicians (4 nurses, 10 respiratory therapists, 15 intensivists, 1 nurse practitioner; median years of practice 17 [interquartile range, 13–21]). Ninety-one components were serially rated and revised over two rounds of online and one in-person review. The final pathway included 46 elements. For the validation survey, 692 responses (including 59% nurses, 33% respiratory therapists, 7% intensivists and 1% nurse practitioners) were received. Agreement of greater than 75% was achieved on 43 of 46 pathway elements. Conclusions: A 46-element evidence-informed hypoxemic respiratory failure and acute respiratory distress syndrome standardized management pathway was developed and demonstrated to have content validity.
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Sevransky JE, Agarwal A, Jabaley CS, Rochwerg B. Standardized Care Is Better Than Individualized Care for the Majority of Critically Ill Patients. Crit Care Med 2021; 49:151-155. [PMID: 33060504 PMCID: PMC8635275 DOI: 10.1097/ccm.0000000000004676] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Jonathan E Sevransky
- Division of Pulmonary, Allergy, Critical Care, and Sleep and Emory Center for Critical Care, Emory University, Atlanta, GA
| | - Ankita Agarwal
- Division of Pulmonary, Allergy, Critical Care, and Sleep and Emory Center for Critical Care, Emory University, Atlanta, GA
| | - Craig S Jabaley
- Department of Anesthesiology and Emory Center for Critical Care, Emory University, Atlanta, GA
| | - Bram Rochwerg
- Department of Medicine, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Clinicians' Perceptions of Behavioral Economic Strategies to Increase the Use of Lung-Protective Ventilation. Ann Am Thorac Soc 2020; 16:1543-1549. [PMID: 31525319 DOI: 10.1513/annalsats.201905-410oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Rationale: Lung-protective ventilation (LPV) improves outcomes in patients with acute respiratory distress syndrome (ARDS) and has also shown benefits in patients without ARDS. Despite this evidence, LPV use remains low.Objectives: To understand clinicians' perceptions of using behavioral economic strategies to improve rates of LPV use.Methods: We conducted semistructured interviews of clinicians across seven intensive care units within a university health system. We purposefully sampled clinicians of different professional backgrounds and experience levels. Each interview included descriptions of three of five strategies grounded in behavioral economic theory designed to facilitate clinicians' use of LPV: 1) an order set autopopulated with LPV settings ("default"), 2) an order set providing a choice between autopopulated LPV settings and open-ended order entry for alternative settings ("active choice"), 3) requirement of written justification if settings other than LPV were ordered or documented ("accountable justification"), 4) automated ARDS identification and clinician prompting ("alert"), and 5) provision of clinicians' and their peers' individual rates of LPV use ("peer comparison"). Descriptions were followed by open-ended questions to elicit perceptions about advantages, disadvantages, and acceptability. Initial interview transcripts were reviewed by two investigators to develop a thematic codebook, which was refined iteratively with the use of constant comparative methods.Results: We completed 17 interviews of physicians, nurse practitioners, and respiratory therapists. Strategies that prepopulated settings (default, active choice, and accountable justification) were perceived as providing benefit by reducing workloads and serving as cognitive prompts. The default and active choice strategies were more acceptable than accountable justification, which was perceived as potentially frustrating due to workflow impedance. The alert strategy was met with concerns about alert accuracy and alarm fatigue. The peer comparison strategy led to concerns about timing and fear of punitive measures. Participants believed that the default and active choice strategies would be highly acceptable, whereas few interviewees thought the alert would be acceptable. The active choice strategy was most consistently identified as potentially highly effective.Conclusions: Behavioral economic strategies have great potential as acceptable and potentially effective strategies to increase the use of LPV.
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Knighton AJ, Kean J, Wolfe D, Allen L, Jacobs J, Carpenter L, Winberg C, Berry JG, Peltan ID, Grissom CK, Srivastava R. Multi-factorial barriers and facilitators to high adherence to lung-protective ventilation using a computerized protocol: a mixed methods study. Implement Sci Commun 2020; 1:67. [PMID: 32835225 PMCID: PMC7385713 DOI: 10.1186/s43058-020-00057-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 07/15/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Lung-protective ventilation (LPV) improves outcomes for patients with acute respiratory distress syndrome (ARDS) through the administration of low tidal volumes (≤ 6.5 ml/kg predicted body weight [PBW]) with co-titration of positive end-expiratory pressure and fraction of inspired oxygen. Many patients with ARDS, however, are not managed with LPV. The purpose of this study was to understand the implementation barriers and facilitators to the use of LPV and a computerized LPV clinical decision support (CDS) tool in intensive care units (ICUs) in preparation for a pilot hybrid implementation-effectiveness clinical trial. METHODS We performed an explanatory sequential mixed methods study from June 2018 to March 2019 to evaluate the variation in LPV adherence across 17 ICUs in an integrated healthcare system with > 4000 mechanically ventilated patients annually. We analyzed 47 key informant interviews of ICU physicians, respiratory therapists (RTs), and nurses in 3 of the ICUs using a qualitative content analysis paradigm to investigate site variation as defined by adherence level (low, medium, high) and to identify barriers and facilitators to LPV and LPV CDS tool use. RESULTS Forty-two percent of patients had an initial set tidal volume of ≤ 6.5 ml/kg PBW during the measurement period (site range 21-80%). LPV CDS tool use was 28% (site range 6-91%). This study's main findings revealed multi-factorial facilitators and barriers to use that varied by ICU site adherence level. The primary facilitator was that LPV and the LPV CDS tool could be used on all mechanically ventilated patients. Barriers included a persistent gap between clinician attitudes regarding the use of LPV and actual use, the perceived loss of autonomy associated with using a computerized protocol, the nature of physician-RT interaction in ventilation management, and the lack of clear organization measures of success. CONCLUSIONS Variation in adherence to LPV persists in ICUs within a healthcare delivery system that was an early adopter of LPV. Potentially promising strategies to increase adherence to LPV and the LPV CDS tool for ARDS patients include initiating low tidal ventilation on all mechanically ventilated patients, establishing and measuring adherence measures, and focused education addressing the physician-RT interaction. These strategies represent a blueprint for a future hybrid implementation-effectiveness trial.
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Affiliation(s)
- Andrew J. Knighton
- Implementation Science Research, Healthcare Delivery Institute, Intermountain Healthcare, 5026 South State Street, 3rd Floor, Murray, UT 84107 USA
| | - Jacob Kean
- Population Health Sciences, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84108 USA
| | - Doug Wolfe
- Best Practice Implementation, Healthcare Delivery Institute, Intermountain Healthcare, 5026 South State Street, 3rd Floor, Murray, UT 84107 USA
| | - Lauren Allen
- Best Practice Implementation, Healthcare Delivery Institute, Intermountain Healthcare, 5026 South State Street, 3rd Floor, Murray, UT 84107 USA
| | - Jason Jacobs
- Pulmonary and Critical Care Research, Intermountain Healthcare, 5121 S Cottonwood St, Murray, UT 84107 USA
| | - Lori Carpenter
- Pulmonary and Critical Care Research, Intermountain Healthcare, 5121 S Cottonwood St, Murray, UT 84107 USA
| | - Carrie Winberg
- Pulmonary and Critical Care Research, Intermountain Healthcare, 5121 S Cottonwood St, Murray, UT 84107 USA
| | - Jay G. Berry
- Complex Care, Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Ithan D. Peltan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, USA
- Division of Pulmonary and Critical Care Medicine, Intermountain Healthcare, 5121 S Cottonwood St, Murray, UT 84107 USA
| | - Colin K. Grissom
- Intermountain Healthcare, 5121 S Cottonwood St, Murray, UT 84107 USA
| | - Raj Srivastava
- Healthcare Delivery Institute, Intermountain Healthcare, 5026 South State Street 3rd Floor, Murray, UT 84107 USA
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84108 USA
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Prone positioning in non-intubated patients with COVID-19: raising the bar. THE LANCET RESPIRATORY MEDICINE 2020; 8:744-745. [PMID: 32569584 PMCID: PMC7304963 DOI: 10.1016/s2213-2600(20)30269-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 06/08/2020] [Indexed: 01/13/2023]
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Midega TD, Bozza FA, Machado FR, Guimarães HP, Salluh JI, Nassar AP, Normílio-Silva K, Schultz MJ, Cavalcanti AB, Serpa Neto A. Organizational factors associated with adherence to low tidal volume ventilation: a secondary analysis of the CHECKLIST-ICU database. Ann Intensive Care 2020; 10:68. [PMID: 32488524 PMCID: PMC7266115 DOI: 10.1186/s13613-020-00687-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 05/25/2020] [Indexed: 12/15/2022] Open
Abstract
Background Survival benefit from low tidal volume (VT) ventilation (LTVV) has been demonstrated for patients with acute respiratory distress syndrome (ARDS), and patients not having ARDS could also benefit from this strategy. Organizational factors may play a role on adherence to LTVV. The present study aimed to identify organizational factors with an independent association with adherence to LTVV. Methods Secondary analysis of the database of a multicenter two-phase study (prospective cohort followed by a cluster-randomized trial) performed in 118 Brazilian intensive care units. Patients under mechanical ventilation at day 2 were included. LTVV was defined as a VT ≤ 8 ml/kg PBW on the second day of ventilation. Data on the type and number of beds of the hospital, teaching status, nursing, respiratory therapists and physician staffing, use of structured checklist, and presence of protocols were tested. A multivariable mixed-effect model was used to assess the association between organizational factors and adherence to LTVV. Results The study included 5719 patients; 3340 (58%) patients received LTVV. A greater number of hospital beds (absolute difference 7.43% [95% confidence interval 0.61–14.24%]; p = 0.038), use of structured checklist during multidisciplinary rounds (5.10% [0.55–9.81%]; p = 0.030), and presence of at least one nurse per 10 patients during all shifts (17.24% [0.85–33.60%]; p = 0.045) were the only three factors that had an independent association with adherence to LTVV. Conclusions Number of hospital beds, use of a structured checklist during multidisciplinary rounds, and nurse staffing are organizational factors associated with adherence to LTVV. These findings shed light on organizational factors that may improve ventilation in critically ill patients.
