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Lung protective mechanical ventilation
Wolthuis, E.K.
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Wolthuis, E. K. (2008). Lung protective mechanical ventilation
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Download date: 16 Jun 2017
Chapter5
AdoptionofLowerTidalVolume
VentilationImproveswithFeedback
andEducation
E stherK.Wolthuis,JozefKesecioglu , L u c H . H a s s ink,RogierM.
De te rman n, Jo han na C .Ko re vaa r and Ma rcu s J.S ch u lt z
Re spirato ryCare 2007;52 :176166
Chapter5
Abstract
Background: To determine whether feedback and education improve adoption of lungprotective
mechanicalventilation(ie,withlowertidalvolume[VT])
Methods: We conducted a retrospective study of ventilator settings; we used data from 3
consecutivestudiesofpatientswithacutelunginjuryand/oracuterespiratorydistresssyndrome,in
theintensivecareunitsof2universityhospitalsintheNetherlands.Atsite1weconductedatime
series study of before and after feedback and education about lung–protective mechanical
ventilation,andwecomparedtheresultsfromsite1totheventilationstrategiesatsite2,whichdid
not undergo the feedback and education intervention. Feedback and education consisted of
presentationsofactualventilatorsettings,advisedventilatorsettings,anddiscussionsonpotential
reasonsfornotusinglowerVT.
Results:Twostudieswereperformedatsite1,in1999–2000(study1,n=22)andin2002(study2,n
=12).In2003–2004,study3wasperformedsimultaneouslyatsite1(n=8)andsite2(n=17).At
site 1, mean VT was 10.9 ml/kg (95% confidence interval [CI] 10.3 – 11.6) predicted body weight
(PBW) in study 1 and 9.9 ml/kg (95% CI 9.0 – 10.8) PBW in study 2 (not significant). After the
feedback and education intervention at site 1, VT declined to 7.6 ml/kg (95% CI 6.5 – 8.7) PBW in
study3(p=0.003).Atsite2,wherenofeedbackandeducationwasgiven,VTwas10.3ml/kg(95%CI
9.5–11.0)PBW(p<0.001vs.site1).
Conclusions: Adoption of lower VT ventilation strategy in patients with acute lung injury or acute
respiratory distress syndrome is far from complete in the Netherlands. Adoption of a lower VT
strategyimprovesafterfeedbackandeducation.
58
AdoptionofLowerTidalVolumeVentilationImproveswithFeedbackandEducation
Introduction
One major advance in the field of mechanical ventilation (MV) has been the clear
demonstrationthatuseoflowertidalvolumes(VT)(6ml/kgpredictedbodyweight,PBW)
significantly reduces mortality in patients with acute lung injury (ALI) or its more severe
form,acuterespiratorydistresssyndrome(ARDS)[1].Althoughguidelinessupporttheuse
of lower VT in ALI/ARDS–patients [2], physicians have been reluctant to adopt lung–
protective ventilation [35]. Poor recognition by physician of patients with ALI/ARDS [6],
concernsoverhypercapnia,acidosis,andhypoxemia[7],aswellasfearofincreasedneed
for sedation to maintain ventilator synchrony and comfort are several of the barriers to
use lower VT [8,9]. In addition, the importance of using PBW (i.e., weight based on
patient’sheight,insteadofactualbodyweight)mayhavebeenneglected[10].
Inthepresentinvestigation,wedeterminedventilatorsettingsin3consecutiveALI/ARDS–
studiesperformedintheNetherlandsbeforeandafterpublicationofthelandmarkstudy
bytheARDSNetwork[1].Wefocusedontheeffectoffeedbackandeducationonuseof
lung–protective MV using lower VT at one single intensive care unit (ICU) (Academic
Medical Center, Amsterdam, site 1). Feedback and education was not given because of
one of the abovementioned studies, but because ICU–team members did not follow
recommendations in the local MV–guideline, in particular those on use of lower VT,
severalyearsafterthisguidelinebecameeffective.
