Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT.
Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT.
Crit Care Med. 2023 Jun 1;51(6):797-807. doi: 10.1097/CCM.0000000000005840. Epub 2023 Mar 29.
We implemented a computerized protocol for low tidal volume ventilation (LTVV) to improve management and outcomes of mechanically ventilated patients with, and without, the acute respiratory distress syndrome (ARDS).
Pragmatic, nonrandomized stepped wedge type II hybrid implementation/effectiveness trial.
Twelve hospitals in an integrated healthcare system over a 2-year period.
Patients greater than or equal to 18 years old who had initiation of mechanical ventilation in the emergency department or ICU. We excluded patients who died or transitioned to comfort care on the day of admission to the ICU. We defined a subgroup of patients with ARDS for analysis.
Implementation of ventilator protocols for LTVV in the ICU.
Our primary clinical outcome was ventilator-free days (VFDs) to day 28. Our primary process outcome was median initial set tidal volume. We included 8,692 mechanically ventilated patients, 3,282 (38%) of whom had ARDS. After implementation, set tidal volume reported as mL/kg predicted body weight decreased from median 6.1 mL/kg (interquartile range [IQR], 6.0-6.8 mL/kg) to 6.0 mL/kg (IQR, 6.0-6.6 mL/kg) ( p = 0.009). The percent of patients receiving LTVV (tidal volume ≤ 6.5 mL/kg) increased from 69.8% ( n = 1,721) to 72.5% ( n = 1,846) ( p = 0.036) after implementation. The percent of patients receiving greater than 8 mL/kg initial set tidal volume was reduced from 9.0% ( n = 222) to 6.7% ( n = 174) ( p = 0.005) after implementation. Among patients with ARDS, day 1 positive end-expiratory pressure increased from 6.7 to 8.0 cm H 2 O ( p < 0.001). We observed no difference in VFD (adjusted odds ratio, 1.06; 95% CI, 0.91-1.24; p = 0.44), or in secondary outcomes of length of stay or mortality, either within the main cohort or the subgroup of patients with ARDS.
We observed improved adherence to optimal ventilator management with implementation of a computerized protocol and reduction in the number of patients receiving tidal volumes greater than 8 mL/kg. We did not observe improvement in clinical outcomes.
我们实施了一种小潮气量通气（LTVV）的计算机化方案，以改善合并和不合并急性呼吸窘迫综合征（ARDS）的机械通气患者的管理和结局。
实用的、非随机的、阶梯式楔形 II 型混合实施/有效性试验。
在 2 年期间，一个综合医疗系统中的 12 家医院。
年龄大于或等于 18 岁、在急诊科或 ICU 开始机械通气的患者。我们排除了在 ICU 入院当天死亡或过渡到舒适护理的患者。我们为分析定义了一个 ARDS 患者亚组。
在 ICU 实施呼吸机小潮气量通气方案。
我们的主要临床结局是到第 28 天的无呼吸机天数（VFDs）。我们的主要过程结局是初始设定潮气量的中位数。我们纳入了 8692 例机械通气患者，其中 3282 例（38%）患有 ARDS。实施后，以 mL/kg 预测体重报告的设定潮气量从中位数 6.1mL/kg（四分位距[IQR]，6.0-6.8mL/kg）降至 6.0mL/kg（IQR，6.0-6.6mL/kg）（p=0.009）。接受小潮气量通气（潮气量≤6.5mL/kg）的患者比例从 69.8%（n=1721）增加到 72.5%（n=1846）（p=0.036）。接受初始设定潮气量大于 8mL/kg 的患者比例从 9.0%（n=222）降至 6.7%（n=174）（p=0.005）。在 ARDS 患者中，第 1 天呼气末正压从 6.7 增加到 8.0cm H2O（p<0.001）。我们在主要队列或 ARDS 患者亚组中均未观察到 VFD（调整优势比，1.06；95%CI，0.91-1.24；p=0.44）或住院时间或死亡率等次要结局的改善。
我们观察到通过实施计算机化方案，接受大于 8mL/kg 潮气量的患者数量减少，对最佳呼吸机管理的依从性得到改善。但我们没有观察到临床结局的改善。