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Affiliation(s)
- Thais Dias Midega
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 700, São Paulo, Brazil
| | - Fernando A Bozza
- Research Institute, Instituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, Brazil.,Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - Flávia Ribeiro Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, Brazil
| | - Helio Penna Guimarães
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 700, São Paulo, Brazil.,Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jorge I Salluh
- Graduate Program in Translational Medicine and Department of Critical Care, Instituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, Brazil.,Post Graduate Program in Internal Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Antonio Paulo Nassar
- Intensive Care Unit and Postgraduate Program, A.C. Camargo Cancer Center, São Paulo, Brazil
| | | | - Marcus J Schultz
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 700, São Paulo, Brazil. .,Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands.
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Evaluating Delivery of Low Tidal Volume Ventilation in Six ICUs Using Electronic Health Record Data. Crit Care Med 2019; 47:56-61. [PMID: 30308549 DOI: 10.1097/ccm.0000000000003469] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Mechanical ventilation with low tidal volumes is recommended for all patients with acute respiratory distress syndrome and may be beneficial to other intubated patients, yet consistent implementation remains difficult to obtain. Using detailed electronic health record data, we examined patterns of tidal volume administration, the effect on clinical outcomes, and alternate metrics for evaluating low tidal volume compliance in clinical practice. DESIGN Observational cohort study. SETTING Six ICUs in a single hospital system. PATIENTS Adult patients who received invasive mechanical ventilation more than 12 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Tidal volumes were analyzed across 1,905 hospitalizations. Although mean tidal volume was 6.8 mL/kg predicted body weight, 40% of patients were exposed to tidal volumes greater than 8 mL/kg predicted body weight, with 11% for more than 24 hours. At a patient level, exposure to 24 total hours of tidal volumes greater than 8 mL/kg predicted body weight was associated with increased mortality (odds ratio, 1.82; 95% CI, 1.20-2.78), whereas mean tidal volume exposure was not (odds ratio, 0.87/1 mL/kg increase; 95% CI, 0.74-1.02). Initial tidal volume settings strongly predicted exposure to volumes greater than 8 mL/kg for 24 hours; the adjusted rate was 21.5% when initial volumes were greater than 8 mL/kg predicted body weight and 7.1% when initial volumes were less than 8 mL/kg predicted body weight. Across ICUs, correlation of mean tidal volume with alternative measures of low tidal volume delivery ranged from 0.38 to 0.66. CONCLUSIONS Despite low mean tidal volume in the cohort, a significant percentage of patients were exposed to a prolonged duration of high tidal volumes which was correlated with higher mortality. Detailed ventilator records in the electronic health record provide a unique window for evaluating low tidal volume delivery and targets for improvement.
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A quantitative approach for the analysis of clinician recognition of acute respiratory distress syndrome using electronic health record data. PLoS One 2019; 14:e0222826. [PMID: 31539417 PMCID: PMC6754155 DOI: 10.1371/journal.pone.0222826] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 09/09/2019] [Indexed: 11/19/2022] Open
Abstract
IMPORTANCE Despite its efficacy, low tidal volume ventilation (LTVV) remains severely underutilized for patients with acute respiratory distress syndrome (ARDS). Physician under-recognition of ARDS is a significant barrier to LTVV use. We propose a computational method that addresses some of the limitations of the current approaches to automated measurement of whether ARDS is recognized by physicians. OBJECTIVE To quantify patient and physician factors affecting physicians' tidal volume selection and to build a computational model of physician recognition of ARDS that accounts for these factors. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, electronic health record data were collected for 361 ARDS patients and 388 non-ARDS hypoxemic (control) patients in nine adult intensive care units at four hospitals between June 24 and December 31, 2013. METHODS Standardized tidal volumes (mL/kg predicted body weight) were chosen as a proxy for physician decision-making behavior. Using data-science approaches, we quantified the effect of eight factors (six severity of illness, two physician behaviors) on selected standardized tidal volumes in ARDS and control patients. Significant factors were incorporated in computational behavioral models of physician recognition of ARDS. RESULTS Hypoxemia severity and ARDS documentation in physicians' notes were associated with lower standardized tidal volumes in the ARDS cohort. Greater patient height was associated with lower standardized tidal volumes (which is already normalized for height) in both ARDS and control patients. The recognition model yielded a mean (99% confidence interval) physician recognition of ARDS of 22% (9%-42%) for mild, 34% (19%-49%) for moderate, and 67% (41%-100%) for severe ARDS. CONCLUSIONS AND RELEVANCE In this study, patient characteristics and physician behaviors were demonstrated to be associated with differences in ventilator management in both ARDS and control patients. Our model of physician ARDS recognition measurement accounts for these clinical variables, providing an electronic approach that moves beyond relying on chart documentation or resource intensive approaches.
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Raff L, Kerby JD, Reiff D, Jansen J, Schinnerer E, McGwin G, Bosarge P. Use of extracorporeal membranous oxygenation in the management of refractory trauma-related severe acute respiratory distress syndrome: a national survey of the Eastern Association for the Surgery of Trauma. Trauma Surg Acute Care Open 2019; 4:e000341. [PMID: 31467986 PMCID: PMC6699719 DOI: 10.1136/tsaco-2019-000341] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/10/2019] [Accepted: 07/17/2019] [Indexed: 11/04/2022] Open
Abstract
Objective To report results of a national survey of provider attitudes, observations, and opinions regarding the use of extracorporeal membranous oxygenation (ECMO) to manage severe acute respiratory distress syndrome (ARDS) in trauma patients. Design A survey was created to query providers on the use of ECMO in trauma, as well as general management principals related to care of the patient with refractory hypoxic respiratory failure. The survey was sent to all members of Eastern Association for the Surgery of Trauma (EAST). Once completed, the survey was returned to the University of Alabama at Birmingham and results were analyzed. Setting/patients Trauma patients with refractory ARDS. Interventions None. Measurements and main results Respondents were from 37 states, the District of Columbia, and Puerto Rico. 56.9% reported institutional ECMO capabilities, but only 45.2% reported using ECMO for trauma patients. Most respondents (90.2%) reported ECMO use in less than or equal to five trauma patients per year. 20.9% think there is not enough data to support its use in trauma but only 4.7% would absolutely not consider ECMO use for trauma patients. Ranking the preferred modality of treatments for refractory ARDS from most to least preferable is as follows: airway pressure release ventilation, bilevel ventilation, paralysis, prone positioning, inhaled nitric oxide, epoprostenol, high-frequency oscillatory ventilation, corticosteroids, surfactant. Conclusions ARDS has a high mortality among trauma patients. Despite its utility in treating severe ARDS and other pulmonary disease processes, ECMO has not been universally embraced by the trauma community. There are an increasing number of studies that suggest that ECMO is a safe and viable treatment option for trauma patients with ARDS. Based on the results of this survey, ECMO use remains limited by trauma providers that care for patients with refractory hypoxic respiratory failure and ARDS, likely due to a combination of knowledge gaps and lack of access to ECMO. Level of evidence Level V.
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Affiliation(s)
- Lauren Raff
- Trauma and Acute Care Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Donald Reiff
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jan Jansen
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Eric Schinnerer
- Acute Care Surgery, St. John Trauma Services, Tulsa, Oklahoma, USA
| | - Gerald McGwin
- Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Patrick Bosarge
- Acute Care Surgery, University of Phoenix, Phoenix, Arizona, USA
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Prekker ME, Donelan C, Ambur S, Driver BE, O'Brien-Lambert A, Hottinger DG, Adams AB. Adoption of low tidal volume ventilation in the emergency department: A quality improvement intervention. Am J Emerg Med 2019; 38:763-767. [PMID: 31235218 DOI: 10.1016/j.ajem.2019.06.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/07/2019] [Accepted: 06/14/2019] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Ventilator tidal volumes of >8 mL/kg of predicted body weight (PBW) may increase the risk of lung injury. We sought to evaluate the impact of a quality improvement intervention among intubated Emergency Department (ED) patients to protocolize the prescription of low tidal volume ventilation. METHODS In this before-and-after study, the average tidal volume delivered to ED patients receiving volume assist-control ventilation was compared before (2007-2014) and after (2015-2016) implementation of a ventilator initiation protocol (the quality improvement intervention). The intervention emphasized 1) measurement of the patient's height to calculate PBW and therefore tailor the tidal volume to estimated lung size (<8 mL/kg PBW), and 2) focused education and reference materials for ED physicians and respiratory therapists. RESULTS Among ventilated ED patients meeting inclusion criteria in the before (N = 2185) and after (N = 774) cohorts, the mean (±SD) tidal volume decreased from 9.0 ± 1.4 mL/kg to 7.2 ± 0.9 mL/kg PBW following the intervention (absolute difference 1.8 mL/kg, 95% confidence interval 1.7 to 1.9 mL/kg, p < 0.001). The proportion of patients receiving low tidal volume ventilation increased after the intervention (72%), as compared to before (23%). Low tidal volume ventilation continued to be utilized at 24 h after ICU admission in patients who remained intubated in the cohort following the intervention (mean tidal volume 7.3 mL/kg PBW). CONCLUSIONS Pairing a ventilator initiation protocol with focused education and resources for emergency physicians and respiratory therapists was associated with a significant reduction in tidal volume delivered to ED patients.
