A multi-faceted strategy to reduce ventilation-associated mortality in brain-injured patients. The BI-VILI project: a nationwide quality improvement project.
OBJECTIVE
We assessed outcomes in brain-injured patients after implementation of a multi-faceted approach to reduce respiratory complications in intensive care units.


METHODS
Prospective nationwide before-after trial. Consecutive adults with acute brain injury requiring mechanical ventilation for ≥24 h in 20 French intensive care units (ICUs) were included. The management of invasive ventilation in brain-injured patients admitted between 1 July 2013 and 31 October 2013 (4 months) was monitored and analysed. After the baseline period (1 November 2013-31 December 2013), ventilator settings and decision to extubate were selected as targets to hasten weaning from invasive ventilation. During the intervention period, low tidal volume (≤7 ml/kg), moderate positive end-expiratory pressure (PEEP, 6-8 cm H2O) and an early extubation protocol were recommended. The primary endpoint was the number of days free of invasive ventilation at day 90. Comparisons were performed between the two periods and between the compliant and non-compliant groups.


RESULTS
A total of 744 patients from 20 ICUs were included (391 pre-intervention; 353 intervention). No difference in the number of invasive ventilation-free days at day 90 was observed between the two periods [71 (0-80) vs. 67 (0-80) days; P = 0.746]. Compliance with the complete set of recommendations increased from 8 (2%) to 52 (15%) patients after the intervention (P < 0.001). At day 90, the number of invasive ventilation-free days was higher in the 60 (8%) patients whose care complied with recommendations than in the 684 (92%) patients whose care deviated from recommendations [77 (66-82) and 71 (0-80) days, respectively; P = 0.03]. The mortality rate was 10% in the compliant group and 26% in the non-compliant group (P = 0.023). Both multivariate analysis [hazard ratio (HR) 1.78, 95% confidence interval (95% CI) 1.41-2.26; P < 0.001] and propensity score-adjusted analysis (HR 2.25, 95% CI 1.56-3.26, P < 0.001) revealed that compliance was an independent factor associated with the reduction in the duration of mechanical ventilation.


CONCLUSIONS
Adherence to recommendations for low tidal volume, moderate PEEP and early extubation seemed to increase the number of ventilator-free days in brain-injured patients, but inconsistent adoption limited their impact. Trail registration number: NCT01885507.
Intensive Care Unit, Anesthesia and Critical Care Department, Hôtel Dieu-HME-University Hospital of Nantes , Centre Hospitalier Universitaire (CHU) de Nantes, Nantes, France. karim.asehnoune@chu-nantes.fr.|Service d'Anesthésie Réanimation, CHU de Nantes, 1 Place Alexis Ricordeau, 44093, Nantes Cedex 1, France. karim.asehnoune@chu-nantes.fr.
Karim
K
Asehnoune
Department of Anesthesiology and Critical Care Department, University Hospital of Toulouse, Toulouse, France.
Ségolène
S
Mrozek
Intensive Care Unit, Anesthesia and Critical Care Department, Gui Chauliac University Hospital of Montpellier, Montpellier, France.
Pierre François
PF
Perrigault
Intensive Care Unit, Anesthesia and Critical Care Department, Pontchaillou-University Hospital of Rennes, Rennes, France.
Philippe
P
Seguin
Neuro-Intensive Care Unit, Anesthesia and Critical Care Department, University Hospital of Poitiers, Poitiers, France.
Claire
C
Dahyot-Fizelier
Intensive Care Unit, Anesthesia and Critical Care Department, University Hospital of Angers, Angers, France.
Sigismond
S
Lasocki
Intensive Care Unit, Anesthesia and Critical Care Department, University Hospital of Tours, Tours, France.
Anne
A
Pujol
Intensive Care Unit, Anesthesia and Critical Care Department, University Hospital of Créteil-CHU Henri Mondor, Assistance publique-Hôpitaux de Paris (AP-HP), Créteil, France.
Mathieu
M
Martin
Department of Anesthesiology and Intensive Care, University Hospital of Clermont Ferrand, Clermont Ferrand, France.
Russel
R
Chabanne
Department of Anesthesiology and Intensive Care, University Hospital of Nimes, Nimes, France.
Laurent
L
Muller
Department of Anesthesiology and Intensive Care, University Hospital of Caen, Caen, France.
Jean Luc
JL
Hanouz
Department of Anesthesiology and Intensive Care, University Hospital of Marseille, Marseille, France.
Emmanuelle
E
Hammad
Intensive Care Unit, Anesthesia and Critical Care Department, Laennec-University Hospital of Nantes, Nantes, France.
Bertrand
B
Rozec
Surgical Intensive Care Unit, Anesthesia and Critical Care Department, University Hospital of Poitiers, Poitiers, France.
Thomas
T
Kerforne
Intensive Care Unit , Pasteur 2-University Hospital of Nice, Nice, France.
Carole
C
Ichai
Intensive Care Unit, Anesthesia and Critical Care Department, Hôtel Dieu-HME-University Hospital of Nantes , Centre Hospitalier Universitaire (CHU) de Nantes, Nantes, France.
Raphael
R
Cinotti
Department of Anesthesiology and Critical Care Department, University Hospital of Toulouse, Toulouse, France.
Thomas
T
Geeraerts
Intensive Care Unit, Anesthesia and Critical Care Department, University Hospital of Tours, Tours, France.
Djillali
D
Elaroussi
Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino-IST National Cancer Research Institute, University of Genoa, Genoa, Italy.
Paolo
P
Pelosi
Intensive Care Unit, Anesthesia and Critical Care Department, Saint Eloi University Hospital of Montpellier, Montpellier, France.
Samir
S
Jaber
Plateforme de Biométrie, Département Promotion de la Recherche Clinique, University Hospital of Nantes, Nantes, France.
Marie
M
Dalichampt
EA 4275, MethodS for Patients-centered Outcomes and HEalth REsearch (SPHERE), UFR des Sciences Pharmaceutiques, Nantes University, Nantes, France.
Fanny
F
Feuillet
Plateforme de Biométrie, Département Promotion de la Recherche Clinique, University Hospital of Nantes, Nantes, France.|EA 4275, MethodS for Patients-centered Outcomes and HEalth REsearch (SPHERE), UFR des Sciences Pharmaceutiques, Nantes University, Nantes, France.
Véronique
V
Sebille
Intensive Care Unit, Anesthesia and Critical Care Department, Hôtel Dieu-HME-University Hospital of Nantes , Centre Hospitalier Universitaire (CHU) de Nantes, Nantes, France.
Antoine
A
Roquilly
D000328:Adult; D000368:Aged; D060666:Airway Extubation / Q000009:adverse effects / Q000401:mortality; D001930:Brain Injuries / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D065187:Controlled Before-After Studies; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D065228:Non-Randomized Controlled Trials as Topic; D011175:Positive-Pressure Respiration / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D011446:Prospective Studies; D058996:Quality Improvement; D018709:Statistics, Nonparametric; D013990:Tidal Volume; D014057:Tomography, X-Ray Computed; D015300:Ventilator Weaning / Q000379:methods*; D055397:Ventilator-Induced Lung Injury / Q000401:mortality / Q000517:prevention & control*
Airway extubation; Brain injuries; PEEP; Tidal volume; Ventilator weaning