Evolution of mechanical ventilation in response to clinical research.
BACKGROUND
Recent literature in mechanical ventilation includes strong evidence from randomized trials. Little information is available regarding the influence of these trials on usual clinical practice.


OBJECTIVE
To describe current mechanical ventilation practices and to assess the influence of interval randomized trials when compared with findings from a 1998 cohort.


METHODS
A prospective international observational cohort study, with a nested comparative study performed in 349 intensive care units in 23 countries. We enrolled 4,968 consecutive patients receiving mechanical ventilation over a 1-month period. We recorded demographics and daily data related to mechanical ventilation for the duration of ventilation. We systematically reviewed the literature and developed 11 practice-change hypotheses for the comparative cohort study before seeing these results. In assessing practice changes, we only compared data from the 107 intensive care units (1,675 patients) that also participated in the 1998 cohort (1,383 patients).


RESULTS
In 2004 compared with 1998, the use of noninvasive ventilation increased (11.1 vs. 4.4%, P < 0.001). Among patients with acute respiratory distress syndrome, tidal volumes decreased (7.4 vs. 9.1 ml/kg, P < 0.001) and positive end-expiratory pressure levels increased slightly (8.7 vs. 7.7 cm H(2)O, P = 0.02). More patients were successfully extubated after their first attempt of spontaneous breathing (77 vs. 62%, P < 0.001). Use of synchronized intermittent mandatory ventilation fell dramatically (1.6 vs. 11%, P < 0.001). Observations confirmed 10 of our 11 practice-change hypotheses.


CONCLUSIONS
The strong concordance of predicted and observed practice changes suggests that randomized trial results have advanced mechanical ventilation practices internationally.
Esteban
Andrés
A
Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo Km 12,500, 28905 Getafe, Madrid, Spain. aesteban@ucigetafe.com
Ferguson
Niall D
ND
Meade
Maureen O
MO
Frutos-Vivar
Fernando
F
Apezteguia
Carlos
C
Brochard
Laurent
L
Raymondos
Konstantinos
K
Nin
Nicolas
N
Hurtado
Javier
J
Tomicic
Vinko
V
González
Marco
M
Elizalde
José
J
Nightingale
Peter
P
Abroug
Fekri
F
Pelosi
Paolo
P
Arabi
Yaseen
Y
Moreno
Rui
R
Jibaja
Manuel
M
D'Empaire
Gabriel
G
Sandi
Fredi
F
Matamis
Dimitros
D
Montañez
Ana María
AM
Anzueto
Antonio
A
D035843:Biomedical Research; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D016032:Randomized Controlled Trials as Topic; D012121:Respiration, Artificial / Q000379:methods* / Q000639:trends; D012128:Respiratory Distress Syndrome / Q000401:mortality / Q000628:therapy*; D012196:Review Literature as Topic; D014600:Utilization Review; D015300:Ventilator Weaning