Methods
Wecollecteddataonventilatorsettingsofpatientsrecruitedin3consecutiverandomized
controlledALI/ARDS–studiesintheintensivecareunits(ICUs)of2universityhospitals.Site
1 was the Academic Medical Center, University of Amsterdam, Amsterdam, the
Netherlands.Site2wastheUniversityMedicalCenter,UniversityofUtrecht,Utrecht,the
Netherlands. We conducted 3 separate studies. Study 1 (performed in 1999–2000) and
study 2 (in 2002) were performed at site 1 (figure 1). Study 3 (in 20032004) was
performed simultaneously at site 1 and site 2. The feedback and education intervention
on lung–protective mechanical ventilation occurred at site 1, but not at site 2.
ParticipatingsubjectsmetthestandarddefinitionofALI/ARDS[11].The3studiestested
thesafetyandefficacyofinstillationofsurfactantversusstandardtherapy(these3studies
areasyetunpublished).
Studycentres
TheICUatsite1isa28–beddepartment;theICUatsite2isa32–beddepartment.Both
ICUsareso–called“closed–format”units(i.e.,allpatientsareunderthedirectcareofthe
membersoftheICU–team).AspartoftheteamICU–nursescanmakeventilatortherapy
recommendations, but unit policy mandates that all changes in ventilator settings be
59
Chapter5
ordered by ICU–physicians. However, since in all patients’ pressure controlled MV was
used, ICU–nurses were allowed to change applied airway pressures to assure theuse of
correctlysizedVTatalltimes.TheICU–teamatsite1comprises5–8full–timeintensivists,
6–8subspecialtyfellows,12residents,andoccasionally1intern.TheICU–teamatsite2
comprises6–8fullandpart–timeintensivists,3–4subspecialtyfellows15residentsand3
interns.
1999
Site 1
2000
Study I
Site 2
2001
2002
Study 2
2003
2004
Study 3
Study 3
Figure 1 Diagram of studies of which ventilator settings were analyzed. Three consecutive studies were
performedduringaperiodof6years.Study1,study2andstudy3wereallperformedatsite1;study3wasalso
performed at site 2. The grey boxes illustrate what was compared: ventilator settings of patients recruited in
study1andstudy2atsite1werecomparedwithstudy3–inaddition,ventilatorsettingsofpatientsrecruitedin
study 3 at site 1 and site 2 were compared. The black box illustrates the moment at which feedback and
educationwasgivenatsite1.
Intervention:feedbackandeducation
At site 1, in between study 2 and study 3, the intervention consisted of: (1) a concise
presentation to all ICU–physicians on results from several animal studies [12,13] and
clinicalstudiesoflung–protectiveMVusinglowerVTinALI/ARDS–patients[1,1419];(2)a
recallonwhatwasstatedinthelocalMV–guidelineonsizeofVT(“sizeofVTshouldbe6–
8ml/kgPBW”)andarecallonthatweallagreedonuseoflowerVTwhenthisguideline
wasmadeeffective;(3)presentationondataonactualsizeofVTbeforethisintervention
(“feedback”, for this, two of us (EKW and MJS) collected all ventilator settings of all
patients during a period of 2 weeks); and (4) a discussion on potential reasons for not
usinglowerVT,includingtheimportanceofusingPBWinsteadofactualbodyweighttoset
VT, and potentially existing fear of increased need for sedation to maintain ventilator
synchronyandcomfort(“education”).ThesamestrategywaspracticedintheICU–nurse
teamofsite1.Thiswasrepeated3times.Finally,thepatientdatamanagementsystem
(PDMS; Metavision, iMDsoft, Sassenheim, the Netherlands) was equipped with a special
tool that automatically calculated the ideal VT from patient’s height, after which the
60
AdoptionofLowerTidalVolumeVentilationImproveswithFeedbackandEducation
targets were automatically readable in the “respiratory tab” (i.e., for all patients it was
easytocheckwhetherVTwasbetween6–8ml/kgPBW).
