Matsumoto Kenki, Prowle John R, Puthucheary Zudin, Cecconi Maurizio, Fazzini Brigitta, Malcolm Hannah, Nydahl Peter, Osman Magda, Santini Alessandro, Schaller Stefan J, Thomson William, van den Berke Danielle, Poll Marcel, Stephens Timothy
Barts Health NHS Trust, London, UK.
Queen Mary University of London Faculty of Medicine and Dentistry, London, UK.
BMJ Open Respir Res. 2025 May 11;12(1):e002637. doi: 10.1136/bmjresp-2024-002637.
Coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) was an emergent syndrome that led to high volumes of critically ill ventilated patients. We explored influences on decision-making regarding management of COVID-19 ARDS mechanical ventilation to identify modifiable factors to improve preparedness for future pandemics.
A systematic review and small group interviews informed the development of an international questionnaire (UK, Italy, Germany and Netherlands) on factors influencing COVID-19 ARDS ventilation decision-making in critical care professionals. Participants ranked four themes in order of importance: disease (uncertainties around COVID-19 ARDS), contextual (cognitive strain), environmental (structural logistics) and team factors. Participants also ranked the subthemes within each theme. Thematic analysis was used to derive findings from qualitative data. Kruskal-Wallis, Mann-Whitney U and Kendall's tau were used for quantitative data analysis.
Patient factors (comorbidities, clinical/biochemical parameters) were the most studied influences in the extant literature on decision-making; uncertainty was one of the least studied. 371 critical care professionals responded to the questionnaire. Disease uncertainty (lack of applicable guidelines, unfamiliarity with pathophysiology) was ranked as the most important influence on ventilation decision-making for COVID-19 ARDS across regions, professions and experience levels (p<0.001). Participants expressed underconfidence in their decision-making (median score: 9/20); this was unaffected by experience (p=0.79) or profession (p=0.58). Qualitative findings supported and extended the initial proposed influences, including the impact of team factors (+ve) and resource limitations (-ve) on disease uncertainty.
Future pandemic preparedness programmes should target modifiable influences such as information sharing, teamworking and resource limitations to mitigate against the negative influence of uncertainty and thereby improve decision-making overall.
2019冠状病毒病（COVID-19）急性呼吸窘迫综合征（ARDS）是一种导致大量重症通气患者的紧急综合征。我们探讨了对COVID-19 ARDS机械通气管理决策的影响，以确定可改变的因素，以提高对未来大流行的应对准备。
一项系统评价和小组访谈为一份关于影响重症监护专业人员对COVID-19 ARDS通气决策因素的国际调查问卷（英国、意大利、德国和荷兰）的制定提供了信息。参与者按重要性顺序对四个主题进行了排序：疾病（围绕COVID-19 ARDS的不确定性）、背景（认知压力）、环境（结构后勤）和团队因素。参与者还对每个主题中的子主题进行了排序。采用主题分析从定性数据中得出研究结果。使用Kruskal-Wallis、Mann-Whitney U和Kendall's tau进行定量数据分析。
患者因素（合并症、临床/生化参数）是现有文献中对决策影响研究最多的因素；不确定性是研究最少的因素之一。371名重症监护专业人员回复了问卷。疾病不确定性（缺乏适用指南、对病理生理学不熟悉）被列为跨地区、专业和经验水平对COVID-19 ARDS通气决策最重要的影响因素（p<0.001）。参与者对自己的决策表示信心不足（中位数得分：9/20）；这不受经验（p=0.79）或专业（p=0.58）的影响。定性研究结果支持并扩展了最初提出的影响因素，包括团队因素（积极）和资源限制（消极）对疾病不确定性的影响。
未来的大流行防范计划应针对信息共享、团队合作和资源限制等可改变的影响因素，以减轻不确定性的负面影响，从而总体上改善决策。
