Low Tidal Volume Ventilation Use in Acute Respiratory... : Critical Care Medicine (original) (raw)

Clinical Investigations

Weiss, Curtis H. MD, MS1; Baker, David W. MD, MPH2,3; Weiner, Shayna MPH4; Bechel, Meagan BS5; Ragland, Margaret MD, MS6; Rademaker, Alfred PhD7; Weitner, Bing Bing MS7; Agrawal, Abha MD8; Wunderink, Richard G. MD1; Persell, Stephen D. MD, MPH2

1Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.

2Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL.

3The Joint Commission, Oakbrook Terrace, IL.

4University of Michigan School of Medicine, Ann Arbor, MI.

5Northwestern University Feinberg School of Medicine, Chicago, IL.

6Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.

7Department of Preventive Medicine-Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, IL.

8Norwegian American Hospital, Chicago, IL.

*See also p. 1611.

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Work was performed at Northwestern University Feinberg School of Medicine (Chicago, IL), Northwestern Memorial Hospital (Chicago, IL), Northwestern Lake Forest Hospital (Lake Forest, IL), Elmhurst Memorial Hospital (Elmhurst, IL), Norwegian American Hospital (Chicago, IL).

Dr. Weiss served as a nonpaid member of the Mathematica Policy Research Hospital Inpatient and Outpatient Process and Structural Measure Development and Maintenance Expert Working Group on Lung Protective Ventilation. He received support for article research from the National Institutes of Health (NIH). His institution received funding from the National Heart, Lung, and Blood Institute (NHLBI) grant K23HL118139; Francis Family Foundation; and National Center for Advancing Translational Sciences Grants UL1TR0001560 and UL1TR001422 (Northwestern University Clinical and Translational Sciences Institute Enterprise Data Warehouse) and the Department of Medicine, Northwestern University Feinberg School of Medicine. Dr. Baker received support for article research from the NIH. His institution received funding from the NHLBI. Dr. Weiner received support for article research from the NIH. Her institution received funding from the NIH. Dr. Rademaker disclosed other support from Georgetown University (external advisory board member, ongoing, money paid); received support for article research from the NIH; and received funding from the NIH (grant reviewer), JAMA Surgery manuscript reviewer, and the American Association of Cancer Research/American Society of Clinical Oncology (workshop faculty). His institution received funding from the NIH. Dr. Weitner received support for article research from the NIH. Her institution received funding from NIH grant to institution. Dr. Persell received support for article research from the NIH; institution received funding from Pfizer. His institution received funding from the NIH, NHLBI, Parker B Francis Fellowship Program, and the National Center for Advancing Translational Sciences. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: Curtis Weiss, MD, MS, Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, 676 N. Saint Clair St., Suite 1400, Chicago, IL 60611. E-mail: [email protected]

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.