Mechanicalventilationprotocols
Duringconductofthefirst2studiesnospecificrecommendationsweremadeonVTinthe
study–protocols. It was advised to follow local MV–guidelines. The protocol of study 3,
however,containedarecommendationonVT–settings–VTwasadvisedtobe6–8ml/kg
PBW. At site 1 and site 2, the local MV–guidelines recommended using pressure
controlled (PC) MV or pressuresupport (PS) MV. Levels of positive end–expiratory
pressure(PEEP)weretobeadjustedtoPaO2levels(atsite1thealgorithmadvisedhigher
PEEPlevelsascomparedtosite2).Useofpronepositioningwasrecommendedinpatients
requiringFIO2levels>0.6.MildhypercapniawasacceptedinpatientswithALI/ARDS(but
nolimitsforPaCO2weregiven).
Patientsanddata–collection
Thefollowingdatawereextractedfromthetrialrecordfilesat0,4,8,12,16,20,24,30,
36,40,48,60and72hoursafterrandomization:VT,respiratoryrate(breaths/min),level
ofPEEP(cmH2O),maximumairwaypressure(Paw–max)incmH2O,FiO2,PaO2,PaCO2,and
arterialpH.VTwasexpressedinml/kgPBW.
Statisticalanalysis
All ventilator settings (including VT) and blood gas analysis results were similar between
patientsinthedifferenttreatmentarmsofthestudies.Thereforedataofeachstudywere
pooled and further analysis compared settings between the 3 consecutive studies, and
between the 2 sites. To detect differences regarding baseline data in the studies an
ANOVA test and post–hoc analysis with Tukey test was performed. These data are all
presented as mean ± SD or median [interquartile range (IQR)]. Ventilator data of the
studieswereallstatisticallyanalyzedusingalinearmixedmodelanalysis.Thefixedeffects
werestudy,sampletimeandstudyxsampletime.Therandomeffectwaspatient.These
data are all presented as mean [95% confidence interval (CI)]. For categorical data the
Chi–squaretestwasused.Datainthefiguresarepresentedasmean±standarddeviation
(SD).Apvalue<0.05wasconsideredsignificant.TheanalysiswasperformedwithSPSS
version12.0(SPSSInc.,Chicago,IL).
Results
Studysubjects
The present analysis included 22 patients and 12 patients in study 1 and study 2,
respectively. Study 3 consisted of 8 patients at site 1 and 17 patients at site 2.
Demographics of patients are given in table 1. There were significantly less women in
61
Chapter5
study 3 at site 1 as compared to the other studies (p < 0.001 versus study 1 and 2 and
study3atsite2).Inaccordance,heightandPBWvaluesweresignificantlylowerinstudy1
and study 2 as compared to study 3. Acute Physiology and Chronic Health Evaluation II
scoreswerelowerinstudy1ascomparedtostudy2andstudy3(p=0.013vs.study2,p=
0.004vs.study3atsite1andp<0.001vs.study3atsite2).
Tidalvolumeandrespiratoryrate
All patients in all 3 studies were initially ventilated with pressure controlled MV. In
addition, proning was used in all patients in the first few days after start of MV. During
weaningpressuresupportMVwasused.MeanVTinstudy1andstudy2weresimilar:10.9
(95%CI10.3–11.6)ml/kgPBWand9.9(95%CI9.0–10.8)ml/kgPBW,respectively(not
significant). In study 3, at site 2 mean VT was 10.3 (95% CI 9.5 – 11.0) ml/kg PBW as
comparedto7.6[95%CI6.5–8.7)ml/kginthatstudyatsite1(p<0.001vs.study3at
site2,p<0.001andp=0.003vs.study1andstudy2,respectively)(figure2)Thenumber
ofdatapointswithVT>10ml/kgPBWdeclinedfrom62%and49%instudy1andstudy2,
respectively,to3%instudy3atsite1(p<0.001).Atsite2thenumberofdatapointswith
VT>10ml/kgPBWwas48%.ThenumberofobservationswithVT>8ml/kgPBWdecreased
from 95%and 86% in study1 and study 2, respectively, to 28% in study 3 at site1(p <
0.001).Atsite2thenumberofobservationswithVT>8ml/kgPBWwas81%.
