Risk factors for underuse of lung-protective ventilation in acute lung injury

doi:10.1016/j.jcrc.2011.06.015

Journal of Critical Care

Volume 27, Issue 3, June 2012, Pages 323.e1-323.e9

https://doi.org/10.1016/j.jcrc.2011.06.015 Get rights and content

Abstract

Purpose

We assessed factors associated with underuse of lung-protective ventilation (LPV) in patients with acute lung injury (ALI).

Methods

A secondary analysis of Acute Respiratory Distress Syndrome Clinical Trials Network trial data, 1999 to 2005, was conducted. Tidal volumes recorded before trial randomization were analyzed to determine receipt of LPV (tidal volume ≤6.5 mL/kg of predicted body weight [PBW]).

Results

Of 1385 participants, 430 (31.2%) received LPV. Average tidal volume was 7.65 ± 1.82 mL/kg PBW; measured tidal volumes were greater than “lung-protective” tidal volumes predicted by 6.5 mL/kg PBW (mean difference, 67 ± 108 mL; P < .0001). Multivariate predictors of LPV underuse were older age (odds ratio [OR] per SD year, 1.18; 95% confidence interval [CI], 1.02-1.38), white race (OR, 1.40; 95% CI, 1.05-1.88), shorter stature (OR per SD centimeter, 0.55; 95% CI, 0.48-0.63), lower Simplified Acute Physiology II Score (OR per SD, 0.78; 95% CI, 0.67-0.92), lower lung injury score (OR per SD, 0.83; 95% CI, 0.70-0.95), decreased serum bicarbonate (OR per SD mmol/L, 0.83; 95% CI, 0.71-0.97), shorter preenrollment intensive care unit stay (OR per SD day, 0.84; 95% CI, 0.73-0.98), and use of non–volume-controlled ventilation (OR, 3.07; 95% CI, 1.78-5.27). Setting tidal volumes to 450 mL (men) or 350 mL (women) would provide LPV to 80% of patients with ALI.

Conclusions

Simple interventions could substantially improve adherence with LPV among patients with ALI and warrant prospective study.

Introduction

Although a decade has elapsed since publication of the landmark Acute Respiratory Distress Syndrome Clinical Trials Network (ARDSNet) “ARMA” trial in support of a lung-protective ventilation (LPV) approach, LPV has been poorly adopted [1]. Previous studies have found that less than 50% of patients with acute lung injury (ALI) are ventilated with evidence-based 6 mL/kg predicted body weight (PBW) tidal volumes [2], [3], [4], [5], [6]. Two small studies have investigated specific factors associated with the use of LPV. These showed that metabolic acidosis, lack of a formal ARDS protocol [5] higher lung compliance, and higher Pao₂/fraction of inspired oxygen (Fio₂) [4] were associated with underuse of LPV. Others have hypothesized that underrecognition of ALI [7] and difficulties with calculating PBW [8], [9], [10] may be factors contributing to underuse of ALI.

Identification of barriers to implementation of evidence-based practice is a critical step toward improving patient outcomes. However, no adequately powered studies have investigated patient-level clinical and demographic factors associated with underuse of LPV. Baseline data from ARDSNet trial participants present a unique opportunity to study practice patterns across multiple centers. We sought to determine the factors associated with underuse of LPV before randomization of these trial participants with recognized ALI. We hypothesized that demographic (eg, age, sex, and race), anthropometric, and severity of illness–associated factors would be predictive of LPV underuse.

