Ventilator Settings in Community Hospitals: Are We Doing It Right?

Abstract

SESSION TITLE: Mechanical Ventilation & Respiratory Failure I SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM PURPOSE: The poor outcomes associated with high tidal volume ventilation (HTVV) including increased mortality, length of ICU and hospital stay, and reduced ventilator free days is well documented in the literature. We performed this study to find out the compliance with standard of care tidal volume (Vt) settings in our ICU and the difference in outcomes if they are not in the recommended range. METHODS: This retrospective chart review looked at the patterns of ordering ventilator settings for Vt in patients admitted to the medical ICU in a university affiliated community hospital between 2014 and 2015. Patients of age > 18 years intubated for a medical illness and on the ventilator for at least 24 hours were included in the study. Patients who had dismal prognosis such as a severe neurological insult or underlying neuromuscular disorders to begin with were excluded from the study. Two sets of Vt from the day of intubation and the day of extubation/ death/ tracheostomy were obtained. The whole cohort was divided into appropriate Vt (6-8 ml/kg ideal body weight (IBW)) and inappropriate Vt (>8 ml/kg IBW). APACHE-II scores for the patients were obtained to compare the severity of illnesses between the two groups of patients. The study outcomes were mortality, re-intubation within 48 hours of extubation, tracheostomy and number of ventilator days. Statistical analysis was performed with SAS 9.4 software. RESULTS: Out of 93 patients studied, only 52 (55.9%) were on appropriate Vt whereas 41 (44.1%) were not. In the overall population, median age was 64.5 years and 59.14% were women. Median weight, IBW and BMI were 76.1 kg, 58.25 kg and 27.47 kg/m2 respectively. Inappropriate Vt led to increased in-hospital mortality (14.63% vs 7.69%, p=0.28), increased re-intubation (2.44% vs 1.92%, p=0.86) and increased tracheostomy (12.2% vs 3.85%, p=0.12). The median number of ventilator days were the same for the two groups at 5 days (p=0.63). CONCLUSIONS: Although the results of our study were not statistically significant, there was a trend for worse outcomes in patients with inappropriate Vt. Although our study was underpowered due to the low sample size, the in-hospital mortality rate being twice as high in the inappropriate group reflects similar poor outcomes in other studies. CLINICAL IMPLICATIONS: As there is unequivocal evidence of the adverse outcomes related to HTVV, it is of paramount importance that the appropriateness of Vt be regularly checked based on IBW as opposed to actual body weight. It should not be left at inappropriately high levels with false assurances from improving blood gas results. DISCLOSURE: The following authors have nothing to disclose: Srijan Tandukar, Sonika Thukral, Arslan Talat, Tejbir Malhi, Samir Patel, Praful Tewari, Manuel Bautista No Product/Research Disclosure Information