With the use of lower VT, the respiratory rate increased from 15.6 breaths/min (95% CI
16.6–20.1)and18.3breaths/min(95%CI16.5–20.2)inthefirst2studies(notsignificant
betweenstudy1andstudy2)to20.4breaths/min(95%CI18.1–22.7)instudy3atsite1
(p=0.001vs.study1).Atsite2,respiratoryratewassignificantlylower:17.1breaths/min
(95%CI15.5–18.6)(p=0.002vs.study3atsite1).
Table1Baselinecharacteristicsofpatientsinthestudies
Study
1
2
3
3
Studylocation
Site1
Site1
Site1
Site2
n=17
Numberofpatients
n=22
n=12
n=8
Gender;M/F
15/7
9/3
8/0*
13/4
Age(years);mean±SD
59±14
59±15
60±11
56±18
†
APACHEII;mean±SD
19.2±6.8
19.8±8.6
19.9±6.3
17.1±5.7
‡
Mortalityn(%)atday28
4(18.2)
2(16.7)
1(12.5)
2(11.8) ReasonforALI/ARDS:
Sepsis
6
4
3
3
Pneumonia
6
3
0
6
Trauma
1
1
0
3
Shock
8
3
5
4
Other
1
1
0
1
†
§
PaO2/FiO2;median[IQR]
191[41242]
107[86158]
150[136220]
150[124213]
Height,cm;mean±SD
171±8.1
178±7.2
177±11.7
173±9.9
†
¶
ActualBW(kg);mean±SD
77.6±17.2
80.5±18.7
84.9±13.7
73.1±12.5
PredictedBW(kg);mean±SD 67.2±9.6
65.9±8.0
73.6±6.6
70.5±12.5
Abbreviations:APACHEII,AcutePhysiologyAndChronicHealthEvaluationII;IQR,interquartilerange;BW,body
weight.Adjustedpvalues:*,p<0.001vs.study1,2andstudy3atsite2;†,p<0.05vs.study2and3;‡,p<0.05
vs.study1,2andstudy3atsite1;§,p<0.001vs.study1and3;,p<0.01vs.study3;¶,p<0.05vs.study1
andstudy3atsite2.Seetextforexactpvalues.
62
AdoptionofLowerTidalVolumeVentilationImproveswithFeedbackandEducation
14
Study 1
Study 2
Study 3 at site 1
Study 3 at site 2
VT (ml/kg PBW)
12
10
8
6
4
0
12
24
36
48
60
72
Time (hours)
Figure2Tidalvolumes(ml/kgpredictedbodyweight)inthreeconsecutivetrials(,study1;,study2;,study3
atsite1;,study3atsite2)inthefirst72hoursafterinclusion.Areabetweenthedottedlinesindicatetarget
VTasexplicitlymentionedinthemechanicalventilationprotocolduringconductofstudy3.Dataaremeansand
SE.
PEEPandPaw–max
IndividualPEEPlevelsdecreasedsignificantlyovertimeinallpatientsinthe3studies(p<
0.001).ThemeanPEEPlevelinstudy3atsite2(9.5cmH2O[95%CI8.5–10.5])waslower
ascomparedtothemeanPEEPlevelinstudy1,study2,andstudy3atsite1(11.2cmH2O
[95%CI10.3–12.1],13.7cmH2O[95%CI12.5–14.9]and14.1cmH2O[95%CI12.6–
15.6],respectively)(p=0.059vs.study1,p<0.001vs.study2andstudy3atsite1).
