Barriers To Adherence: Low Tidal Volume Ventilation in the Acute Respiratory Distress Syndrome

摘要 急性呼吸窘迫综合征（ARDS）是危重病患者死亡和致残的主要原因， 患者，估计死亡率为30- 40%。尽管低潮气量被广泛认可 通气（LTVV）是唯一已知的降低ARDS死亡率的治疗方法（在一项随机临床试验中，LTVV 死亡率从40%降低至31%，对于单一治疗策略而言，绝对值显著降低）， 对LTVV的依从性仍然很低。迄今为止的其他研究的代表，我们研究的初步数据 UCSF的一组研究表明，不到25%的ARDS患者达到LTVV，定义为潮气量为 预测体重≤ 6.5 cc/kg。更好地了解患者、提供者和ICU组织 增加接受LTVV失败风险的特征是至关重要的，如果我们要改善结果， ARDS患者。此外，尚不清楚LTVV产生的死亡率获益是否是时间- 取决于实现LTVV所需的时间或接受此时间的比例 通风策略其他支持性干预措施，如适当的抗生素治疗，显然是可行的。 时间相关的（例如，适当抗生素治疗的时间和适当治疗的持续时间 与改善的结果相关），因此可以合理假设类似的原则适用于低潮 容量通气本申请中提出的研究将检验特定患者和 医生特征使患者处于无法接受LTVV的风险中（目标1），特别是较低的 在轻中度疾病严重程度的患者中识别ARDS（假设1A），潮气量 与白班相比，晚班更容易脱靶（假设 此外，我们还将测试是否从ARDS发作开始达到LTVV，以及时间比例 在此期间，作为接受机械通气的总时间的函数， 患者的结局（目标2）。最后，我们假设，一个机构的方法，结合低潮， 容量通气作为推荐的默认值和初始呼吸机策略将改善对LTVV的依从性， 减少实现LTVV所需的时间，增加收到LTVV的时间比例，并导致 总体较低的潮气量（cc/kg预测体重）（目标3）。该项目将有一个 通过阐明患者和过程对ARDS患者的临床结局产生重要和有利的影响 使患者面临接受偏离目标潮气量风险的特征，进一步定义了相关性 及时和持续接受LTVV对死亡率和ARDS结局的影响，并测试 严格的质量改进措施，以提高对LTVV的遵守。该项目还将为一个 K23项目，研究质量改进措施的影响和效力， 坚持LTVV，也将促进我的长期职业目标，以改善重症患者的护理 通过研究执行科学和循证实践的系统应用。

Abstract The Acute Respiratory Distress Syndrome (ARDS) is a major cause of mortality and morbidity in critically ill patients, with an estimated mortality rate of 30-40%. Despite the widespread recognition of low tidal volume ventilation (LTVV) as the only known therapy to reduce mortality in ARDS (in a randomized clinical trial, LTVV reduced mortality from 40% to 31%, a remarkable absolute reduction for a single treatment strategy), compliance with LTVV remains low. Representative of other studies to date, preliminary data from our research group at UCSF indicates that less than 25% of all ARDS patients achieve LTVV as defined as a tidal volume of ≤ 6.5 cc/kg of predicted body weight. A better understanding of the patient, provider, and ICU organizational characteristics that increase the risk of failure to receive LTVV is critical if we are to improve outcomes for patients with ARDS. Furthermore, it is unknown whether the mortality benefit derived from LTVV is time- dependent, either with regards to the time needed to achieve LTVV or proportion of time receiving this ventilation strategy. Other supportive interventions, such as treatment with appropriate antibiotics, are clearly time-dependent (e.g., time to appropriate antibiotic therapy and duration of appropriate treatment are both associated with improved outcomes), so it is reasonable to hypothesize that similar principles apply to low tidal volume ventilation. The studies proposed in this application will test the hypothesis that specific patient and physician characteristics place patients at risk for failure to receive LTVV (Aim 1), in particular lower rates of recognition of ARDS in patients with mild-moderate disease severity (Hypothesis 1A), and that tidal volumes are more likely to be off-target during the evening shift as compared with day shift (Hypothesis 1B).Furthermore, we will test whether the to achieve LTVV from the onset of ARDS, and the proportion of time during which LTVV was administered as a function of total time receiving mechanical ventilation are associated with patient outcomes (Aim 2). Finally, we hypothesize that an institutional approach incorporating low-tidal volume ventilation as a recommended default and initial ventilator strategy will improve compliance with LTVV, decrease time needed to achieve a LTVV, increase the proportion of time of receipt of LTVV, and result in overall lower tidal volumes achieved in cc/kg of predicted body weight (Aim 3). This project will have an important and favorable impact on clinical outcomes in ARDS patients by elucidating patient and process characteristics that place patients at risk for receipt of off-target tidal volumes, further defining the association between timely and sustained receipt of LTVV on mortality and ARDS outcomes, and testing the efficacy of a rigorous quality improvement measure to improve adherence to LTVV. This project will also pave the way for a K23 project to study the impact and efficacy of quality improvement measures geared towards increasing adherence to LTVV and will also facilitate my long-term career goals to improve the care of critically ill patients through studying the science of implementation and the systematic application of evidence-based practices.