title: Adjuvants to Mechanical Ventilation for Acute Respiratory Failure. Adoption, De-adoption, and Factors Associated with Selection.
abstract: BACKGROUND
  Adoption and de-adoption of adjuvant strategies to mechanical ventilation for acute respiratory failure (ARF), and factors associated with their selection, have not been extensively evaluated.
  
  
  OBJECTIVE
  To evaluate change in use of adjuvants to mechanical ventilation for ARF (2008-2013), the impact of landmark publications on adoption and de-adoption, and factors associated with use.
  
  
  METHODS
  Changes in use of four adjuvants for ARF from 2008 to 2013, the impact of landmark publications on use, and factors associated with use were evaluated with the Premier Database. Extracorporeal membrane oxygenation (ECMO), inhaled nitric oxide, inhaled epoprostenol, and continuous neuromuscular blockading agents (cNMBAs) in adult mechanically ventilated patients were identified on the basis of International Classification of Diseases, Ninth Revision, Clinical Modification codes and billing data.
  
  
  RESULTS
  Among 514,913 patients with ARF, 11,567 (2.3%) were treated with at least one adjuvant. cNMBAs were the most frequently used adjuvants (n = 10,073, 2.1% in capable hospitals), followed by inhaled pulmonary vasodilators (n = 1,878, 1.0% in capable hospitals; 58% nitric oxide), and ECMO (n = 195, 0.2% in capable hospitals). There was an increase in ECMO and inhaled epoprostenol over time but no change in nitric oxide or cNMBAs. Segmented regression analysis was used to evaluate whether clinical practice was in accordance with emerging evidence from landmark studies. Using the relevant landmark publication dates, these analyses did not reveal any change in use over time after publication with the exception of inhaled epoprostenol-for which rates of growth decreased over time, possibly in response to the evidence. There was a significant amount of variability in patient and hospital factors associated with use with between adjuvants.
  
  
  CONCLUSIONS
  Between 2008 and 2013, there was an increase in use of ECMO and inhaled epoprostenol, and no change in use of inhaled nitric oxide or continuous intravenous infusion of a neuromuscular blocking agent. There was considerable variability in patient and hospital factors associated with use across different adjuvants.
authors.affiliation: 1 Interdepartmental Division of Critical Care, Mount Sinai Hospital, University Health Network, and University of Toronto, Toronto, Ontario, Canada.
authors.forename: Laveena
authors.initials: L
authors.lastname: Munshi
authors.affiliation: 2 Division of Critical Care, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York.
authors.forename: Hayley B
authors.initials: HB
authors.lastname: Gershengorn
authors.affiliation: 1 Interdepartmental Division of Critical Care, Mount Sinai Hospital, University Health Network, and University of Toronto, Toronto, Ontario, Canada.
authors.forename: Eddy
authors.initials: E
authors.lastname: Fan
authors.affiliation: 3 Interdepartmental Division of Critical Care, Sunnybrook Health Sciences Center, and University of Toronto, Toronto, Ontario, Canada; and.
authors.forename: Hannah
authors.initials: H
authors.lastname: Wunsch
authors.affiliation: 1 Interdepartmental Division of Critical Care, Mount Sinai Hospital, University Health Network, and University of Toronto, Toronto, Ontario, Canada.
authors.forename: Niall D
authors.initials: ND
authors.lastname: Ferguson
authors.affiliation: 4 Clinical Epidemiology and Health Care Research Program, Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada.
authors.forename: Therese A
authors.initials: TA
authors.lastname: Stukel
authors.affiliation: 3 Interdepartmental Division of Critical Care, Sunnybrook Health Sciences Center, and University of Toronto, Toronto, Ontario, Canada; and.
authors.forename: Gordon D
authors.initials: GD
authors.lastname: Rubenfeld
mesh_terms: D000208:Acute Disease; D000280:Administration, Inhalation; D000368:Aged; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D001993:Bronchodilator Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D011464:Epoprostenol / Q000627:therapeutic use*; D015199:Extracorporeal Membrane Oxygenation / Q000379:methods* / Q000639:trends; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019148:Neuromuscular Blockade / Q000379:methods* / Q000639:trends; D009569:Nitric Oxide / Q000627:therapeutic use*; D012121:Respiration, Artificial / Q000379:methods* / Q000639:trends; D012128:Respiratory Distress Syndrome / Q000628:therapy*; D012131:Respiratory Insufficiency / Q000628:therapy*; D012189:Retrospective Studies
chemical_list: D000959:Antihypertensive Agents; D001993:Bronchodilator Agents; D009569:Nitric Oxide; D011464:Epoprostenol
keywords: acute respiratory distress syndrome; epoprostenol; extracorporeal membrane oxygenation; neuromuscular blockade; nitric oxide