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Affiliation(s)
- Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America; Department of Medicine, Division of Pulmonary and Critical Care, Hennepin County Medical Center, Minneapolis, MN, United States of America.
| | - Crystal Donelan
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America.
| | - Sum Ambur
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America.
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America.
| | - Alex O'Brien-Lambert
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America.
| | - Daniel G Hottinger
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America.
| | - Alexander B Adams
- Department of Medicine, Division of Pulmonary and Critical Care, Hennepin County Medical Center, Minneapolis, MN, United States of America; Respiratory Therapy Department, Hennepin County Medical Center, Minneapolis, MN, United States of America
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Recognition and Appropriate Treatment of the Acute Respiratory Distress Syndrome Remains Unacceptably Low. Crit Care Med 2018; 44:1611-2. [PMID: 27428124 DOI: 10.1097/ccm.0000000000001771] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW The use of evidence-based practices in clinical practice is frequently inadequate. Recent research has uncovered many barriers to the implementation of evidence-based practices in critical care medicine. Using a comprehensive conceptual framework, this review identifies and classifies the barriers to implementation of several major critical care evidence-based practices. RECENT FINDINGS The many barriers that have been recently identified can be classified into domains of the consolidated framework for implementation research (CFIR). Barriers to the management of patients with acute respiratory distress syndrome (ARDS) include ARDS under-recognition. Barriers to the use of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility (ABCDE) bundle for mechanically ventilated patients and the sepsis bundle include patient-related, clinician-related, protocol-related, contextual-related, and intervention-related factors. Although these many barriers can be classified into all five CFIR domains (intervention, outer setting, inner setting, individuals, and process), most barriers fall within the individuals and inner setting domains. SUMMARY There are many barriers to the implementation of evidence-based practice in critical care medicine. Systematically classifying these barriers allows implementation researchers and clinicians to design targeted implementation strategies, giving them the greatest chance of success in improving the use of evidence-based practice.
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Translating evidence into practice in acute respiratory distress syndrome: teamwork, clinical decision support, and behavioral economic interventions. Curr Opin Crit Care 2018; 23:406-411. [PMID: 28742539 DOI: 10.1097/mcc.0000000000000437] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Although the treatment of the acute respiratory distress syndrome (ARDS) with low tidal volume (LTV) mechanical ventilation improves mortality, it is not consistently administered in clinical practice. This review examines strategies to improve LTV and other evidence-based therapies for patients with ARDS. RECENT FINDINGS Despite the well established role of LTV in the treatment of ARDS, a recent multinational study suggests it is under-utilized in clinical practice. Strategies to improve LTV include audit and feedback, provider education, protocol development, interventions to improve ICU teamwork, computer decision support, and behavioral economic interventions such as making LTV the default-ventilator setting. These strategies typically target all patients receiving invasive mechanical ventilation, effectively avoiding the problem of poor ARDS recognition in clinical practice. To more effectively administer advanced ARDS therapies, such as prone positioning, better approaches for ARDS recognition will also be required. SUMMARY Multiple strategies can be utilized to improve adherence to LTV ventilation in ARDS patients.
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Spece LJ, Mitchell KH, Caldwell ES, Gundel SJ, Jolley SE, Hough CL. Low tidal volume ventilation use remains low in patients with acute respiratory distress syndrome at a single center. J Crit Care 2017; 44:72-76. [PMID: 29073535 DOI: 10.1016/j.jcrc.2017.10.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 09/19/2017] [Accepted: 10/17/2017] [Indexed: 12/18/2022]
Abstract
PURPOSE Low tidal volume ventilation (LTVV) reduces mortality in acute respiratory distress syndrome (ARDS) patients. Understanding local barriers to LTVV use at a former ARDS Network hospital may provide new insight to improve LTVV implementation. METHODS A cohort of 214 randomly selected adults met the Berlin definition of ARDS at Harborview Medical Center between 2008 and 2012. The primary outcome was the receipt of LTVV (tidal volume of ≤6.5mL/kg predicted body weight) within 48h of ARDS onset. We constructed a multivariable logistic regression model to identify factors associated with the outcome. RESULTS Only 27% of patients received tidal volumes of ≤6.5mL/kg PBW within 48h of ARDS onset. Increasing plateau pressure (OR 1.11; 95% CI 1.03 to 1.19; p-value<0.01) was positively associated with LTVV use while increasing PaO2:FIO2 ratio was negatively associated (OR 0.75; 95% CI 0.57 to 0.98; p-value 0.03). Physicians documented an ARDS diagnosis in only 21% of the cohort. Neither patient height nor gender was associated with LTVV use. CONCLUSIONS Most ARDS patients did not receive LTVV despite implementation of a protocol. ARDS was also recognized in a minority of patients, suggesting an opportunity for improvement of care.
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Affiliation(s)
- Laura J Spece
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, United States.
| | - Kristina H Mitchell
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, United States
| | - Ellen S Caldwell
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, United States
| | - Stephanie J Gundel
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, United States
| | - Sarah E Jolley
- Section of Pulmonary/Critical Care and Allergy/Immunology, Louisiana State University, New Orleans, LA, United States
| | - Catherine L Hough
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, United States
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Weiss CH, Krishnan JA, Au DH, Bender BG, Carson SS, Cattamanchi A, Cloutier MM, Cooke CR, Erickson K, George M, Gerald JK, Gerald LB, Goss CH, Gould MK, Hyzy R, Kahn JM, Mittman BS, Mosesón EM, Mularski RA, Parthasarathy S, Patel SR, Rand CS, Redeker NS, Reiss TF, Riekert KA, Rubenfeld GD, Tate JA, Wilson KC, Thomson CC. An Official American Thoracic Society Research Statement: Implementation Science in Pulmonary, Critical Care, and Sleep Medicine. Am J Respir Crit Care Med 2017; 194:1015-1025. [PMID: 27739895 PMCID: PMC5441016 DOI: 10.1164/rccm.201608-1690st] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Many advances in health care fail to reach patients. Implementation science is the study of novel approaches to mitigate this evidence-to-practice gap. METHODS The American Thoracic Society (ATS) created a multidisciplinary ad hoc committee to develop a research statement on implementation science in pulmonary, critical care, and sleep medicine. The committee used an iterative consensus process to define implementation science and review the use of conceptual frameworks to guide implementation science for the pulmonary, critical care, and sleep community and to explore how professional medical societies such as the ATS can promote implementation science. RESULTS The committee defined implementation science as the study of the mechanisms by which effective health care interventions are either adopted or not adopted in clinical and community settings. The committee also distinguished implementation science from the act of implementation. Ideally, implementation science should include early and continuous stakeholder involvement and the use of conceptual frameworks (i.e., models to systematize the conduct of studies and standardize the communication of findings). Multiple conceptual frameworks are available, and we suggest the selection of one or more frameworks on the basis of the specific research question and setting. Professional medical societies such as the ATS can have an important role in promoting implementation science. Recommendations for professional societies to consider include: unifying implementation science activities through a single organizational structure, linking front-line clinicians with implementation scientists, seeking collaborations to prioritize and conduct implementation science studies, supporting implementation science projects through funding opportunities, working with research funding bodies to set the research agenda in the field, collaborating with external bodies responsible for health care delivery, disseminating results of implementation science through scientific journals and conferences, and teaching the next generation about implementation science through courses and other media. CONCLUSIONS Implementation science plays an increasingly important role in health care. Through support of implementation science, the ATS and other professional medical societies can work with other stakeholders to lead this effort.
