Understanding Current Practice

There are probably more data on current mechanical ventilation practice in the ICU than any other aspect of critical care. There are several techniques for measuring process of care. Clinicians can be surveyed about their attitudes about using different treatments or their practice in hypothetical case vignettes. Charts can be abstracted retrospectively by protocol by research staff. Clinicians can report on their practice prospectively. Administrative databases collected for billing or ad ministrative purposes can be analyzed. As with all research methods each approach has specific benefits, limitations, and costs. Surveys of clinicians' behavior to measure their practice is notoriously unreliable at capturing their actual practice. Analysis of administrative data has been used to understand the outcomes of mechanical ventilation in large patient populations, but does not provide detailed data on patient management or diagnosis [36-40].

Several recent studies have explored practice in broad populations of mechanically ventilated patients or patients with acute lung injury (ALI) [41-44]. These studies used a combination of self report of practice by clinicians and survey of attitudes to describe clinical practice. The studies did not specifically compare patients' care with current practice recommendations. Despite recommendations and clinical experience that mechanical ventilation should be customized for individual diseases, patients received remarkably similar average tidal volume (Vt), positive end-expiratory pressure (PEEP), and FiO2 regardless ofwhetherthey were diagnosed with ALI, ARDS, acute hypoxemic respiratory failure, or chronic obstructive pulmonary disease (COPD) (Fig. 1). In one study, 63% of patients managed on assisted mechanical ventilation received Vt < 10 ml/kg, but patients diagnosed by their physicians with ALI were no more likely to receive low Vt than other patients [41]. Two studies have evaluated the use of long-term mechanical ventilation in the community, documenting the resources used by this population of patients with primarily neuromuscular disease and a shift from home-based care to institutional care [45,46]. Considerable variability in the process of performing weaning parameters and in documentation of patient-ventilator system checks have been noted [47]. There is surprisingly little research documenting the penetration of non-invasive ventilation (NIV) into current practice. Doherty and Greenstone surveyed 268 hospitals in the United Kingdom and found considerable regional variation in the availability of NIV [48]. Barriers to implementation of NIV included lack of staff training, inconsistent funding to purchase equipment, and lack of training [48]. In a single site audit at a teaching hospital, Sinuff and colleagues found that NIV was used by physicians of different training levels in various settings within the hospital and found important areas for improving the quality of documentation, monitoring, and implementation of non-invasive ventilation [49].

Fig. 1. Comparison of FiO2 tidal volume, and PEEP, in large cohorts of mechanically ventilated patients. ARF=acute respiratory failure. COPD = chronic obsctructive pulmonary disease. Scandinavia, Australia, and International are from [44, 43, 41], respectively.

Respondents to a physician questionnaire indicated a broad range ofapproaches to weaning and tracheostomy with inter-country variability [41]. Although physicians' attitudes to various weaning regimens were assessed, there was no attempt to identify how many patients received a standardized approach to weaning readiness assessment. In a study of patients with traumatic brain injury, investigators found that guideline recommendations to avoid hyperventilation were frequently violated at community hospitals and during transport to a treatment center [50]. A survey of critical care physician members of the American Thoracic Society reported a wide range of Vt used to treat patients with ARDS [51]. Wong and colleagues surveyed Canadian intensivists about their attitudes toward using oxygen in patients in the ICU. Although the study found that all responding physicians believed that oxygen contributed to complications in the ICU, there was wide variabilityin the tradeoffs between inspired oxygen and hemoglobin saturation [26, 52]. Finally, survey data from 1994 on withdrawal ofmechanical ventilation showed significant variability in practice in withdrawing mechanical ventilation and, at least at the time of the survey, that 15% of respondents almost never withdrew mechanical ventilation when limiting life sustaining treatment in the ICU [53].

Two important Franco-Canadian studies based on a survey of ventilator circuit and secretion management practices have been performed. These showed considerable inter-country variability in physicians' stated practice regarding intubation route, ventilator circuit change frequency, humidification system, endotracheal suction system, subglottic secretion drainage, kinetic therapy beds, and body position [54, 55]. This study validated the finding that guidelines and consensus recommendations have little impact on practice even when practice is assessed by survey. Many centers reported practice that deviated from recommended evidence based standards. In a study that combined patient level data and survey data from physicians, Heyland et al. identified NIV, subglottic secretion drainage endotracheal tubes, kinetic bed therapy, small bowel feedings, and elevation of the head of the bed as effective preventive treatments for ventilator associated pneumonia (VAP) that were not being used in a set of Canadian ICUs [56].

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