Weiss Curtis H, Baker David W, Weiner Shayna, Bechel Meagan, Ragland Margaret, Rademaker Alfred, Weitner Bing Bing, Agrawal Abha, Wunderink Richard G, Persell Stephen D
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.
Crit Care Med. 2016 Aug;44(8):1515-22. doi: 10.1097/CCM.0000000000001710.
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.
Retrospective cross-sectional study.
One academic and three community hospitals in the Chicago region.
A total of 362 adults meeting the Berlin Definition of acute respiratory distress syndrome consecutively admitted between June and December 2013.
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.
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.
低潮气量通气可降低急性呼吸窘迫综合征的死亡率。既往研究报告称低潮气量通气的实施情况不佳。我们试图确定低潮气量通气的使用比例、质量及预测因素。
回顾性横断面研究。
芝加哥地区的一家学术医院和三家社区医院。
2013年6月至12月期间连续收治的共362例符合柏林急性呼吸窘迫综合征定义的成年患者。
70例患者（19.3%）在机械通气的某个时间段接受了低潮气量通气（潮气量<6.5 ml/kg预计体重）。总体而言，22.2%需要吸入氧浓度高于40%的患者以及37.3%吸入氧浓度高于40%且平台压高于30 cm H₂O的患者接受了低潮气量通气。在整个队列中，患者急性呼吸窘迫综合征发作期间有11.4%的时间接受了低潮气量通气。在接受低潮气量通气的患者中，其使用时间占急性呼吸窘迫综合征发作时间的平均（标准差）百分比为59.1%（38.2%），34%的患者在开始低潮气量通气前等待了超过72小时。女性接受低潮气量通气的可能性较小，而脓毒症和吸入氧浓度高于40%与使用低潮气量通气的几率增加相关。4名主治医师（6.2%）在急性呼吸窘迫综合征发作1天内为其50%及以上的患者启动了低潮气量通气，而34名医师（52.3%）在急性呼吸窘迫综合征发作1天内从未启动过低潮气量通气。总体而言，54.4%的患者接受的潮气量低于8 ml/kg预计体重，急性呼吸窘迫综合征发作后最初72小时内的平均潮气量从未低于8 ml/kg预计体重。
具有里程碑意义的低潮气量通气研究发表12年多后，其应用情况仍然不佳。需要采取干预措施来提高低潮气量通气的采用率。