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Miller AC, Ferrada PA, Kadri SS, Nataraj-Bhandari K, Vahedian-Azimi A, Quraishi SA. High-Frequency Ventilation Modalities as Salvage Therapy for Smoke Inhalation-Associated Acute Lung Injury: A Systematic Review. J Intensive Care Med 2017. [PMID: 28651475 DOI: 10.1177/0885066617714770] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Smoke inhalation-associated acute lung injury (SI-ALI) is a major cause of morbidity and mortality in victims of fire tragedies. To date, there are no evidence-based guidelines on ventilation strategies in acute respiratory distress syndrome (ARDS) after smoke inhalation. We reviewed the existing literature for clinical studies of salvage mechanical ventilation (MV) strategies in patients with SI-ALI, focusing on mortality and pneumonia as outcomes. METHODS A systematic search was designed in accordance with preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Risk of bias assessment was performed using the Newcastle-Ottawa Quality Assessment Scale (NOS; 0 to 9 stars), with a score ≥7 being the threshold for inclusion in the meta-analysis. A systematic search strategy was used to search 10 databases. Clinical studies were included in which patients: (1) experienced smoke inhalation, (2) treated with MV, and (3) described a concurrent or historical control group. RESULTS A total of 226 potentially relevant studies were identified, of which 7 studies on high-frequency percussive ventilation (HFPV) met inclusion criteria. No studies met inclusion for meta-analysis (NOS ≥ 7). In studies comparing HFPV to conventional mechanical ventilation (CMV), mortality and pneumonia incidence improved in 3 studies and remained unchanged in 3 others. No change in ventilator days or ICU length of stay was observed; however, oxygenation and work of breathing improved with HFPV. CONCLUSIONS Mechanical ventilation in patients with SI-ALI has not been well studied. High-frequency percussive ventilation may decrease in-hospital mortality and pneumonia incidence when compared to CMV. The absence of "good" quality evidence precluded meta-analysis. Based upon low-quality evidence, there was a very weak recommendation that HFPV use may be associated with lower mortality and pneumonia rates in patients with SI-ALI. Given SI-ALI's unique underlying pathophysiology, and its potential implications on therapy, randomized controlled studies are required to ensure that patients receive the safest and most effective care. TRIAL REGISTRATION The study was registered with PROSPERO International prospective register of systematic reviews (#47015).
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Affiliation(s)
- Andrew C Miller
- 1 Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA.,2 Department of Emergency Medicine, West Virginia University, Morgantown, WV, USA
| | - Paula A Ferrada
- 3 Division of Trauma and Critical Care, Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Sameer S Kadri
- 1 Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | | | - Amir Vahedian-Azimi
- 4 Trauma Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Sadeq A Quraishi
- 5 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.,6 Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
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Abstract
OBJECTIVE Low tidal volume ventilation lowers mortality in the acute respiratory distress syndrome. Previous studies reported poor low tidal volume ventilation implementation. We sought to determine the rate, quality, and predictors of low tidal volume ventilation use. DESIGN Retrospective cross-sectional study. SETTING One academic and three community hospitals in the Chicago region. PATIENTS A total of 362 adults meeting the Berlin Definition of acute respiratory distress syndrome consecutively admitted between June and December 2013. MEASUREMENTS AND MAIN RESULTS Seventy patients (19.3%) were treated with low tidal volume ventilation (tidal volume < 6.5 mL/kg predicted body weight) at some time during mechanical ventilation. In total, 22.2% of patients requiring an FIO2 greater than 40% and 37.3% of patients with FIO2 greater than 40% and plateau pressure greater than 30 cm H2O received low tidal volume ventilation. The entire cohort received low tidal volume ventilation 11.4% of the time patients had acute respiratory distress syndrome. Among patients who received low tidal volume ventilation, the mean (SD) percentage of acute respiratory distress syndrome time it was used was 59.1% (38.2%), and 34% waited more than 72 hours prior to low tidal volume ventilation initiation. Women were less likely to receive low tidal volume ventilation, whereas sepsis and FIO2 greater than 40% were associated with increased odds of low tidal volume ventilation use. Four attending physicians (6.2%) initiated low tidal volume ventilation within 1 day of acute respiratory distress syndrome onset for greater than or equal to 50% of their patients, whereas 34 physicians (52.3%) never initiated low tidal volume ventilation within 1 day of acute respiratory distress syndrome onset. In total, 54.4% of patients received a tidal volume less than 8 mL/kg predicted body weight, and the mean tidal volume during the first 72 hours after acute respiratory distress syndrome onset was never less than 8 mL/kg predicted body weight. CONCLUSIONS More than 12 years after publication of the landmark low tidal volume ventilation study, use remains poor. Interventions that improve adoption of low tidal volume ventilation are needed.
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Belard A, Buchman T, Forsberg J, Potter BK, Dente CJ, Kirk A, Elster E. Precision diagnosis: a view of the clinical decision support systems (CDSS) landscape through the lens of critical care. J Clin Monit Comput 2017; 31:261-271. [PMID: 26902081 DOI: 10.1007/s10877-016-9849-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 02/17/2016] [Indexed: 10/22/2022]
Abstract
Improving diagnosis and treatment depends on clinical monitoring and computing. Clinical decision support systems (CDSS) have been in existence for over 50 years. While the literature points to positive impacts on quality and patient safety, outcomes, and the avoidance of medical errors, technical and regulatory challenges continue to retard their rate of integration into clinical care processes and thus delay the refinement of diagnoses towards personalized care. We conducted a systematic review of pertinent articles in the MEDLINE, US Department of Health and Human Services, Agency for Health Research and Quality, and US Food and Drug Administration databases, using a Boolean approach to combine terms germane to the discussion (clinical decision support, tools, systems, critical care, trauma, outcome, cost savings, NSQIP, APACHE, SOFA, ICU, and diagnostics). References were selected on the basis of both temporal and thematic relevance, and subsequently aggregated around four distinct themes: the uses of CDSS in the critical and surgical care settings, clinical insertion challenges, utilization leading to cost-savings, and regulatory concerns. Precision diagnosis is the accurate and timely explanation of each patient's health problem and further requires communication of that explanation to patients and surrogate decision-makers. Both accuracy and timeliness are essential to critical care, yet computed decision support systems (CDSS) are scarce. The limitation arises from the technical complexity associated with integrating and filtering large data sets from diverse sources. Provider mistrust and resistance coupled with the absence of clear guidance from regulatory bodies further retard acceptance of CDSS. While challenges to develop and deploy CDSS are substantial, the clinical, quality, and economic impacts warrant the effort, especially in disciplines requiring complex decision-making, such as critical and surgical care. Improving diagnosis in health care requires accumulation, validation and transformation of data into actionable information. The aggregate of those processes-CDSS-is currently primitive. Despite technical and regulatory challenges, the apparent clinical and economic utilities of CDSS must lead to greater engagement. These tools play the key role in realizing the vision of a more 'personalized medicine', one characterized by individualized precision diagnosis rather than population-based risk-stratification.
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Affiliation(s)
- Arnaud Belard
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
- Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA.
| | - Timothy Buchman
- Emory University and Grady Memorial Hospital, Atlanta, GA, USA
- Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
| | - Jonathan Forsberg
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Naval Medical Research Center, Bethesda, MD, USA
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
| | - Benjamin K Potter
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
| | - Christopher J Dente
- Emory University and Grady Memorial Hospital, Atlanta, GA, USA
- Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
| | - Allan Kirk
- Duke University, Durham, NC, USA
- Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
| | - Eric Elster
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
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L’her E, Martin-Babau J, Lellouche F. Accuracy of height estimation and tidal volume setting using anthropometric formulas in an ICU Caucasian population. Ann Intensive Care 2016; 6:55. [PMID: 27325410 PMCID: PMC4916127 DOI: 10.1186/s13613-016-0154-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 05/30/2016] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Knowledge of patients' height is essential for daily practice in the intensive care unit. However, actual height measurements are unavailable on a daily routine in the ICU and measured height in the supine position and/or visual estimates may lack consistency. Clinicians do need simple and rapid methods to estimate the patients' height, especially in short height and/or obese patients. The objectives of the study were to evaluate several anthropometric formulas for height estimation on healthy volunteers and to test whether several of these estimates will help tidal volume setting in ICU patients. METHODS This was a prospective, observational study in a medical intensive care unit of a university hospital. During the first phase of the study, eight limb measurements were performed on 60 healthy volunteers and 18 height estimation formulas were tested. During the second phase, four height estimates were performed on 60 consecutive ICU patients under mechanical ventilation. RESULTS In the 60 healthy volunteers, actual height was well correlated with the gold standard, measured height in the erect position. Correlation was low between actual and calculated height, using the hand's length and width, the index, or the foot equations. The Chumlea method and its simplified version, performed in the supine position, provided adequate estimates. In the 60 ICU patients, calculated height using the simplified Chumlea method was well correlated with measured height (r = 0.78; ∂ < 1 %). Ulna and tibia estimates also provided valuable estimates. All these height estimates allowed calculating IBW or PBW that were significantly different from the patients' actual weight on admission. In most cases, tidal volume set according to these estimates was lower than what would have been set using the actual weight. CONCLUSION When actual height is unavailable in ICU patients undergoing mechanical ventilation, alternative anthropometric methods to obtain patient's height based on lower leg and on forearm measurements could be useful to facilitate the application of protective mechanical ventilation in a Caucasian ICU population. The simplified Chumlea method is easy to achieve in a bed-ridden patient and provides accurate height estimates, with a low bias.