Similarly,individualPaw–maxlevelsdecreasedovertimeinallpatientsinthe3studies(p
< 0.001). The mean Paw–max level in study 2 (31.4 cm H2O [95% CI 28.7 – 34.0]) was
higherascomparedtostudy3atsite1(26.8cmH2O[95%CI23.5–30.1],p=0.034).In
theother2studiesthemeanPaw–maxlevelswere28.1cmH2O[95%CI26.1–30.0]and
28.3cmH2O[95%CI26.1–30.5]instudy1andstudy3atsite1,respectively.
FiO2,PaO2,PaCO2andpH
Data for FiO2, PaO2, PaCO2 and pH are given in table 2. No differences were found
betweenthestudiesregardingFiO2andpH.LevelsofPaCO2werestatisticallysignificant
(butclinicallyinsignificant)lowerinstudy1andstudy2ascomparedtostudy3atsite2(p
63
Chapter5
= 0.011 and 0.021, respectively). Levels of PaCO2 were not different between site 1 and
site 2 in study 3. Levels of PaO2 were significantly higher in study 1 and study 2 as
comparedtostudy3atsite2(p=0.013andp=0.01,respectively).LevelsofPaO2were
notdifferentbetweensite1andsite2instudy3.
Table2Bloodgasanalysisvariables
Study
1
2
3
3
Studylocation
Site1
Site1
Site1
Site2
Numberofpatients
n=22
n=12
n=8
n=17
FiO2
0.50
0.52
0.46
0.51
[0.47–0.54]
[0.47– 0.56]
[0.41– 0.52]
[0.47–0.55]
PaO2(torr)
140
140
122
110
[128–151]*
[125– 155]*
[104– 140]
[98–122]
PaCO2(torr)
36.9
37.8
41.1
40.4
[35.3–38.6]*
[35.6– 40.1]*
[38.3– 44.0]
[38.6–42.3]
pH
7.40
7.40
7.38
7.41
[7.38–7.42]
[7.37– 7.43]
[7.35– 7.42]
[7.39–7.44]
*
Dataaremean[95%ConfidenceInterval]. ,p<0.05vs.study3atsite2(adjustedpvalue).Seetextforexactp
values.
Discussion
Useoflung–protectivemechanicalventilationwithlowerVTisrecommendedforpatients
suffering from ALI/ARDS [2]. We demonstrate, similar to a growing number of other
published manuscripts [35], the poor penetration of the use of 6 ml/kg PBW VT for
ALI/ARDS–patients. Indeed, no adoption of use of lower VT was found in the first years
afterpublicationoftheARDSNetworktrial[1].AlthoughadoptionoflowerVTventilation
improved after feedback and education on lung–protective mechanical ventilation, in
mostpatientsVTwerestilllargerthan6ml/kgPBW.
Ouranalysishasseveraldrawbacks.First,weanalyzeddifferenttreatmentgroupswithin
each study together, because neither the study protocols prescribed different ventilator
settings for the 2 arms of those studies nor differences regarding respiratory variables
were found between the 2 arms. We are uncertain, however, whether changes in the
pulmonary condition as a result of the differences in treatment may have resulted in a
changeinventilatorsettings.Groupsmaybetoosmalltorecognizethis.Second,aswith
anysecondarysubsetanalysisfromalargetrial,thisreportmayhavesignificantinherent
flawsduetoitsretrospectivedesign,smallsamplesize,andfocusonasinglesitewhere
the ventilation practices may not be representative of the norm. Finally, a study makes
clinicians aware that patients meet criteria for ALI/ARDS, which may change clinical
behavior(likeuseoflung–protectiveventilation);inotherwordsVT–practicemaynotat
allhavechangedinpatientsnotrecruitedinstudies.
Analternativeexplanationforthechangeinventilatorsettingsisseculartrendsovertime.
Indeed,onecouldarguethatthisdeclinewas(also)aneffectoftime(i.e.,betheresultof
less lack of awareness about the benefit of lower VT, less disagreement about the
evidenceandmoremotivationtoapplylowerVT).Forseveralreasonsweconsiderthisless
likely,however.First,althoughatrendtowardslowerVTwasnoticedbetweenstudy1and
64
AdoptionofLowerTidalVolumeVentilationImproveswithFeedbackandEducation
study2,differenceswereindeedsmallandnotstatisticallysignificant.Second,ventilator
settingsinstudy3didnotshowaseculartrendovertime,neitheratsite1noratsite2.
