Saturday February 4, 2006
Are we doctors most resistant to change?
This month's issue of Critical Care Medicine has published an article on physicians lack of embracing of low tidal volume despite clear and proven benefits from Arma trial of ARDSnet. Interestingly, this study (n=88 patients) was done at an ARDSnet participating university hospital. Patients who were ventilated with a tidal volume ≤7.5 mL/kg PBW 2 days after meeting criteria for ALI was only 39% and at day 7 only 56% of patients. During this study, physicians ordered the lung-protective ventilation protocol on only 16% of patients by day 2. In another earlier study to identify the barriers to the implementation of lung-protective ventilation - nursing and respiratory therapy staff at ten ARDSnet centers point finger to physicians' unwillingness to follow a ventilator protocol or recognize the patient as having ALI/ARDS.
Its almost 6 years since ARDSnet study was published and we are still having problem accepting the clear benefit ! Its time to read again famous JAMA article from 1999: " Why don't physicians follow clinical practice guidelines?.." and few major problems were deficits in physician knowledge, attitude difficulties, inertia of previous practice and behavioral issues !!!.
Note: Article from CCM-02'06 also tried to postulate various reasons of this lack of embracing of low tidal volume on available data, which can be found in full content of article and it includes possible fears of side effects from this approach or may be due to the anticipation of rapid recovery by patients with less severe disease.
References: Click to get article/abstract: (appears in popup window and second popup overwrites first popup)
1. Underuse of lung protective ventilation: Analysis of potential factors to explain physician behavior - Critical Care Medicine. 34(2):300-306, February 2006.
2. Prospective, Randomized, Multi-Center Trial of 12ml/kg Tidal Volume Positive Pressure Ventilation for Treatment of Acute Lung Injury and Acute Respiratory Distress Syndrome (ARMA) - ardsnet.org
3. Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome - NEJM May 2000, Volume 342:1301-1308
4. Rubenfeld G, Caldwell E, Hudson L: Publication of study results does not increase use of lung protective ventilation in patients with acute lung injury. Am J Respir Crit Care Med 2001; 163:A295
5. Why Don't Physicians Follow Clinical Practice Guidelines?: A Framework for Improvement - JAMA. 1999;282:1458-1465. - full article available with free registration