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Affiliation(s)
- Erwan L’her
- />Réanimation Médicale, CHRU de Brest – La Cavale Blanche, Bvd Tanguy-Prigent, 29609 Brest Cedex, France
- />LATIM INSERM UMR 1101, Université de Bretagne Occidentale, Brest Cedex, France
| | - Jérôme Martin-Babau
- />Réanimation Médicale, CHRU de Brest – La Cavale Blanche, Bvd Tanguy-Prigent, 29609 Brest Cedex, France
| | - François Lellouche
- />Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada
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Ward SL, Quinn CM, Valentine SL, Sapru A, Curley MAQ, Willson DF, Liu KD, Matthay MA, Flori HR. Poor Adherence to Lung-Protective Mechanical Ventilation in Pediatric Acute Respiratory Distress Syndrome. Pediatr Crit Care Med 2016; 17:917-923. [PMID: 27513687 PMCID: PMC5199719 DOI: 10.1097/pcc.0000000000000903] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the frequency of low-tidal volume ventilation in pediatric acute respiratory distress syndrome and assess if any demographic or clinical factors improve low-tidal volume ventilation adherence. DESIGN Descriptive post hoc analysis of four multicenter pediatric acute respiratory distress syndrome studies. SETTING Twenty-six academic PICU. PATIENTS Three hundred fifteen pediatric acute respiratory distress syndrome patients. MEASUREMENTS AND MAIN RESULTS All patients who received conventional mechanical ventilation at hours 0 and 24 of pediatric acute respiratory distress syndrome who had data to calculate ideal body weight were included. Two cutoff points for low-tidal volume ventilation were assessed: less than or equal to 6.5 mL/kg of ideal body weight and less than or equal to 8 mL/kg of ideal body weight. Of 555 patients, we excluded 240 for other respiratory support modes or missing data. The remaining 315 patients had a median PaO2-to-FIO2 ratio of 140 (interquartile range, 90-201), and there were no differences in demographics between those who did and did not receive low-tidal volume ventilation. With tidal volume cutoff of less than or equal to 6.5 mL/kg of ideal body weight, the adherence rate was 32% at hour 0 and 33% at hour 24. A low-tidal volume ventilation cutoff of tidal volume less than or equal to 8 mL/kg of ideal body weight resulted in an adherence rate of 58% at hour 0 and 60% at hour 24. Low-tidal volume ventilation use was no different by severity of pediatric acute respiratory distress syndrome nor did adherence improve over time. At hour 0, overweight children were less likely to receive low-tidal volume ventilation less than or equal to 6.5 mL/kg ideal body weight (11% overweight vs 38% nonoverweight; p = 0.02); no difference was noted by hour 24. Furthermore, in the overweight group, using admission weight instead of ideal body weight resulted in misclassification of up to 14% of patients as receiving low-tidal volume ventilation when they actually were not. CONCLUSIONS Low-tidal volume ventilation is underused in the first 24 hours of pediatric acute respiratory distress syndrome. Age, Pediatric Risk of Mortality-III, and pediatric acute respiratory distress syndrome severity were not associated with improved low-tidal volume ventilation adherence nor did adherence improve over time. Overweight children were less likely to receive low-tidal volume ventilation strategies in the first day of illness.
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Affiliation(s)
- Shan L Ward
- 1Division of Critical Care, Department of Pediatrics, UCSF Benioff Children's Hospital San Francisco, San Francisco, CA.2Department Volunteer Services, UCSF Benioff Children's Hospital Oakland, Oakland, CA.3Department of Pediatric Critical Care, UMass Memorial Medical Center, Worcester, MA.4Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at UCLA Medical Center, Los Angeles, CA.5Department of Family and Community Health, University of Pennsylvania, School of Nursing, Philadelphia, PA.6Division of Pediatric Critical Care, Children's Hospital of Richmond at VCU, Richmond, VA.7Department of Medicine, UCSF Medical Center, San Francisco, CA.8Department of Anesthesia, UCSF Medical Center, San Francisco, CA.9Cardiovascular Research Institute, UCSF Medical Center, San Francisco, CA.10Division of Pediatric Critical Care Medicine, C.S. Mott Children's Hospital, Ann Arbor, MI
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Use of ECMO in the Management of Severe Acute Respiratory Distress Syndrome: A Survey of Academic Medical Centers in the United States. ASAIO J 2016; 61:556-63. [PMID: 25914957 DOI: 10.1097/mat.0000000000000245] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Mortality of severe acute respiratory distress syndrome (ARDS) remains high. Once conventional mechanical ventilation fails, alternative modes of therapy are used; most of which have limited evidence to support their use. No definitive guidelines exist for the management of these patients with alternate modalities of treatment. We conducted a cross-sectional national survey of 302 adult critical care training programs in the United States to understand the current preferences of intensivists regarding the use of different therapies for severe ARDS, including the use of extracorporeal membrane oxygenation (ECMO). A total of 381 responses were received: 203 critical care faculty and 174 critical care trainees. Airway pressure release ventilation was the initial choice of treatment reported by most when conventional mechanical ventilation strategy failed followed by inhaled nitric oxide and prone positioning. Extracorporeal membrane oxygenation availability was reported by 80% of the respondents at their institutions. Most respondents (83%) would consider ECMO in patients who fail optimal mechanical ventilation strategies, and the majority (60%) believed that ECMO use can facilitate lung protective ventilation, but few favored its use as a first-line modality. The majority of respondents reported limited knowledge of ECMO and desired specific ECMO education during training.
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Nguyen AP, Hyder JA, Wanta BT, Stelfox HT, Schmidt U. Measuring intensive care unit performance after sustainable growth rate reform: An example with the National Quality Forum metrics. J Crit Care 2016; 36:81-84. [PMID: 27546752 DOI: 10.1016/j.jcrc.2016.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 05/11/2016] [Accepted: 06/09/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Performance measurement is essential for quality improvement and is inevitable in the shift to value-based payment. The National Quality Forum is an important clearinghouse for national performance measures in health care in the United States. AIM We reviewed the National Quality Forum library of performance measures to highlight measures that are relevant to critical care medicine, and we describe gaps and opportunities for the future of performance measurement in critical care medicine. CONCLUSION Crafting performance measures that address core aspects of critical care will be challenging, as current outcome and performance measures have problems with validity. Future quality measures will likely focus on interdisciplinary measures across the continuum of patient care.
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Affiliation(s)
- Albert P Nguyen
- Department of Anesthesiology, University of California, San Diego, La Jolla, CA.
| | - Joseph A Hyder
- Department of Anesthesiology, Mayo Clinic, Rochester, MN.
| | | | - Henry T Stelfox
- Department of Medicine, University of Calgary, Calgary, AB, Canada; Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Ulrich Schmidt
- Department of Anesthesiology, University of California, San Diego, La Jolla, CA.
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Excellence in Critical Care Units. Crit Care Med 2016; 44:1-2. [PMID: 26672921 DOI: 10.1097/ccm.0000000000001490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sevransky JE, Checkley W, Herrera P, Pickering BW, Barr J, Brown SM, Chang SY, Chong D, Kaufman D, Fremont RD, Girard TD, Hoag J, Johnson SB, Kerlin MP, Liebler J, O'Brien J, O'Keefe T, Park PK, Pastores SM, Patil N, Pietropaoli AP, Putman M, Rice TW, Rotello L, Siner J, Sajid S, Murphy DJ, Martin GS. Protocols and Hospital Mortality in Critically Ill Patients: The United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study. Crit Care Med 2015; 43:2076-84. [PMID: 26110488 PMCID: PMC5673100 DOI: 10.1097/ccm.0000000000001157] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Clinical protocols may decrease unnecessary variation in care and improve compliance with desirable therapies. We evaluated whether highly protocolized ICUs have superior patient outcomes compared with less highly protocolized ICUs. DESIGN Observational study in which participating ICUs completed a general assessment and enrolled new patients 1 day each week. PATIENTS A total of 6,179 critically ill patients. SETTING Fifty-nine ICUs in the United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary exposure was the number of ICU protocols; the primary outcome was hospital mortality. A total of 5,809 participants were followed prospectively, and 5,454 patients in 57 ICUs had complete outcome data. The median number of protocols per ICU was 19 (interquartile range, 15-21.5). In single-variable analyses, there were no differences in ICU and hospital mortality, length of stay, use of mechanical ventilation, vasopressors, or continuous sedation among individuals in ICUs with a high versus low number of protocols. The lack of association was confirmed in adjusted multivariable analysis (p = 0.70). Protocol compliance with two ventilator management protocols was moderate and did not differ between ICUs with high versus low numbers of protocols for lung protective ventilation in acute respiratory distress syndrome (47% vs 52%; p = 0.28) and for spontaneous breathing trials (55% vs 51%; p = 0.27). CONCLUSIONS Clinical protocols are highly prevalent in U.S. ICUs. The presence of a greater number of protocols was not associated with protocol compliance or patient mortality.
