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Potential reasons why physicians underuse lung-protective ventilation: a retrospective cohort study using physician
Mark E Mikkelsen1, Pali M Dedhiya, Ravi Kalhan
1Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA. mark.mikkelsen@uphs.upenn.edu
Respiratory Care
|March 28, 2008
Summary
Physicians often don't use lung-protective ventilation (LPV) for acute lung injury due to diagnostic uncertainty and protocol failures. Even when LPV is ordered, it may not be consistently used or implemented correctly.
Area of Science:
- Critical Care Medicine
- Respiratory Therapy
- Clinical Practice Guidelines
Background:
- Lung-protective ventilation (LPV) is underutilized in acute lung injury (ALI).
- Understanding physician-documented reasons for non-initiation or discontinuation of LPV is crucial.
Purpose of the Study:
- To identify physician-documented barriers to initiating and continuing LPV in ALI patients.
- To analyze discrepancies between LPV orders and actual use.
Main Methods:
- Retrospective cohort study at a university hospital (Sept 2000 - Nov 2002).
- LPV defined as tidal volume ≤ 7.5 mL/kg predicted body weight (PBW); sensitivity analysis used ≤ 6.0 mL/kg PBW.
- Physician documentation was reviewed to ascertain reasons for LPV non-use or discontinuation.
Main Results:
- LPV was used or intended in 56% of 75 ALI cases.
- In 33% of cases where LPV was intended, it was not used or only used transiently.
- Documented reasons for non-use included diagnostic uncertainty (n=14), relative contraindications (n=2), comfort care goals (n=1), and rapid hypoxemia resolution (n=4).
- Diagnostic uncertainty was common in transient LPV use (n=6).
Conclusions:
- LPV initiation and continuation are frequently hindered by diagnostic uncertainty in ALI.
- Concerns about metabolic acidosis and improved oxygenation can prevent LPV initiation.
- Protocol implementation failures contribute to inconsistent LPV use, even when intended.
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