title: Refractory Hypoxemia and Use of Rescue Strategies. A U.S. National Survey of Adult Intensivists.
abstract: The management of severe and refractory hypoxemia in critically ill adult patients is practice based. Variability across individual practitioners and institutions is not well documented.
  
  
  
  To conduct a nationwide survey of critical care physicians in the United States regarding accepted definitions and management strategies for severe and refractory hypoxemia.
  
  
  
  A web-based survey was distributed to a stratified random sample of adult intensivists listed in the American Medical Association Physician Masterfile. The survey was generated by using a mixed-methods approach.
  
  
  
  In the survey, 4,865 e-mails were sent and 791 (16.3%) were opened. Among those who opened the e-mail message, 50% (n = 396) responded, representing 8.1% of total surveys sent. Seventy-two percent stated that their institutions lacked a protocol for identification and management of severe or refractory hypoxemia in the setting of acute respiratory failure. While the majority of respondents used low-Vt ventilation (81%), high positive end-expiratory pressure (86%), recruitment maneuvers (89%), and either bolus or infusion neuromuscular blockade (94%), there was marked variability in the use of specific rescue strategies as tier 1 or 2 interventions: prone position (27.8% vs. 47.8%, respectively), extracorporeal membrane oxygenation (2.3% vs. 51.2%, respectively), airway pressure release ventilation (49% vs. 34.5%, respectively), inhaled vasodilators (30.1% vs. 40%, respectively), and high-frequency oscillatory ventilation (7.8% vs. 40%, respectively). The variability was partly explained by providers' expertise with particular rescue strategies (77.7%), advance directives (70.1%), the training of allied health staff (62.3%), and institutional availability (53.8%).
  
  
  
  U.S. adult critical care physicians predominantly employ lung-protective ventilation for severe hypoxemia. A wide variation in other rescue strategies is noted, which is partly explained by user expertise and availability. Less than 30% institutions have formal protocols for management of refractory hypoxemia.
authors.affiliation: 1 METRIC (Multidisciplinary Epidemiology and Translational Research in Intensive Care), Mayo Clinic.|2 Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine; and.
authors.forename: Rabe E
authors.initials: RE
authors.lastname: Alhurani
authors.affiliation: 1 METRIC (Multidisciplinary Epidemiology and Translational Research in Intensive Care), Mayo Clinic.|2 Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine; and.
authors.forename: Richard A
authors.initials: RA
authors.lastname: Oeckler
authors.affiliation: 1 METRIC (Multidisciplinary Epidemiology and Translational Research in Intensive Care), Mayo Clinic.|3 Department of Transplantation, Division of Transplant Medicine, Mayo Clinic, Jacksonville, Florida; and.
authors.forename: Pablo Moreno
authors.initials: PM
authors.lastname: Franco
authors.affiliation: 4 Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota.
authors.forename: Sarah M
authors.initials: SM
authors.lastname: Jenkins
authors.affiliation: 1 METRIC (Multidisciplinary Epidemiology and Translational Research in Intensive Care), Mayo Clinic.|2 Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine; and.
authors.forename: Ognjen
authors.initials: O
authors.lastname: Gajic
authors.affiliation: 1 METRIC (Multidisciplinary Epidemiology and Translational Research in Intensive Care), Mayo Clinic.|5 Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, The Ohio State University Medical Center, Columbus, Ohio.
authors.forename: Sonal R
authors.initials: SR
authors.lastname: Pannu
mesh_terms: D000328:Adult; D000488:Allied Health Personnel / Q000193:education; D001993:Bronchodilator Agents / Q000008:administration & dosage; D003422:Critical Care / Q000379:methods*; D019468:Disease Management; D015199:Extracorporeal Membrane Oxygenation / Q000706:statistics & numerical data; D006612:High-Frequency Ventilation / Q000706:statistics & numerical data; D006801:Humans; D000860:Hypoxia / Q000628:therapy*; D011175:Positive-Pressure Respiration / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic; D012128:Respiratory Distress Syndrome / Q000150:complications; D011795:Surveys and Questionnaires; D014481:United States
chemical_list: D001993:Bronchodilator Agents
keywords: electronic survey; national survey; refractory hypoxemia; severe hypoxemia