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Research ArticleOriginal Research

A Pragmatic Pilot Trial Comparing Patient Triggered Adaptive Pressure Control to Patient Triggered Volume Control Ventilation in Critically ill Adults

Kevin W. Gibbs, Jonathan L. Forbes, Kelsey Harrison, Jennifer T.W. Krall, Aubrae Isenhart, Stephanie P. Taylor, R. Shayn Martin, Nathaniel S. O’Connell, Rita N. Bakhru, Jessica A. Palakshappa and D. Clark Files
Respiratory Care March 2023, respcare.10803; DOI: https://doi.org/10.4187/respcare.10803
Kevin W. Gibbs
Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA.
Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA.
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  • For correspondence: [email protected]
Jonathan L. Forbes
Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA.
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Kelsey Harrison
Department of Respiratory Care, Atrium Health Wake Forest Baptist Medical Center, Medical Center Blvd, Winston-Salem, NC, 27157, USA.
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Jennifer T.W. Krall
Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA.
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Aubrae Isenhart
Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA.
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Stephanie P. Taylor
Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA.
Department of Internal Medicine, Wake Forest School of Medicine, 2001 Vail Avenue, Charlotte, NC 28207.
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R. Shayn Martin
Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA.
Department of Surgery, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA.
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Nathaniel S. O’Connell
Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA.
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Rita N. Bakhru
Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA.
Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA.
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Jessica A. Palakshappa
Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA.
Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA.
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D. Clark Files
Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA.
Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA.
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Abstract

Background: Patient triggered Adaptive Pressure Control (APC-CMV) has been widely adopted as an alternative ventilator mode to patient-triggered Volume control (VC-CMV). However, the comparative effectiveness of the two ventilator modes remain uncertain.

Research Question: We sought to explore clinical and implementation factors pertinent to a future definitive RCT assessing APC-CMV vs VC-CMV as an initial ventilator mode strategy. The research objectives in our pilot trial test clinician adherence and explore clinical outcomes.

Methods: In a single-center pragmatic sequential cluster crossover pilot trial, we enrolled all eligible adults admitted during a nine week period to the Medical Intensive Care Unit (ICU) with acute respiratory failure requiring mechanical ventilation. 2-week time epochs were assigned a priori in which subjects received either APC-CMV or VC-CMV The primary outcome of the trial was feasibility, defined as 80% of patients receiving the assigned mode within 1 hour of initiation of ICU ventilation. The secondary outcome was proportion of the first 24 hours on the assigned mode. Finally, we surveyed clinician stakeholders to understand potential facilitators and barriers to conducting a definitive randomized trial.

Results: We enrolled 137 subjects undergoing 152 discreet episodes of mechanical ventilation during time epochs assigned to APC-CMV (n=61) and VC-CMV (n=91). 131 episodes were included in the prespecified primary outcome. 126 (96%) received the assigned mode within the first hour of ICU admission (60 of 61 subjects assigned APC-CMV and 66 of 70 assigned VC-CMV). VC-CMV subjects spent a lower proportion of first 24 hours (84% [95% CI: 78%-89%]) on the assigned mode than APC-CMV recipients (95% [95% CI: 91%-100%]). Mixed-methods analyses identified pre-conceived perceptions of subject comfort by clinicians and need for real-time education to address this concern.

Conclusion: In this pilot pragmatic, sequential crossover trial, unit-wide allocation to a ventilator mode was feasible and acceptable to clinicians.

  • Mechanical ventilation
  • Critical Illness
  • Respiratory Failure
  • ICU
  • ARDS
  • Pragmatic trial

Footnotes

  • corresponding author: 2nd floor Watlington Hall. Section on Pulmonary, Critical Care, Allergy, and Immunology. Medical Center Blvd, Winston-Salem, NC, 27157, USA, kgibbs{at}wakehealth.edu
  • Received December 13, 2022.
  • Accepted March 14, 2023.
  • Copyright © 2023 by Daedalus Enterprises

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Respiratory Care: 68 (10)
Respiratory Care
Vol. 68, Issue 10
1 Oct 2023
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A Pragmatic Pilot Trial Comparing Patient Triggered Adaptive Pressure Control to Patient Triggered Volume Control Ventilation in Critically ill Adults
Kevin W. Gibbs, Jonathan L. Forbes, Kelsey Harrison, Jennifer T.W. Krall, Aubrae Isenhart, Stephanie P. Taylor, R. Shayn Martin, Nathaniel S. O’Connell, Rita N. Bakhru, Jessica A. Palakshappa, D. Clark Files
Respiratory Care Mar 2023, respcare.10803; DOI: 10.4187/respcare.10803

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A Pragmatic Pilot Trial Comparing Patient Triggered Adaptive Pressure Control to Patient Triggered Volume Control Ventilation in Critically ill Adults
Kevin W. Gibbs, Jonathan L. Forbes, Kelsey Harrison, Jennifer T.W. Krall, Aubrae Isenhart, Stephanie P. Taylor, R. Shayn Martin, Nathaniel S. O’Connell, Rita N. Bakhru, Jessica A. Palakshappa, D. Clark Files
Respiratory Care Mar 2023, respcare.10803; DOI: 10.4187/respcare.10803
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Keywords

  • mechanical ventilation
  • critical illness
  • respiratory failure
  • ICU
  • ARDS
  • pragmatic trial

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