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In this issue of Respiratory Care, Moy et al1 discuss the results of a multi-center retrospective cohort study that included subjects who underwent air medical transport by a single air transport provider (130 bases). The objectives of the study were to characterize mechanical ventilation practices and to assess variables/barriers that contributed to subjects not receiving lung-protective tidal volumes (VT) (≤ 8 mL/kg predicted body weight [PBW]) per ARDS Network (ARDSNet) guidelines2 over a 5-year period. Of the 68,365 patients who met inclusion criteria, only 4,168 (6.1%) subjects could be included due to absence of documented height. Of these, 511 (12.2%) received VT greater than lung-protective guidelines, with 75% of these being female. This study showed that being female was an independent predictor for non–lung-protective ventilation.
Despite 2 decades of evidence that lung-protective ventilation provides a mortality benefit, adoption of the strategy has been slow although education and quality improvement initiatives have helped improve adherence.3-5 Maddry et al6 performed a retrospective review of 650 mechanically ventilated subjects requiring aeromedical transport by military critical-care air transport teams. The authors found that 62% of subjects’ ventilator settings were noncompliant for VT and ARDSNet table recommendations. Additionally, subjects whose ventilator settings that were compliant with ARDSNet guidelines were associated with decreased ventilator days, ICU days, and 30-d mortality.6 Barriers to adoption of lung-protective strategies included concern for patient discomfort, hypoxemia, acidosis, prolonging duration of mechanical ventilation, uncertainty of acute lung injury diagnosis, and unwillingness to relinquish control to a protocol.7,8 Contrary to the belief that patients without acute lung injury/ARDS diagnosis will not benefit from low VT strategies, several studies suggest that lung-protective ventilation in these patients is associated with better outcomes.9-12 Additionally, Mikkelsen …
Correspondence: Thomas C Blakeman MSc RRT, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267. E-mail: thomas.blakeman{at}uc.edu
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