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UvA-DARE (Digital Academic Repository) Lung protective mechanical ventilation Wolthuis, E.K. Link to publication Citation for published version (APA): Wolthuis, E. K. (2008). Lung protective mechanical ventilation General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: http://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam (http://dare.uva.nl) 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 References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. Ventilationwithlowertidalvolumesascomparedwithtraditionaltidalvolumesforacutelunginjury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N EnglJMed2000;342:13018. Dellinger RP, Carlet JM, Masur H, et al. Surviving sepsis campaign guidelines for management of severesepsisandsepticshock.CritCareMed2004;32:85873. WeinertCR,GrossCR,MarinelliWA.Impactofrandomizedtrialresultsonacutelunginjuryventilator therapyinteachinghospitals.AmJRespirCritCareMed2003;167:13049. Young MP, Manning HL, Wilson DL, et al. Ventilation of patients with acute lung injury and acute respiratory distress syndrome: has new evidence changed clinical practice? Crit Care Med 2004; 32: 12605. SakrY,VincentJL,ReinhartK,etal.Hightidalvolumeandpositivefluidbalanceareassociatedwith worseoutcomeinacutelunginjury.Chest2005;128:3098108. RubenfeldGD,CooperC,CarterG,etal.Barrierstoprovidinglungprotectiveventilationtopatients withacutelunginjury.CritCareMed2004;32:128993. MikkelsenME,DedhiyaP,KalhanR,etal.Factorscontributingtophysiciannoncomplianceinuseof lung protective ventilation in patients with acute lung injury. Am J Respir Crit Care Med 2004; 169: A17. KalletRH,CorralW,SilvermanHJ,etal.Implementationofalowtidalvolumeventilationprotocolfor patientswithacutelunginjuryoracuterespiratorydistresssyndrome.RespirCare2001;46:102437. Eichacker PQ, Gerstenberger EP, Banks SM, et al. Metaanalysis of acute lung injury and acute respiratorydistresssyndrometrials testinglowtidalvolumes.Am JRespirCritCareMed2002; 166: 15104. KamEP,EslickGD,JamesA,etal.Acuterespiratorydistresssyndrome(ARDS)andlowtidalvolume ventilation:thedebateaboutweight.IntensiveCareMed2004;30:1502. International consensus conferences in intensive care medicine. Ventilatorassociated lung injury in ARDS. American Thoracic Society, European Society of Intensive Care Medicine, Societe de ReanimationLangueFrancaise.IntensiveCareMed1999;25:144452. Webb HH, Tierney DF. Experimental pulmonary edema due to intermittent positive pressure ventilation with high inflation pressures. Protection by positive endexpiratory pressure. Am Rev RespirDis1974;110:55665. DreyfussD, Soler P,BassetG,etal.Highinflationpressurepulmonary edema. Respectiveeffectsof highairwaypressure,hightidalvolume,andpositiveendexpiratorypressure.AmRevRespirDis1988; 137:115964. AmatoMB,BarbasCS,MedeirosDM,etal.Effectofaprotectiveventilationstrategyonmortalityin theacuterespiratorydistresssyndrome.NEnglJMed1998;338:34754. Brochard L, RoudotThoraval F, Roupie E, et al. Tidal volume reduction for prevention of ventilator induced lung injury in acute respiratory distress syndrome. The Multicenter Trail Group on Tidal VolumereductioninARDS.AmJRespirCritCareMed1998;158:18318. StewartTE,MeadeMO,CookDJ,etal.Evaluationofaventilationstrategytopreventbarotraumain patients at high risk for acute respiratory distress syndrome. Pressure and VolumeLimited VentilationStrategyGroup.NEnglJMed1998;338:35561. BrowerRG,ShanholtzCB,FesslerHE,etal.Prospective,randomized,controlledclinicaltrialcomparing traditional versus reduced tidal volume ventilation in acute respiratory distress syndrome patients. CritCareMed1999;27:14928. RanieriVM,SuterPM,TortorellaC,etal.Effectofmechanicalventilationoninflammatorymediators inpatientswithacuterespiratorydistresssyndrome:arandomizedcontrolledtrial.Jama1999;282: 5461. Ranieri VM, Giunta F, Suter PM, et al. Mechanical ventilation as a mediator of multisystem organ failureinacuterespiratorydistresssyndrome.Jama2000;284:434. BeroLA,GrilliR,GrimshawJM,etal.Closingthegapbetweenresearchandpractice:anoverviewof systematic reviews of interventions to promote the implementation of research findings. The CochraneEffectivePracticeandOrganizationofCareReviewGroup.BMJ1998;317:4658. Cook DJ, Montori VM, McMullin JP, et al. Improving patients' safety locally: changing clinician behaviour.Lancet2004;363:122430. 67 Chapter5 22. 23. 24. 25. 26. 68 WolthuisEK,KorevaarJC,SpronkP,etal.Feedbackandeducationimprovephysiciancompliancein useoflungprotectivemechanicalventilation.IntensiveCareMed2005;31:5406. Brower RG, Thompson BT, Ancukiewicz M. Clinical trial of mechanical ventilation with traditional versus lower tidal volumes in acute lung injury and acute respiratory distress syndrome: effects on physicians'practices.AmJRespirCritCareMed2004;169:A256. GovertJA.Anotherexcusebitesthedust:lowtidalvolumeventilationdoesnotincreasesedationuse. CritCareMed2005;33:9034. ChengIW,EisnerMD,ThompsonBT,etal.Acuteeffectsoftidalvolumestrategyonhemodynamics, fluidbalance,andsedationinacutelunginjury.CritCareMed2005;33:6370. KahnJM,AnderssonL,KarirV,etal.Lowtidalvolumeventilationdoesnotincreasesedationusein patientswithacutelunginjury.CritCareMed2005;33:76671.