Evidence and Consensus

Since evidence of benefit is the first step in translating research into practice, it is important to ask which aspects of mechanical ventilation are known to be beneficial. The amount of evidence it takes to convince individual clinicians may vary and will certainly vary with the plausibility, cost, risks, andbenefits ofthe proposed treatment [26]. We need more compelling evidence to convince us to use inhaled nitric oxide or prone positioning in patients with ARDS than to provide oxygen supplementation to patients with acute hypoxemic respiratory failure and a PaO2 of 40 mmHg. In fact, the purpose of this chapter is to present the current evidence for various aspects of mechanical ventilation. A number of consensus conferences on mechanical ventilation have been published over the years [29-35]. This chapter is not focused on the evidence base or consensus on the practice of mechanical ventilation but on research directed at understanding its translation into practice in the community. Research in this area includes: studies that evaluate current practice in the community, studies that explore the barriers and facilitators to changing practice, and studies that evaluate specific interventions to change the practice of mechanical ventilation.

To identify articles that address these topics the following MEDLINE search strategy was used: Artificial respiration was combined with each of the following: Guideline adherence, physician's practice patterns; questionnaires; medical audit; and surveys. This list was screened for articles that covered one of the three topics: understanding current practice, barriers to changing practice, effective strategies to change practice. It is important to note that some implementation research occurs without publication in mainstream academic research journals. For example, the Institute for Healthcare Improvement is a non-profit organization that sponsors workshops to help clinicians improve the quality of care they provide [13]. Many of these quality improvement projects have focused on critical care interventions. The projects are usually single institution, before-after studies and the results are not peer reviewed. Nevertheless, this is an important source of information about projects designed to change clinical practice at single sites or within collaborative ofhospitals.

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