Bagga Sidharth, Paluzzi Dalton E, Chen Christine Y, Riggio Jeffrey M, Nagaraja Manjula, Marik Paul E, Baram Michael
Respir Care. 2014 Aug;59(8):1172-7. doi: 10.4187/respcare.02223.
The Acute Respiratory Distress Syndome (ARDS) Network low tidal volume (VT) trial paved the ground for mechanically ventilating ARDS patients with a VT of 6 mL/kg ideal body weight (IBW). Although there is no consensus that a low VT is advantageous in non-ARDS patients,it is accepted that high VT should be avoided. Because compliance rates with ventilator recommendations are 30%, there is a need for process improvement. We postulated that a computerized screen prompt that recommended VT based on height would improve compliance with low VT.During ventilator order entry, the computerized decision tool prompts the clinician and encourages ventilation of patients at 8 mL/kg IBW, and 6 mL/kg IBW for patients with ARDS.
A retrospective review was performed on patients who required volume controlled mechanical ventilation over a 3-y period. Subjects were chosen randomly from the respiratory records of 6 different ICUs at a single tertiary care academic center. Half of the charts selected were before intervention of on-screen prompt, and the other half were after implementation of the computerized decision tool.
The initial set VT ranged from 6.26 to 13.45 mL/kg IBW, with a mean of 8.92 mL/kg. After implementation of the on-screen prompt, mean VT decreased by 0.84 mL/kg to 8.07 mL/kg (P= .001) with a lower range of 4.73-11.56 mL/kg IBW. We also noted a significant decrease in the number of subjects placed on an initial VT > 10 mL/kg IBW from 20% to 4% (P= .003).
A computerized clinical decision tool with the preferred initial VT settings based on the patients' sex and height is a safe and reliable way to increase low VT strategy compliance across multiple ICUs. Its limitations are similar to those shared by other computer-generated prompts.
急性呼吸窘迫综合征（ARDS）网络低潮气量（VT）试验为以6 mL/kg理想体重（IBW）对ARDS患者进行机械通气奠定了基础。尽管对于低潮气量在非ARDS患者中是否有利尚无共识，但普遍认为应避免高潮气量。由于呼吸机建议的依从率为30%，因此需要改进流程。我们推测基于身高推荐VT的计算机屏幕提示会提高对低潮气量的依从性。在呼吸机医嘱录入过程中，计算机决策工具会提示临床医生，并鼓励对患者采用8 mL/kg IBW进行通气，对于ARDS患者则采用6 mL/kg IBW。
对在3年期间需要容量控制机械通气的患者进行回顾性研究。研究对象从一家三级医疗学术中心6个不同重症监护病房（ICU）的呼吸记录中随机选取。所选病历的一半是在屏幕提示干预之前，另一半是在实施计算机决策工具之后。
初始设定的VT范围为6.26至13.45 mL/kg IBW，平均为8.92 mL/kg。实施屏幕提示后，平均VT降至8.07 mL/kg，降低了0.84 mL/kg（P = 0.001），范围为4.73 - 11.56 mL/kg IBW。我们还注意到，初始VT > 10 mL/kg IBW的患者数量从20%显著降至4%（P = 0.003）。
具有根据患者性别和身高设置首选初始VT的计算机化临床决策工具，是一种在多个ICU中提高低潮气量策略依从性的安全可靠方法。其局限性与其他计算机生成的提示类似。
