From ventilator-induced lung injury to physician-induced lung injury: why the reluctance to use small tidal volumes?

Abstract

know that medicine cannot always be a pro-vided by a protocol. Unlike drugs and medicaldevices, which cannot be sold unless their effective-ness has been documented, actual treatment in criticalcare medicine is often dictated by authority, personalexperience, and bias. To effectively practise moderncritical care medicine, clinicians must be knowledge-able of the complete spectrum of clinical disease andthe safety and efficacy of all treatments for any dis-ease. Training critical care physicians requires avoid-ing confusing opinions with evidence or personalignorance with scientific uncertainty (1). The betterwe understand the quality of the evidence we use tomake clinical decisions, the better we are able to judgewhether new scientific evidence should be incorpo-rated into our practice. But, how can we ensure thatthe current generation of physicians are trained tomake clinical decisions based on the judicious use ofthe current best evidence-based practice?Practising evidence-based medicine relies on mak-ing evidence from clinical research available to sup-port medical practice (2). In other words, critically illpatients should be treated by evidence-based clinicalpractice guidelines as standards of care. If medicine isnot based on scientific evidence, one must wonder onwhat it is based. The fact that we generally do a poorjob of translating research into practise is well docu-mented (3). There is the perception that the lack ofeducational initiatives at the departmental level inmany teaching hospitals around the world preventsus from implementing interventions that can improveclinically relevant outcomes. Instead, many of us stillpractise medicine based on our personal experiencesduring training and from treating patients over theyears (4). Although many randomized controlledtrials in critically ill patients have been conductedover the last 20years, some procedures that are welldocumented have still not become part of ‘standardpractice’ (5, 6). Physicians seem to be unwilling tochange their practice (7, 8). Insufficient evidence-based medical education, scientific ignorance, bias,and lack of financial incentives or lack of belief inthe research evidence are among some of the factorsthat may explain this attitude among critical carephysicians (2, 8). As a result, a gap remains betweenwhat the evidence recommends and what is practised.In this commentary, we discuss the evidence regard-ing the impact of mechanical ventilation on outcomein acute respiratory distress syndrome (ARDS) and itsimplementation or more precisely lack of implemen-tation.