Burger-Klepp Ursula, Maleczek Mathias, Ristl Robin, Kroyer Bettina, Raudner Marcus, Krenn Claus G, Ullrich Roman
Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria.
Ludwig Boltzmann Institute for Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria.
BMC Med. 2025 Jan 29;23(1):52. doi: 10.1186/s12916-025-03898-2.
Patients at need for ventilation often are at risk of acute respiratory distress syndrome (ARDS). Although lung-protective ventilation strategies, including low driving pressure settings, are well known to improve outcomes, clinical practice often diverges from these strategies. A clinical decision support (CDS) system can improve adherence to current guidelines; moreover, the potential of a CDS to enhance adherence can possibly be further increased by combination with a nudge type intervention.
A prospective cohort trial was conducted in patients at risk of ARDS admitted to an intensive care unit (ICU). Patients were assigned to control or intervention by their date of admission: First, the control group was included without changing anything in clinical practice. Next, the CDS was activated showing an alert in the patient data management system if driving pressure exceeded recommended values; additionally, data on the performance of the wards were sent to the healthcare professionals as the nudge intervention. The main hypothesis was that this combined intervention would lead to a significant decrease in excess driving pressure.
The 472 included patients (230 in the control group and 242 in the intervention group) consisted of 33% females. The median age was 64 years; median Sequential Organ Failure Assessment score was 8. There was a significant reduction in excess driving pressure in the augmented ventilation modes (0.28 ± 0.67 mbar vs. 0.14 ± 0.45 mbar, p = 0.012) but not the controlled mode (0.37 ± 0.83 mbar vs. 0.32 ± 0.8 mbar, p = 0.53). However, there was no significant difference between groups in mechanical power, the number of ventilator-free days, or the percentage of patients showing progression to ARDS. Although there was no difference in progression to ARDS, 28-day mortality was higher in the intervention group. Notably, the mean overall driving pressure across both groups was low (12.02 mbar ± 2.77).
In a population at risk of ARDS, a combined intervention of a clinical decision support system and a nudge intervention was shown to reduce the excessive driving pressure above 15 mbar in augmented but not in controlled modes of ventilation.
需要通气的患者常常面临急性呼吸窘迫综合征（ARDS）的风险。尽管包括低驱动压设置在内的肺保护性通气策略已被熟知可改善预后，但临床实践往往与这些策略存在偏差。临床决策支持（CDS）系统可提高对现行指南的依从性；此外，通过与助推式干预相结合，CDS增强依从性的潜力可能会进一步提高。
对入住重症监护病房（ICU）且有ARDS风险的患者进行了一项前瞻性队列试验。根据患者的入院日期将其分配至对照组或干预组：首先，对照组纳入，临床实践不做任何改变。接下来，激活CDS，若驱动压超过推荐值，则在患者数据管理系统中显示警报；此外，将病房的表现数据作为助推干预发送给医护人员。主要假设是这种联合干预将导致过高驱动压显著降低。
纳入的472例患者（对照组230例，干预组242例）中女性占33%。中位年龄为64岁；序贯器官衰竭评估评分中位数为8。在增强通气模式下，过高驱动压显著降低（0.28±0.67 mbar对0.14±0.45 mbar，p = 0.012），但在控制模式下未降低（0.37±0.83 mbar对0.32±0.8 mbar，p = 0.53）。然而，两组在机械功率、无呼吸机天数或进展为ARDS的患者百分比方面无显著差异。尽管进展为ARDS无差异，但干预组的28天死亡率更高。值得注意的是，两组的平均总体驱动压较低（12.02 mbar±2.77）。
在有ARDS风险的人群中，临床决策支持系统与助推干预的联合干预显示可降低增强通气模式而非控制通气模式下超过15 mbar的过高驱动压。
