Respiratory Therapist-Driven Mechanical Ventilation Protocol Is Associated With Increased Lung Protective Ventilation

Abstract

Background: Mechanical ventilation is a common life-saving procedure but can lead to serious complications, including ARDS and oxygen toxicity. Nonadherence to lung-protective ventilation guidelines is common. We hypothesized that a respiratory therapist-driven mechanical ventilation bundle could increase adherence to lung-protective ventilation and decrease the incidence of pulmonary complications in the ICU.

Methods: A respiratory therapist-driven protocol was implemented on August 1, 2018, in all adult ICUs of a Midwestern academic tertiary center. The protocol targeted low tidal volume, adequate PEEP, limiting oxygen, adequate breathing frequency, and head of the bed elevation. Adherence to lung-protective guidelines and clinical outcomes were retrospectively observed in adult subjects admitted to the ICU and on ventilation for ≥ 24 h between January 2011 and December 2019.

Results: We included 666 subjects; 68.5% were in the pre-intervention group and 31.5% were in the post-intervention group. After adjusting for body mass index and intubation indication, a significant increase in overall adherence to lung-protective ventilation guidelines was observed in the post-intervention period (adjusted odds ratio 2.48, 95% CI 1.73-3.56). Fewer subjects were diagnosed with ARDS in the post-intervention group (adjusted odds ratio 0.22, 95% CI 0.08-0.65) than in the pre-intervention group. There was no difference in the incidence of ventilator-associated pneumonia, ventilator-free days, ICU mortality, or death within 1 month of ICU discharge.

Conclusions: A respiratory therapist-driven protocol increased adherence to lung-protective mechanical ventilation guidelines in the ICU and was associated with decreased ARDS incidence.

Keywords: ARDS; Mechanical ventilation; clinical protocol; critically ill; quality improvement; respiratory therapy.

Fig. 1.

ICU lung-protective ventilation protocol. BMI = body mass index.

Fig. 2.

Ventilator mode utilization and adherence within each ventilator mode category pre- and post-intervention. A: Shows mode choice pre-and post-intervention; B: displays the percentage of subjects with ventilator settings adherent to the lung protective ventilation protocol in the pre-and post-intervention period, stratified by ventilator mode category; C: unadjusted and adjusted odds ratios of protocol adherence overall and within each ventilator mode group post-intervention. *Adjusted for body mass index and indication for intubation. VC-CMV = volume control–continuous mandatory ventilation; VC-IMV = volume control–intermittent mandatory ventilation; PRVC-CMV = pressure-regulated volume control ventilation–continuous mandatory ventilation; PSV, pressure support ventilation; PC-CMV, pressure control–continuous mandatory ventilation; PC-IMV = pressure control–intermittent mandatory ventilation.

Fig. 3.

Adherence to the 5 components of lung-protective ventilation demonstrated as raw adherence pre-and post-intervention and odds of adherence. A: Shows the percentage of subjects receiving protocol-adherent ventilation that concerned the 5 components of lung protective ventilation: tidal volume, positive end-expiratory pressure, ${\text{F}}_{{\text{IO}}_{\text{2}}}$ , breathing frequency, and head of bed elevation in the post-intervention period; B: unadjusted and adjusted odds of adherence post-intervention to each of the 5 components of lung-protective ventilation. *Adjusted for body mass index and indication for intubation.

Fig. 4.

Unadjusted and adjusted odds ratios of selected clinical outcomes post-intervention. *Adjusted for body mass index and indication for intubation.