Ventilation of patients with acute lung injury and acute respiratory distress syndrome: has new evidence changed clinical practice?
OBJECTIVE
A recent randomized trial of mechanical ventilation in acute lung injury (ALI)/adult respiratory distress syndrome (ARDS) demonstrated a 22% relative reduction in mortality rate using 6 mL/kg predicted body weight tidal volume vs. 12 mL/kg predicted body weight tidal volume. We determined whether publication of these findings changed clinical practice.


METHODS
Retrospective cohort, 12 months before (Pre) and 12 months after publication (Post) of a randomized trial supporting the use of a 6 mL/kg predicted body weight tidal volume strategy.


METHODS
Three tertiary care hospitals in northern New England.


METHODS
From a sample of 943 patients receiving prolonged mechanical ventilation between 1998 and 1999 (Pre) and between 2000 and 2001 (Post), 300 patients meeting the American-European Consensus Conference definition of ALI or ARDS were selected for analysis.


METHODS
The tidal volume, tidal volume/kg predicted body weight, and proportion receiving tidal volume/kg > or =6 mL/kg and < or =12 mL/kg predicted body weight were recorded at noon the first day after the diagnosis of ALI or ARDS was established.


RESULTS
Pre and Post mean tidal volume (+/- sd) size and tidal volume size/kg predicted body weight were 759 +/- 158 mL (median 750 mL) vs. 639 +/- 138 mL (median 600 mL, p <.001) and 12.3 +/- 2.7 mL/kg (median 11.7 mL/kg) vs. 10.6 +/- 2.4 mL/kg (median 10.7 mL/kg, p <.001) respectively. Pre and Post plateau pressures and peak airway pressures were similar.


CONCLUSIONS
Publication of a trial demonstrating large mortality reductions using small tidal volume was associated with significant reductions in tidal volume delivered to patients with ALI/ARDS. However, wide variation in practice persists, and the proportion of patients receiving tidal volumes within recommended limits (< or =8 mL/kg) remains modest.
Young
Michael P
MP
Division of Pulmonary and Critical Care, University of Vermont College of Medicine and Fletcher Allen Health Care, Burlington, VT, USA.
Manning
Harold L
HL
Wilson
Diana L
DL
Mette
Stephen A
SA
Riker
Richard R
RR
Leiter
J C
JC
Liu
Stephen K
SK
Bates
Jason T
JT
Parsons
Polly E
PE
D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012121:Respiration, Artificial; D012128:Respiratory Distress Syndrome / Q000503:physiopathology* / Q000628:therapy; D012189:Retrospective Studies; D013990:Tidal Volume