Published ahead of print on October 25, 2007, doi:10.1164/rccm.200706-893OC
Am. J. Respir. Crit. Care Med., Volume 177, Number 2, January 2008, 170-177
A more recent version of this article appeared on January 15, 2008
Submitted on June 20, 2007
Accepted on October 25, 2007
Evolution of Mechanical Ventilation in Response to Clinical Research
Andres Esteban1*, Niall D Ferguson2, Maureen O Meade3, Fernando Frutos-Vivar1, Carlos Apezteguia4, Laurent Brochard5, Konstantinos Raymondos6, Nicolas Nin1, Javier Hurtado7, Vinko Tomicic8, Marco Gonzalez9, Jose Elizalde10, Peter Nightingale11, Fekri Abroug12, Paolo Pelosi13, Yaseen Arabi14, Rui Moreno15, Manuel Jibaja16, Gabriel D'Empaire17, and Fredi Sandi18
1 CIBER Enfermedades respiratorias, Hospital Universitario de Getafe, Madrid, Spain,
2 Interdepartmental Division of Critical Care Medicine, and Department of Medicine, Division of Respirology, University Health Network, University of Toronto, Toronto, Ontario, Canada,
3 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada,
4 Hospital Profesor A.Posadas, Buenos Aires, Argentina,
5 AP-HP, Centre hospitalier Albert-Chenvier-Henri Modor, Paris, France,
6 Medizinische Hochschule, Hannover, Germany,
7 Hospital de Clinicas, Montevideo, Uruguay,
8 Clinica Alemana, Santiago, Chile,
9 Clinica Medellin y Universidad Pontificia Bolivariana, Medellin, Colombia,
10 Hospital ABC, Mexico DF, Mexico,
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 Antonio dos Capuchos, Lisboa, Portugal,
16 Hospital Militar, Quito, Ecuador,
17 Hospital de Clinicas, Caracas, Venezuela,
18 Hospital Obrero Numero 1, La Paz, Bolivia
* To whom correspondence should be addressed. 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.
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: Prospective international observational cohort study, with a nested comparative study carried out in 349 intensive care units in 23 countries. We enrolled 4968 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 (1675 patients) that also participated in the 1998 cohort (1383 patients).
Measurements and main results: In 2004 compared with 1998, the use of non-invasive ventilation increased (11.1 versus 4.4%; p<0.001). Among patients with acute respiratory distress syndrome tidal volumes decreased (7.4 versus 9.1 ml/kg; p<0.001) and positive end-expiratory pressure levels increased slightly (8.7 versus 7.7 cm of water; p=0.02). More patients were successfully extubated after their first attempt of spontaneous breathing (77 versus 62%; p<0.001). Use of synchronized intermittent mandatory ventilation fell dramatically (1.6 versus 11%; p<0.001). Observed practice confirmed 10 of our 11 practice-change hypotheses.
Conclusion: The strong concordance of predicted and observed practice changes suggests that randomized trials results have advanced mechanical ventilation practices internationally.
Key words: Mechanical ventilation, mortality, acute respiratory distress syndrome, non-invasive positive pressure ventilation, weaning
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