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Evolution of Mechanical Ventilation in Response to Clinical Research

¹ CIBER Enfermedades Respiratorias, Hospital Universitario de Getafe, Madrid, Spain; ² Interdepartmental Division of Critical Care Medicine, and Division of Respirology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada; ³ Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada; ⁴ Hospital Profesor A. Posadas, El Palomar, Buenos Aires, Argentina; ⁵ AP-HP, Centre Hospitalier Albert-Chenvier–Henri Mondor, INSERM U 841, Université Paris 12, Paris, France; ⁶ Medizinische Hochschule, Hannover, Germany; ⁷ Hospital de Clínicas, Montevideo, Uruguay; ⁸ Clínica Alemana de Santiago, Santiago, Chile; ⁹ Clínica Medellín y Universidad Pontificia Bolivariana, Medellín, Colombia; ¹⁰ Hospital ABC, México DF, México; ¹¹ Wythenshawe Hospital, Manchester, United Kingdom; ¹² Fattouma Bourguiba Monastir, Tunisia; ¹³ Ospedale di Circolo, Universita' degli Studi dell'Insubria, Varese, Italy; ¹⁴ King Fahad National Guard Hospital, Riyadh, Saudi Arabia; ¹⁵ Hospital de Santo António dos Capuchos, Lisboa, Portugal; ¹⁶ Hospital Militar de Quito, Quito, Ecuador; ¹⁷ Hospital de Clínicas, Caracas, Venezuela; ¹⁸ Hospital Obrero Número 1, La Paz, Bolivia; ¹⁹ Papageorgiou General Hospital, Thessaloniki, Greece; ²⁰ Sociedad Peruana de Medicina Intensiva, Lima, Peru; and ²¹ South Texas Veterans Health Care System and University of Texas Health Science Center, San Antonio, Texas

Correspondence and requests for reprints should be addressed to Andrés Esteban, M.D., Ph.D., Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo Km 12,500, 28905 Getafe, Madrid, Spain. E-mail: aesteban{at}ucigetafe.com

Rationale: 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.

Objectives: 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).

Measurements and Main 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 H₂O, 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.

Key Words: mechanical ventilation • mortality • acute respiratory distress syndrome • noninvasive positive-pressure ventilation • weaning

AT A GLANCE COMMENTARY Scientific Knowledge on the Subject There is little information about the influence of clinical trials on clinical practice in the field of the mechanical ventilation. What This Study Adds to the Field The strong concordance of predicted and observed practice changes suggests that randomized trial results have advanced mechanical ventilation practices internationally.