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Low Tidal Volume Ventilation Is Poorly Implemented for Patients in North American and United Kingdom ICUs Using Electronic Health Records.

Accepted version
Peer-reviewed

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Authors

Samanta, Romit J 
Ercole, Ari 
Harris, Steven 
Summers, Charlotte 

Abstract

BACKGROUND: Low tidal volume ventilation (LTVV; < 8 mL/kg predicted body weight [PBW]) is a well-established standard of care associated with improved outcomes. This study used data collated in multicenter electronic health record ICU databases from the United Kingdom and the United States to analyze the use of LTVV in routine clinical practice. RESEARCH QUESTION: What factors are associated with adherence to LTVV in the United Kingdom and North America? STUDY DESIGN: This was a retrospective, multicenter study across the United Kingdom and United States of patients who were mechanically ventilated. METHODS: Factors associated with adherence to LTVV were assessed in all patients in both databases who were mechanically ventilated for > 48 h. We observed trends over time and investigated whether LTVV was associated with patient outcomes (30-day mortality and duration of ventilation) and identified strategies to improve adherence to LTVV. RESULTS: A total of 5,466 (Critical Care Health Informatics Collaborative [CCHIC]) and 7,384 electronic ICU collaborative research database [eICU-CRD] patients were ventilated for > 48 h and had data of suitable quality for analysis. The median tidal volume (VT) values were 7.48 mL/kg PBW (CCHIC) and 7.91 mL/kg PBW (eICU-CRD). The patients at highest risk of not receiving LTVV were shorter than 160 cm (CCHIC) and 165 cm (eICU-CRD). Those with BMI > 30 kg/m2 (CCHIC OR, 1.9 [95% CI, 1.7-2.13]; eICU-CRD OR, 1.61 [95% CI, 1.49-1.75]) and female patients (CCHIC OR, 2.39 [95% CI, 2.16-2.65]; eICU-CRD OR, 2.29 [95% CI, 2.26-2.31]) were at increased risk of having median VT > 8 mL/kg PBW. Patients with median VT < 8 mL/kg PBW had decreased 30-day mortality in the CCHIC database (CCHIC cause-specific hazard ratio, 0.86 [95% CI, 0.76-0.97]; eICU-CRD cause-specific hazard ratio, 0.9 [95% CI, 0.86-1.00]). There was a significant reduction in VT over time in the CCHIC database. INTERPRETATION: There has been limited implementation of LTVV in routine clinical practice in the United Kingdom and the United States. VT > 8 mL/kg PBW was associated with worse patient outcomes.

Description

Keywords

acute hypoxemic respiratory failure, electronic health records, low tidal volume ventilation, outcomes, Humans, Female, Tidal Volume, Respiration, Artificial, Retrospective Studies, Electronic Health Records, Intensive Care Units, North America

Journal Title

Chest

Conference Name

Journal ISSN

0012-3692
1931-3543

Volume Title

Publisher

Elsevier BV
Sponsorship
MRC (MR/P502091/1�)
Medical Research Council (MR/S035753/1)
Department of Health (via National Institute for Health Research (NIHR)) (NIHR133788)
MRC (via University of Glasgow) (304212)
National Institute for Health and Care Research (IS-BRC-1215-20014)
Medical Research Council (MR/P502091/1)