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Affiliation(s)
- Jonathan E Sevransky
- 1Division of Pulmonary, Allergy and Critical Care, Emory University, Atlanta, GA. 2Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD. 3Department of Anesthesia, Mayo Clinic, Rochester, MN. 4Department of Anesthesiology, Stanford University, Palo Alto, CA. 5Division of Pulmonary and Critical Care, Intermountain Medical Center and University of Utah, Salt Lake City, UT. 6Division of Pulmonary and Critical Care, UCLA, Los Angeles, CA. 7Division of Pulmonary and Critical Care Medicine, Columbia University Medical Center, New York, NY. 8Section of Pulmonary and Critical Care Medicine, Yale University School of Medicine, New Haven, CT. 9Division of Pulmonary and Critical Care, Meharry Medical College, Nashville, TN. 10Division of Allergy, Pulmonary, and Critical Care Medicine and Center for Health Services Research at the, Vanderbilt University School of Medicine, Nashville, TN. 11Division of Pulmonary and Critical Care, Drexel University, Philadelphia, PA. 12Department of Surgical Critical Care, University of Maryland, Baltimore, MD. 13Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia, PA. 14Division of Pulmonary Critical Care and Sleep Medicine, University of Southern California, Los Angeles, CA. 15Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Ohio State University, Columbus, OH. 16Department of Surgery, University of Arizona, Tucson, AZ. 17Division of Acute Care Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI. 18Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY. 19Department of Surgery, Division of Thoracic Surgery, Division of Trauma, Burn & Critical Care, Brigham and Women's Hospital, Boston, MA. 20Division of Pulmonary and Critical Care Medicine, University of Rochester, Rochester, NY. 21INOVA Fairfax Hospital, Falls Church, VA. 22Suburban Hospital, Bethesda, MD. 23Department of A
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Lapinsky SE, Rojas-Suarez JA, Crozier TM, Vasquez DN, Barrett N, Austin K, Plotnikow GA, Orellano K, Bourjeily G. Mechanical ventilation in critically-ill pregnant women: a case series. Int J Obstet Anesth 2015; 24:323-8. [PMID: 26355021 DOI: 10.1016/j.ijoa.2015.06.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 06/01/2015] [Accepted: 06/27/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Approximately 0.1-0.2% of pregnancies are complicated by respiratory failure requiring mechanical ventilatory support, but few data exist to inform clinical management. This study aimed to characterize current practice and the effect of delivery on respiratory function. METHODS A retrospective review was performed of pregnant women who received mechanical ventilation for more than 24h, from four intensive care units in institutions with large-volume obstetric units. RESULTS Data were collected from 29 patients with a mean gestation at intensive care unit admission of 25.3 ± 6 weeks. Tidal volumes were 7.7 ± 1.7 mL/kg predicted body weight. Estimated respiratory system compliance was reduced, but was higher in four patients ventilated for neurological conditions without lung disease. Three maternal and three neonatal deaths occurred. Ten patients delivered while on ventilatory support: one spontaneous delivery, four for obstetric indications and five for worsening maternal condition. Following delivery of these 10 patients, three demonstrated a greater than 50% decrease in oxygenation index and five a greater than 50% increase in compliance. No characteristics identified which patients may benefit from delivery. CONCLUSIONS Review of current practice in four centers suggests that mechanical ventilation in pregnant patients follows usual guidelines applicable to non-pregnant patients. Delivery was associated with modest improvement in maternal respiratory function in some patients. Any potential benefit of delivery in improving maternal physiology must be weighed against the stress of delivery. The risks of premature birth for the fetus must be weighed against continued exposure to maternal hypoxemia and hypotension.
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Affiliation(s)
- S E Lapinsky
- Intensive Care Unit, Mount Sinai Hospital, Toronto, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
| | - J A Rojas-Suarez
- Intensive Care Unit, Gestión Salud Clinic, Cartagena, Colombia; Grupo de Investigación en Cuidados intensivos y Obstetricia, GRICIO, Universidad de Cartagena, Gestión Salud Clinic, Cartagena, Colombia
| | - T M Crozier
- Intensive Care Unit, Monash Medical Centre, Clayton, Victoria, Australia; The Ritchie Centre, Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Clayton, Australia
| | - D N Vasquez
- Sanatorio Anchorena, Ciudad de Buenos Aires, Argentina
| | - N Barrett
- The Ritchie Centre, Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Clayton, Australia
| | - K Austin
- Intensive Care Unit, Mount Sinai Hospital, Toronto, Canada
| | - G A Plotnikow
- Sanatorio Anchorena, Ciudad de Buenos Aires, Argentina
| | - K Orellano
- Grupo de Investigación en Cuidados intensivos y Obstetricia, GRICIO, Universidad de Cartagena, Gestión Salud Clinic, Cartagena, Colombia; Universidad del Sinu, Cartagena, Colombia
| | - G Bourjeily
- Pulmonary and Critical Care Medicine, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA; The Miriam Hospital, Providence, RI, USA
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Bourdeaux CP, Birnie K, Trickey A, Thomas MJC, Sterne J, Donovan JL, Benger J, Brandling J, Gould TH. Evaluation of an intervention to reduce tidal volumes in ventilated ICU patients. Br J Anaesth 2015; 115:244-51. [PMID: 25979150 DOI: 10.1093/bja/aev110] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is considerable evidence that the use of tidal volumes <6 ml kg(-1) predicted body weight (PBW) reduces mortality in mechanically ventilated patients. We evaluated the effectiveness of using a large screen displaying delivered tidal volume in ml kg(-1) (PBW) for reducing tidal volumes. METHODS We assessed the intervention in two 6-month periods. A qualitative study was undertaken after the intervention period to examine staff interaction with the intervention. The study was conducted in a mixed medical and surgical intensive care unit at University Hospitals Bristol, UK. Consecutive patients requiring controlled mechanical ventilation for more than 1 h were included. Alerts were triggered when tidal volume breached predetermined targets and these alerts were visible to ICU clinicians in real time. RESULTS A total of 199 patients with 7640 h of data were observed during the control time period and 249 patients with 10 656 h of data were observed in the intervention period. Time spent with tidal volumes <6 ml kg(-1) PBW increased from 17.5 to 28.6% of the period of controlled mechanical ventilation. Time spent with a tidal volume <8 ml kg(-1) PBW increased from 60.6 to 73.9%. The screens were acceptable to staff and stimulated an increase in attendance of clinicians at the bedside to adjust ventilators. CONCLUSIONS Changing the format of data and displaying it with real-time alerts reduced delivered tidal volumes. Configuring information in a format more likely to result in desired outcomes has the potential to improve the translation of evidence into practice.
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Affiliation(s)
- C P Bourdeaux
- Intensive Care Unit, Queens Building, University Hospitals Bristol, Upper Maudlin Street, Bristol BS2 8HW, UK
| | - K Birnie
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol BS8 2PS, UK
| | - A Trickey
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol BS8 2PS, UK
| | - M J C Thomas
- Intensive Care Unit, Queens Building, University Hospitals Bristol, Upper Maudlin Street, Bristol BS2 8HW, UK
| | - J Sterne
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol BS8 2PS, UK
| | - J L Donovan
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol BS8 2PS, UK
| | - J Benger
- Faculty of Health and Life Sciences, University of the West of England, Glenside Campus, Bristol BS16 1DD, UK
| | | | - T H Gould
- Intensive Care Unit, Queens Building, University Hospitals Bristol, Upper Maudlin Street, Bristol BS2 8HW, UK
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Needham DM, Yang T, Dinglas VD, Mendez-Tellez PA, Shanholtz C, Sevransky JE, Brower RG, Pronovost PJ, Colantuoni E. Timing of low tidal volume ventilation and intensive care unit mortality in acute respiratory distress syndrome. A prospective cohort study. Am J Respir Crit Care Med 2015; 191:177-85. [PMID: 25478681 DOI: 10.1164/rccm.201409-1598oc] [Citation(s) in RCA: 170] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Reducing tidal volume decreases mortality in acute respiratory distress syndrome (ARDS). However, the effect of the timing of low tidal volume ventilation is not well understood. OBJECTIVES To evaluate the association of intensive care unit (ICU) mortality with initial tidal volume and with tidal volume change over time. METHODS Multivariable, time-varying Cox regression analysis of a multisite, prospective study of 482 patients with ARDS with 11,558 twice-daily tidal volume assessments (evaluated in milliliter per kilogram of predicted body weight [PBW]) and daily assessment of other mortality predictors. MEASUREMENTS AND MAIN RESULTS An increase of 1 ml/kg PBW in initial tidal volume was associated with a 23% increase in ICU mortality risk (adjusted hazard ratio, 1.23; 95% confidence interval [CI], 1.06-1.44; P = 0.008). Moreover, a 1 ml/kg PBW increase in subsequent tidal volumes compared with the initial tidal volume was associated with a 15% increase in mortality risk (adjusted hazard ratio, 1.15; 95% CI, 1.02-1.29; P = 0.019). Compared with a prototypical patient receiving 8 days with a tidal volume of 6 ml/kg PBW, the absolute increase in ICU mortality (95% CI) of receiving 10 and 8 ml/kg PBW, respectively, across all 8 days was 7.2% (3.0-13.0%) and 2.7% (1.2-4.6%). In scenarios with variation in tidal volume over the 8-day period, mortality was higher when a larger volume was used earlier. CONCLUSIONS Higher tidal volumes shortly after ARDS onset were associated with a greater risk of ICU mortality compared with subsequent tidal volumes. Timely recognition of ARDS and adherence to low tidal volume ventilation is important for reducing mortality. Clinical trial registered with www.clinicaltrials.gov (NCT 00300248).
