The impact of a quality improvement project based on the assessment of respiratory mechanics in patients with the acute respiratory distress syndrome
CCCF ePoster library. Chen L. Oct 26, 2015; 117321; P36
Dr. Lu Chen
Dr. Lu Chen
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Abstract
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P36


Topic: Quality Assurance/Quality Improvement Project


The impact of a quality improvement project based on the assessment of respiratory mechanics in patients with the acute respiratory distress syndrome



Lu Chen, G. Chen, O. Shklar, C. Martins, B. Devenyi, H. Mcphail, P. Lindsay, K. Shore, I. Soliman, M. Tuma, M. Kim, K. Porretta, P. Greco, H. Every

Keenan Research Centre and Li Ka Shing Institute, Department of Critical Care, St Michael’s Hospital, Interdepartmental Division of Critical Care Medicine, University of Toronto; Keenan Research Centre and Li Ka Shing Institute, Department of Critical Care, St Michael’s Hospital, Toronto, Canada | Dept. of Critical Care, Beijing Tiantan Hospital, Capital Medical University, Beijing, China | Department of Respiratory Therapy, St Michael’s Hospital, Toronto, Canada | Department of Respiratory Therapy, St Michael’s Hospital, Toronto, Canada | Department of Respiratory Therapy, St Michael’s Hospital, Toronto, Canada | Department of Respiratory Therapy, St Michael’s Hospital, Toronto, Canada | Department of Respiratory Therapy, St Michael’s Hospital, Toronto, Canada | Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada | Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada | Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada | Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada | Department of Respiratory Therapy, St Michael’s Hospital, Toronto, Canada | Department of Respiratory Therapy, St Michael’s Hospital, Toronto, Canada | Dep

Introduction:

The mortality of patients with Acute Respiratory Distress Syndrome (ARDS) remains undesirably high (35-40%) and possibly still related to complications of mechanical ventilation [1]. Patients with ARDS present various degrees of impairment in respiratory mechanics and different physiological responses to a given level of positive end-expiratory pressure (PEEP) and applying the same ventilator regimen to every patient sounds inadequate. Monitoring of lung and chest wall respiratory mechanics can allow an individualization of ventilator settings with the potential for a better adapted ventilatory strategy. However, neither the airway pressure (Paw) based respiratory mechanics nor the esophageal pressure (Pes) based lung and chest wall mechanics is systematically assessed in routine practice. We therefore proposed a quality improvement (QI) program based on a systematic assessment of respiratory mechanics and gas exchange. The collected data were also introduced into a registry.



Objectives:

The primary objective was to test whether a QI program for the systematic assessment of respiratory mechanics changed the clinical ventilatory management of patients with ARDS. The secondary objective was to assess whether these potential changes lead to improvement in physiological outcomes.



Methods:

Patients admitted to the two ICUs at St. Michael’s Hospital, and meeting the Berlin definition of ARDS[1], were eligible. Placement of an esophageal catheter was considered when PaO2/FiO2 ≤200. Systematic measurements were performed within 48 hours onset of ARDS by trained clinicians’ including assessing respiratory mechanics, lung and chest wall mechanics, oxygenation response to PEEP, and alveolar derecruitment using a simplified decremental PEEP maneuver[2]. Ventilator settings and physiological variables before and after the first measurements were then compared retrospectively.
The primary endpoint was the proportion of patients who had changes in ventilator settings according to the measurements. The secondary endpoints were the effects of these changes on oxygenation index (OI), which takes into account oxygenation and mean airway pressure, the estimated physiological dead space fraction[3], and the plateau and driving pressures [4].



Results:

61 ARDS patients (Men: 48, Age: 53±22 years, SOFA: 12±5) have been enrolled. The 30-day mortality was 38%. Pes was measured in 52 patients (85%) with an occlusion test ratio (∆Paw/∆Pes) at 0.94±0.16.
In 41 patients (67%), the ventilator settings were changed, often by limiting VT and PEEP (Table 1). The OI, plateau pressure, and driving pressure were significantly improved, whereas dead-space fraction and corrected expired volume per minute remained unchanged (Table 1).



Conclusion:

Systematic assessment of respiratory mechanics led to individual adaptations on ventilator settings, which improved the oxygenation index and reduced the risk of overdistension.



References:

[1] Ranieri VM, Rubenfeld GD, Thompson BT et al. Acute Respiratory Distress Syndrome The Berlin Definition. JAMA-J. Am. Med. Assoc. 2012; 307:2526-2533.

[2] Dellamonica J, Lerolle N, Sargentini C et al. PEEP-induced changes in lung volume in acute respiratory distress syndrome. Two methods to estimate alveolar recruitment. Intensive Care Med 2011; 37:1595-1604.

[3] Beitler JR, Thompson BT, Matthay MA et al. Estimating dead-space fraction for secondary analyses of acute respiratory distress syndrome clinical trials. Crit Care Med 2015; 43:1026-1035.

[4] Amato MB, Meade MO, Slutsky AS et al. Driving pressure and survival in the acute respiratory distress syndrome. The New England journal of medicine 2015; 372:747-755.
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