Implementation of Lung-Protective Ventilation in Patients With Acute Respiratory Failure.
Implementation of Lung-Protective Ventilation in Patients With Acute Respiratory Failure.
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对急性呼吸衰竭患者实施肺保护性通气。
DOI：
10.1097/ccm.0000000000005840
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发表时间：
2023
影响因子：
8.8
通讯作者：
Srivastava,Rajendu
中科院分区：
文献类型：
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作者：
Grissom,ColinK;Lanspa,MichaelJ;Groat,Danielle;Jacobs,JasonR;Carpenter,Lori;Kuttler,KathrynG;Leither,Lindsay;Peltan,IthanD;Brown,SamuelM;Srivastava,Rajendu
目的：我们实施了一个计算机化的协议，低潮气量通气（LTVV），以改善管理和结果的机械通气患者，和没有，急性呼吸窘迫综合征（ARDS.DESIGN）：务实，非随机阶梯楔形II型混合实施/effectiveness trial.SETTING：12家医院在一个综合性的医疗保健系统超过2年的period.Patients：患者大于或等于18岁的开始机械通气在急诊科或ICU。我们排除了在入住ICU当天死亡或转为舒适护理的患者。我们定义了一个亚组的患者与ARDS analysis.INTERVENTIONS：实施呼吸机协议LTVV在ICU.MEASUREMENTS和主要结果：我们的主要临床结果是无呼吸机天（VFD）到第28天。我们的主要过程结果是中位数初始设置潮气量。我们纳入了8，692例机械通气患者，其中3，282例（38%）患有ARDS。实施后，报告为mL/kg的设定潮气量预测体重从中位数6.1 mL/kg（四分位距[IQR]，6.0-6.8 mL/kg）降至6.0 mL/kg（IQR，6.0-6.6 mL/kg）（p= 0.009）。实施后，接受LTVV（潮气量≤ 6.5 mL/kg）的患者百分比从69.8%（n= 1，721）增加至72.5%（n= 1，846）（p= 0.036）。实施后，接受大于8 mL/kg初始设定潮气量的患者百分比从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8.0 cm H2O（p< 0.001）。我们没有观察到差异VFD（调整后的比值比，1.06; 95%CI，0.91-1.24; p= 0.44），或在住院时间或死亡率的次要结果，无论是在主队列或亚组的患者与ARDS.CONCLUSIONS：我们观察到改善遵守最佳呼吸机管理与实施的计算机化协议和减少患者的数量接受潮气量大于8毫升/公斤。我们没有观察到临床结局的改善。
OBJECTIVES: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).DESIGN:Pragmatic, nonrandomized stepped wedge type II hybrid implementation/effectiveness trial.SETTING:Twelve hospitals in an integrated healthcare system over a 2-year period.PATIENTS: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.INTERVENTIONS:Implementation of ventilator protocols for LTVV in the ICU.MEASUREMENTS AND MAIN RESULTS: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.CONCLUSIONS: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.