Section snippets

Patients

We assembled the study cohort using open-access deidentified data from participants previously enrolled in the 2 National Heart Lung and Blood Institute ARDS Network trials conducted after release of ARMA trial [11] results that demonstrated improved outcomes with LPV. These included the Assessment of Low tidal Volume and End expiratory volume to Obviate Lung Injury trial [12] and the factorial Fluid and Catheter Treatment Trials [13], [14]. Data from the Late Steroid Rescue Study [15], which

Results

A baseline tidal volume and PBW was recorded for 1385 (89%) of 1550 of trial participants. The study cohort had an average age of 50 ± 16 years and was 54% male. Of 1385 participants, 430 (31.2%) received LPV, defined as less than or equal to 6.5 mL/kg PBW. Fig. 1 demonstrates the distribution of tidal volumes in all participants; the average tidal volume was 7.65 ± 1.82 mL/kg PBW. Fig. 2 demonstrates the distribution of observed (Fig. 2A and B) and 6.5 mL/kg PBW–calculated “lung-protective”

Discussion

Similar to previous studies, we found substantial underuse of evidence-based LPV among patients with ALI—only 1 of 3 participants with ALI received LPV with tidal volumes less than or equal to 6.5 mL/kg PBW before randomization in the ARDSNet trials [2], [5], [10]. Our study has identified novel patient characteristics associated with underuse of LPV that may be amenable to simple quality improvement interventions. Participants mostly at risk for LPV underuse were older, of shorter stature, and

Acknowledgments

We would like to acknowledge the work by the ARDSNet investigators, without which this work would not be possible.

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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.
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).
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Automatic calculation of process-of-care indicators from clinical information systems high-resolution data can provide an accurate and continuous measure of adherence to recommendations. Adherence to tidal volume recommendations was associated with shorter duration of mechanical ventilation and intensive care unit stay.
Extraer los datos del Sistema de Información Clínica para calcular automáticamente indicadores de calidad de alta resolución para evaluar la adherencia a las recomendaciones sobre el volumen tidal.
Ideamos 2 indicadores: el porcentaje de tiempo en ventilación mecánica con volumen tidal excesivo (> 8 mL/kg peso ideal) y el porcentaje de pacientes con volumen tidal apropiado (≤ 8 mL/kg peso ideal) al menos el 80% del tiempo en ventilación mecánica. Desarrollamos un algoritmo para calcular automáticamente dichos indicadores con los datos del Sistema de Información Clínica y analizamos su asociación con las características de los pacientes y su evolución.
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^☆: This study was performed at Boston University School of Medicine.

^☆☆: Disclaimer: The views expressed do not necessarily represent the views of the Department of Veterans Affairs, the US government, or the National Cancer Institute.

^☆☆☆: Funding/support: Dr Wiener is supported by a career development award through the National Cancer Institute (K07 CA138772) and by the Department of Veterans Affairs.

^★: Dr Walkey contributed to the development of the study protocol and methods, data analysis, and article preparation and takes responsibility for the content of the article.

^★★: Dr Wiener contributed to the development of the study protocol, methods, and article preparation.

^★★★: The authors have no conflicts of interest to declare.

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Risk factors for underuse of lung-protective ventilation in acute lung injury☆,☆☆,☆☆☆,★,★★,★★★

Abstract

Purpose

Methods

Results

Conclusions

Introduction

Section snippets

Patients

Results

Discussion

Acknowledgments

Chest

The science of translating research into practice in intensive care

Am J Respir Crit Care Med

Effects of a clinical trial on mechanical ventilation practices in patients with acute lung injury

Am J Respir Crit Care Med

Evolution of mechanical ventilation in response to clinical research

Am J Respir Crit Care Med

Underuse of lung protective ventilation: analysis of potential factors to explain physician behavior

Crit Care Med

Patient and intensive care unit organizational factors associated with low tidal volume ventilation in acute lung injury

Crit Care Med

Impact of randomized trial results on acute lung injury ventilator therapy in teaching hospitals

Am J Respir Crit Care Med

Acute respiratory distress syndrome: underrecognition by clinicians and diagnostic accuracy of three clinical definitions

Crit Care Med

Potential reasons why physicians underuse lung-protective ventilation: a retrospective cohort study using physician documentation

Respir Care

Barriers to providing lung-protective ventilation to patients with acute lung injury

Crit Care Med

Ventilation of patients with acute lung injury and acute respiratory distress syndrome: has new evidence changed clinical practice?

Crit Care Med

The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome.

N Engl J Med

Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome

N Engl J Med

Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury

N Engl J Med

Comparison of two fluid-management strategies in acute lung injury

N Engl J Med