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Underuse versus equipoise for low tidal volume ventilation in acute respiratory distress syndrome: is this the right question?*. Crit Care Med 2014; 42:2310-1. [PMID: 25226131 DOI: 10.1097/ccm.0000000000000564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tidal volume and plateau pressure use for acute lung injury from 2000 to present: a systematic literature review. Crit Care Med 2014; 42:2278-89. [PMID: 25098333 DOI: 10.1097/ccm.0000000000000504] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Since publication of the Respiratory Management of Acute Lung Injury and Acute Respiratory Distress Syndrome (ARMA) trial in 2000, use of tidal volume (VT) less than or equal to 6 mL/kg predicted body weight with corresponding plateau airway pressures (PPlat) less than or equal to 30 cm H2O has been advocated for acute lung injury. However, compliance with these recommendations is unknown. We therefore investigated VT (mL/kg predicted body weight) and PPlat (cm H2O) practices reported in studies of acute lung injury since ARMA using a systematic literature review (i.e., not a meta-analysis). DATA SOURCES PubMed, Scopus, and EMBASE. STUDY SELECTION Randomized controlled trials and nonrandomized studies enrolling patients with acute lung injury from May 2000 to June 2013 and reporting VT. DATA EXTRACTION Whether the study was a randomized controlled trial or a nonrandomized study and performed or not at an Acute Respiratory Distress Syndrome Network center; in randomized controlled trials, the pre- and postrandomization VT (mL/kg predicted body weight) and PPlat (cm H2O) and whether a VT protocol was used postrandomization; in nonrandomized studies, baseline VT and PPlat. DATA SYNTHESIS Twenty-two randomized controlled trials and 71 nonrandomized studies were included. Since 2000 at acute respiratory distress syndrome Network centers, routine VT was similar comparing randomized controlled trials and nonrandomized studies (p = 0.25) and unchanged over time (p = 0.75) with a mean value of 6.81 (95% CI, 6.45, 7.18). At non-acute respiratory distress syndrome Network centers, routine VT was also similar when comparing randomized controlled trials and nonrandomized studies (p = 0.71), but decreased (p = 0.001); the most recent estimate for it was 6.77 (6.22, 7.32). All VT estimates were significantly greater than 6 (p ≤ 0.02). In randomized controlled trials employing VT protocols, routine VT was reduced in both acute respiratory distress syndrome Network (n = 4) and non-acute respiratory distress syndrome Network (n = 11) trials (p ≤ 0.01 for both), but even postrandomization was greater than 6 (6.47 [6.29, 6.65] and 6.80 [6.42, 7.17], respectively; p ≤ 0.0001 for both). In 59 studies providing data, routine PPlat, averaged across acute respiratory distress syndrome Network or non-acute respiratory distress syndrome Network centers, was significantly less than 30 (p ≤ 0.02). CONCLUSIONS For clinicians treating acute lung injury since 2000, achieving VT less than or equal to 6 mL/kg predicted body weight may not have been as attainable or important as PPlat less than or equal to 30 cm H2O. If so, there may be equipoise to test if VT less than or equal to 6 mL/kg predicted body weight are necessary to improve acute lung injury outcome.
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Wilson JG, Matthay MA. Mechanical ventilation in acute hypoxemic respiratory failure: a review of new strategies for the practicing hospitalist. J Hosp Med 2014; 9:469-75. [PMID: 24733692 PMCID: PMC4139286 DOI: 10.1002/jhm.2192] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 03/07/2014] [Accepted: 03/10/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND The goal of mechanical ventilation in acute hypoxemic respiratory failure is to support adequate gas exchange without harming the lungs. How patients are mechanically ventilated can significantly impact their ultimate outcomes. METHODS This review focuses on emerging evidence regarding strategies for mechanical ventilation in patients with acute hypoxemic respiratory failure including: low tidal volume ventilation in the acute respiratory distress syndrome (ARDS), novel ventilator modes as alternatives to low tidal volume ventilation, adjunctive strategies that may enhance recovery in ARDS, the use of lung-protective strategies in patients without ARDS, rescue therapies in refractory hypoxemia, and an evidence-based approach to weaning from mechanical ventilation. RESULTS Once a patient is intubated and mechanically ventilated, low tidal volume ventilation remains the best strategy in ARDS. Adjunctive therapies in ARDS include a conservative fluid management strategy, as well as neuromuscular blockade and prone positioning in moderate-to-severe disease. There is also emerging evidence that a lung-protective strategy may benefit non-ARDS patients. For patients with refractory hypoxemia, extracorporeal membrane oxygenation should be considered. Once the patient demonstrates signs of recovery, the best approach to liberation from mechanical ventilation involves daily spontaneous breathing trials and protocolized assessment of readiness for extubation. CONCLUSIONS Prompt recognition of ARDS and use of lung-protective ventilation, as well as evidence-based adjunctive therapies, remain the cornerstones of caring for patients with acute hypoxemic respiratory failure. In the absence of contraindications, it is reasonable to consider lung-protective ventilation in non-ARDS patients as well, though the evidence supporting this practice is less conclusive.
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Affiliation(s)
- Jennifer G. Wilson
- Department of Medicine, Division of Critical Care, University of California San Francisco, San Francisco, California
| | - Michael A. Matthay
- Cardiovascular Research Institute and Departments of Medicine and Anesthesiology, Division of Pulmonary and Critical Care, University of California San Francisco, San Francisco, California
- Address for correspondence and reprint requests: Michael A. Matthay, MD, University of California Cardiovascular Research Institute, Box 0624, 505 Parnassus Avenue, Room M917, San Francisco, CA 94143; Telephone: 415-353-1206; Fax: 415-353-1990;
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"Only few find the way, some don't recognize it when they do …"--can we "observe" causality? Crit Care Med 2014; 42:208-9. [PMID: 24346530 DOI: 10.1097/ccm.0b013e3182a26703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rose L, Kenny L, Tait G, Mehta S. Ventilator settings and monitoring parameter targets for initiation of continuous mandatory ventilation: a questionnaire study. J Crit Care 2013; 29:123-7. [PMID: 24331947 DOI: 10.1016/j.jcrc.2013.10.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 09/27/2013] [Accepted: 10/22/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To inform development of educational tools, we sought to identify initial ventilator settings and monitoring targets for 3 scenarios. METHOD A survey was e-mailed to Canadian Society of Respiratory Therapists members with 2 reminders in March/April 2011. RESULTS Total evaluable surveys were 363. More participants selected pressure as opposed to volume ventilation for acute respiratory distress syndrome (ARDS; 77%) than for chronic obstructive pulmonary disease (COPD; 50%) and postoperative ventilation (32%; P < .001). Mean tidal volume was lower for ARDS than for COPD and postoperative ventilation (5.7, 6.9, and 7.2 mL/kg, respectively; P < .001). Maximum acceptable plateau pressures were highest for ARDS (30 cm H2O vs 29 cm H2O [COPD] and 27 cm H2O [postoperative], P < .001). Initial positive expiratory end pressure (12 cm H2O vs 7 cm H2O vs 5 cm H2O) and fraction of inspired oxygen (Fio2; 1.0 vs 0.5 vs 0.3) were also higher for ARDS (both P < .001); however, only 8% selected a positive expiratory end pressure/Fio2 combination as recommended by ARDSnet. Values of oxygen saturation as measured by pulse oximetry of 97% (ARDS) and 94% (COPD and postoperative) were considered appropriate for Fio2 reduction. The lowest pH was 7.28 vs 7.23 vs 7.26; the highest pH was 7.46 vs 7.44 vs 7.46 (P < .001). Partial pressure of carbon dioxide (arterial) of 51 mm Hg (postoperative) to 65 mm Hg (ARDS) was considered acceptable. CONCLUSION Lung protective ventilation was favored, yet distinct differences in ventilator settings were evident. Monitoring targets suggested relatively conservative practices for Fio2 reduction but an understanding of permissive hypercapnia.
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Affiliation(s)
- Louise Rose
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada; Provincial Centre of Weaning Excellence/Prolonged Ventilation Weaning Centre, Toronto East General Hospital, Toronto, Ontario, Canada; Mount Sinai Hospital and the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.
| | - Lisa Kenny
- Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Gordon Tait
- Department of Anesthesia and Pain Management at the Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sangeeta Mehta
- Department of Critical Care, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Murphy DJ, Needham DM, Netzer G, Zeger SL, Colantuoni E, Ness P, Pronovost PJ, Berenholtz SM. RBC transfusion practices among critically ill patients: has evidence changed practice? Crit Care Med 2013; 41:2344-53. [PMID: 23939350 DOI: 10.1097/ccm.0b013e31828e9a49] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Increasing evidence, including publication of the Transfusion Requirements in Critical Care trial in 1999, supports a lower hemoglobin threshold for RBC transfusion in ICU patients. However, little is known regarding the influence of this evidence on clinical practice over time in a large population-based cohort. DESIGN Retrospective population-based cohort study. SETTING Thirty-five Maryland hospitals. PATIENTS Seventy-three thousand three hundred eighty-five nonsurgical adults with an ICU stay greater than 1 day between 1994 and 2007. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The unadjusted odds of patients receiving an RBC transfusion increased from 7.9% during the pre-Transfusion Requirements in Critical Care baseline period (1994-1998) to 14.7% during the post-Transfusion Requirements in Critical Care period (1999-2007). A logistic regression model, including 40 relevant patient and hospital characteristics, compared the annual trend in the adjusted odds of RBC transfusion during the pre- versus post-Transfusion Requirements in Critical Care periods. During the pre-Transfusion Requirements in Critical Care period, the trend in the adjusted odds of RBC transfusion did not differ between hospitals averaging>200 annual ICU discharges and hospitals averaging≤200 annual ICU discharges (odds ratio, 1.07 [95% CI, 1.01-1.13] annually and 1.03 [95% CI, 0.99-1.07] annually, respectively; p=0.401). However, during the post-Transfusion Requirements in Critical Care period, the adjusted odds of RBC transfusion decreased over time in higher ICU volume hospitals (odds ratio, 0.96 [95% CI, 0.93-0.98] annually) but continued to increase in lower ICU volume hospitals (odds ratio, 1.10 [95% CI, 1.08-1.13] annually), p<0.001. CONCLUSIONS In this population-based cohort of ICU patients, the unadjusted odds of RBC transfusion increased in both higher and lower ICU volume hospitals both before and after Transfusion Requirements in Critical Care publication. After adjusting for relevant characteristics, the odds continued to increase in lower ICU volume hospitals in the post-Transfusion Requirements in Critical Care period, but it decreased in higher ICU volume hospitals. This suggests that evidence supporting restrictive RBC transfusion thresholds may not be uniformly translated into practice in different hospital settings.