Third,whensecularchangesovertimeexplainthechangeinventilatorsettingsatsite1,
why did ventilator settings in the other site remain unchanged? Providing feedback on
previous practice has been shown to be more effective than simple education [20].
Recently,Cookandco–workersemphasizedtheimportanceofanenvironmentalscanand
understandingofcurrentbehaviortoimprovedailypractice[21].Inapreviousreportwe
demonstrated the effect of a feedback and educational program, targeting a lower VT
strategy in all mechanically ventilated ICUpatients [22]. We found that VT declined
significantlywithin6monthsinourICUandmoreimportantly,after12monthslowerVT
werestillused.Hereweshowthatinthecenterinwhichfeedbackandeducationonuse
oflowerVTwasgiven,theuseoflowerVT–MVimproved,whileinaneighboringuniversity
hospital, where neither feedback nor education had taken place, VT were larger than
presentlyrecommendedforALI/ARDS–patients.
Ofcourse,other,yetunrecognizeddifferencesbetweenthe2sitesmayaccountforthis
difference.However,the2ICUsareverysimilar,bothbeingso–calledclosedformatunits,
with no changes in staffing over time. The only difference that existed between these
centerswasPEEPlevels:lowerPEEPlevelswereusedatsite2instudy3,ascomparedto
site1inallstudies.TheMV–guidelinecontaineddifferentrecommendationsontheuseof
PEEP,whichcompletelyexplainsthisdifference.
IthasbeenshownthatcliniciansinteachinghospitalsonlyslowlyadoptedthelowerVT–
strategy, several years after publication of the ARDS Network study [3]. Although
significant reductions in VT in ALI/ARDS–patients were described in another study, wide
variationinventilatorpracticepersistedandtheproportionofpatientsreceivingVTwithin
recommended limits ( 8 ml/kg PBW) remained modest [4]. In contrast, physicians at
ARDS Network centers prescribed significant lower VT after completion of their study
(1999 – 2002) as compared to VT during conduct of the study (1996 – 1999) [23]. In an
international observational study on 198 European ICU’s, including over 393 ALI/ARDS–
patients,inmorethanhalfofcasesventilatorsettingswereotherthantheARDSNetwork
lung–protectiveMVstrategy[5].Ourdataareinlinewiththesereports.Indeed,several
years after publication of the ARDS Network trial VT were still large and in fact not
differentwiththosesetbeforethebenefitsoflowerVTinALI/ARDSbecameclear.
VariousreasonsfortheslowadoptionoflowVTwererecentlysummarized[24].Physicians
maychoosetocontrolplateaupressures(orPawmaxinPCMV)insteadofVT,despitethe
clear benefit of using lower VT at every plateau pressure (i.e., also at lower levels).
PhysiciansmayhaveconcernsabouttheinitialworseningofPaO2andPaCO2levelswhen
VTarelowered,despitethedemonstrationthattheinitialdeteriorationinPaO2/FiO2ratio
isshortlived[1].TheARDSNetworkstudydemonstratedthatlowVT–patientshadalower
65
Chapter5
FiO2bythe3rddayascomparedtoconventionalVT–patients.Similarly,althoughlowVT–
ventilationcausesanincreaseinPaCO2initially,thereisnodifferenceinpHbyday7.And
finally, many physicians may worry that a low VT–strategy causes increased ventilator
dyssynchrony. Two retrospective analysis, however, found no difference either in the
number of patients receiving benzodiazepine sedatives or opioid analgesics or in the
dosagesofthesemedications[25,26].
From the present analysis we conclude that adoption of lower VT as standard of care in
patientswithALI/ARDSisstillpoor,butmayimprovewithfeedbackandeducation.
66
AdoptionofLowerTidalVolumeVentilationImproveswithFeedbackandEducation
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