Using a clinical decision support system to reduce excess driving pressure: the ALARM trial

Area of Science:

• Critical Care Medicine
• Pulmonary Medicine
• Health Informatics

Background:

• Patients requiring mechanical ventilation are at risk for acute respiratory distress syndrome (ARDS).
• Lung-protective ventilation strategies, such as low driving pressure, are known to improve outcomes but are underutilized in clinical practice.
• Clinical decision support (CDS) systems and nudge interventions can potentially improve adherence to ventilation guidelines.

Purpose of the Study:

• To evaluate the effectiveness of a combined CDS and nudge intervention in reducing excess driving pressure in patients at risk for ARDS.
• To assess the impact of this intervention on mechanical power, ventilator-free days, ARDS progression, and mortality.

Main Methods:

• A prospective cohort trial was conducted in an intensive care unit (ICU) involving patients at risk of ARDS.
• Patients were assigned to a control group or an intervention group receiving a CDS alert for high driving pressure and performance feedback (nudge).
• The primary outcome was the reduction in excess driving pressure.

Main Results:

• The intervention group showed a significant reduction in excess driving pressure in augmented ventilation modes (p=0.012) but not in controlled modes (p=0.53).
• No significant differences were observed between groups in mechanical power, ventilator-free days, or ARDS progression.
• The intervention group had a higher 28-day mortality, despite low overall mean driving pressure.

Conclusions:

• A combined CDS and nudge intervention effectively reduced excess driving pressure in augmented ventilation for ARDS patients.
• This intervention did not lead to improvements in other key clinical outcomes and was associated with increased mortality.
• Further research is needed to optimize interventions for lung-protective ventilation and patient outcomes.