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Affiliation(s)
- David J Murphy
- 1Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Emory University, Atlanta, GA. 2Division of Pulmonary/Critical Care Medicine, Johns Hopkins University, Baltimore, MD. 3Division of Pulmonary and Critical Care Medicine, Department of Epidemiology and Public Health, University of Maryland, Baltimore, MD. 4Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. 5Department of Pathology, Johns Hopkins University, Baltimore, MD. 6Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, Baltimore, MD
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Arnal JM, Garnero A, Novonti D, Demory D, Ducros L, Berric A, Donati SY, Corno G, Jaber S, Durand-Gasselin J. Feasibility study on full closed-loop control ventilation (IntelliVent-ASV™) in ICU patients with acute respiratory failure: a prospective observational comparative study. Crit Care 2013; 17:R196. [PMID: 24025234 PMCID: PMC4056360 DOI: 10.1186/cc12890] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 03/22/2013] [Accepted: 09/11/2013] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION IntelliVent-ASV™ is a full closed-loop ventilation mode that automatically adjusts ventilation and oxygenation parameters in both passive and active patients. This feasibility study compared oxygenation and ventilation settings automatically selected by IntelliVent-ASV™ among three predefined lung conditions (normal lung, acute respiratory distress syndrome (ARDS) and chronic obstructive pulmonary disease (COPD)) in active and passive patients. The feasibility of IntelliVent-ASV™ use was assessed based on the number of safety events, the need to switch to conventional mode for any medical reason, and sensor failure. METHOD This prospective observational comparative study included 100 consecutive patients who were invasively ventilated for less than 24 hours at the time of inclusion with an expected duration of ventilation of more than 12 hours. Patients were ventilated using IntelliVent-ASV™ from inclusion to extubation. Settings, automatically selected by the ventilator, delivered ventilation, respiratory mechanics, and gas exchanges were recorded once a day. RESULTS Regarding feasibility, all patients were ventilated using IntelliVent-ASV™ (392 days in total). No safety issues occurred and there was never a need to switch to an alternative ventilation mode. The fully automated ventilation was used for 95% of the total ventilation time. IntelliVent-ASV™ selected different settings according to lung condition in passive and active patients. In passive patients, tidal volume (VT), predicted body weight (PBW) was significantly different between normal lung (n = 45), ARDS (n = 16) and COPD patients (n = 19) (8.1 (7.3 to 8.9) mL/kg; 7.5 (6.9 to 7.9) mL/kg; 9.9 (8.3 to 11.1) mL/kg, respectively; P 0.05). In passive ARDS patients, FiO2 and positive end-expiratory pressure (PEEP) were statistically higher than passive normal lung (35 (33 to 47)% versus 30 (30 to 31)% and 11 (8 to 13) cmH2O versus 5 (5 to 6) cmH2O, respectively; P< 0.05). CONCLUSIONS IntelliVent-ASV™ was safely used in unselected ventilated ICU patients with different lung conditions. Automatically selected oxygenation and ventilation settings were different according to the lung condition, especially in passive patients. TRIAL REGISTRATION ClinicalTrials.gov: NCT01489085.
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Affiliation(s)
- Jean-Michel Arnal
- Service de Réanimation Polyvalente, Hôpital Sainte Musse, 54 avenue Henri Sainte Claire Deville, 83056 Toulon, France
- Department of Medical Research, Hamilton Medical, 8 via Crusch, 7402 Bonaduz, Switzerland
| | - Aude Garnero
- Service de Réanimation Polyvalente, Hôpital Sainte Musse, 54 avenue Henri Sainte Claire Deville, 83056 Toulon, France
| | - Dominik Novonti
- Department of Medical Research, Hamilton Medical, 8 via Crusch, 7402 Bonaduz, Switzerland
| | - Didier Demory
- Service de Réanimation Polyvalente, Hôpital Sainte Musse, 54 avenue Henri Sainte Claire Deville, 83056 Toulon, France
| | - Laurent Ducros
- Service de Réanimation Polyvalente, Hôpital Sainte Musse, 54 avenue Henri Sainte Claire Deville, 83056 Toulon, France
| | - Audrey Berric
- Service de Réanimation Polyvalente, Hôpital Sainte Musse, 54 avenue Henri Sainte Claire Deville, 83056 Toulon, France
| | - Stéphane Yannis Donati
- Service de Réanimation Polyvalente, Hôpital Sainte Musse, 54 avenue Henri Sainte Claire Deville, 83056 Toulon, France
| | - Gaëlle Corno
- Service de Réanimation Polyvalente, Hôpital Sainte Musse, 54 avenue Henri Sainte Claire Deville, 83056 Toulon, France
| | - Samir Jaber
- Hôpital Saint Eloi, CHU de Montpellier, 80 avenue Augustin Fliche, 34295 Montpellier, France
| | - Jacques Durand-Gasselin
- Service de Réanimation Polyvalente, Hôpital Sainte Musse, 54 avenue Henri Sainte Claire Deville, 83056 Toulon, France
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Hess DR, Kondili D, Burns E, Bittner EA, Schmidt UH. A 5-year observational study of lung-protective ventilation in the operating room: a single-center experience. J Crit Care 2013; 28:533.e9-533.e5.33E15. [PMID: 23369521 DOI: 10.1016/j.jcrc.2012.11.014] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 11/19/2012] [Accepted: 11/20/2012] [Indexed: 11/25/2022]
Abstract
PURPOSE We assessed the evolution of lung-protective ventilation strategies during anesthesia and identified factors associated with the selection of a nonprotective ventilation strategy. METHODS This retrospective observational study covered a 5-year period from March 2006 to March 2011. It included 45575 adult patients who underwent intubation de novo in the operating room. We considered a tidal volume (VT) greater than 10 mL/kg of ideal body weight (IBW) and/or positive end-expiratory pressure (PEEP) less than 5 cm H2O as not lung protective. We evaluated the use of nonprotective ventilation strategies over time in men and women, by American Society of Anesthesiologists classification, and for elective vs emergent surgery. RESULTS Over the duration of the study, there was a significant reduction in the percentage of patients receiving a VT greater than 10 mL/kg IBW (28.5%-16.3%, P < .001), zero PEEP (27.5%-18.2%, P < .001), and VT greater than 10 mL/kg IBW with PEEP less than 5 cm H2O (13.4%-8.0%, P < .001). The odds of receiving nonprotective ventilation were greater for women than for men, in the first year compared with the last year, and for elective compared with emergent surgery. CONCLUSION Although use of nonprotective ventilation decreased over time, an important percentage of patients continue to receive nonprotective ventilation.
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Affiliation(s)
- Dean R Hess
- Respiratory Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Factors Associated With Elevated Plateau Pressure in Patients With Acute Lung Injury Receiving Lower Tidal Volume Ventilation. Crit Care Med 2013; 41:756-64. [DOI: 10.1097/ccm.0b013e3182741790] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lellouche F, Lipes J. Prophylactic protective ventilation: lower tidal volumes for all critically ill patients? Intensive Care Med 2013; 39:6-15. [PMID: 23108608 DOI: 10.1007/s00134-012-2728-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 09/28/2012] [Indexed: 12/17/2022]
Abstract
High tidal volumes have historically been recommended for mechanically ventilated patients during general anesthesia. High tidal volumes have been shown to increase morbidity and mortality in patients suffering from acute respiratory distress syndrome (ARDS). Barriers exist in implementing a tidal volume reduction strategy related to the inherent difficulty in changing one's practice patterns, to the current need to individualize low tidal volume settings only for a specific subgroup of mechanically ventilated patients (i.e., ARDS patients), the difficulty in determining the predicated body weight (requiring the patient's height and a complex formula). Consequently, a protective ventilation strategy is often under-utilized as a therapeutic option, even in ARDS. Recent data supports the generalization of this strategy prophylactically to almost all mechanically ventilated patients beginning immediately following intubation. Using tools to rapidly and reliably determine the predicted body weight (PBW), as well as the use of automated modes of ventilation are some of the potential solutions to facilitate the practice of protective ventilation and to finally ventilate our patients' lungs in a more gentle fashion to help prevent ARDS.
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Affiliation(s)
- Francois Lellouche
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Université Laval, 2725 Chemin Sainte Foy, G1V4G5, Quebec, QC, Canada.
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