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Paper text:
there is clear evidence for the use of a protective ventilation protocol in patients with acute respiratory distress syndrome ( ards ) .
the hallmark ards network ( ardsnet ) trial of 2000 showed a significant mortality benefit in patients ventilated with a protective ventilation strategy with low tidal volume ( vt ) of 6 ml / kg of ideal body weight ( ibw ) and plateau pressure of 30 cm h2o or below .
ventilator induced lung injury ( vili ) through large vts , volutrauma , high airway pressures , barotrauma , and sheer stress from repetitive opening and closing of alveoli , atelectotrauma , can cause lung damage in normal lungs .
protective ventilation strategies for patients with noninjured lungs remains controversial and large randomized studies are needed .
a number of studies have shown that protective ventilation is beneficial in patients at risk of developing ards .
for instance in patients who have undergone a primary physiological insult such as critically ill patients with sepsis , pneumonia , trauma or high risk surgical patients requiring intensive care unit ( icu ) care postoperatively . in these patients
, it is sensible to implement a protective ventilation strategy to minimize the risk of developing ards .
a multicenter randomized trial in 2013 showed improved clinical outcomes with fewer respiratory complications in patients ventilated with a lung - protective ventilation strategy undergoing major abdominal surgery . in an observational study gajic et al .
they concluded that high vts ( > 6 ml / kg ibw ) were associated with the development of acute lung injury ( ali ) . in another study by gajic et al .
, over 3000 icu patients without ards were mechanically ventilated for 48 h or more .
high vts were associated with ards with an odds ratio of 2.6 for a vt over 700 ml .
performed a randomized trial comparing traditional and protective vts in 152 critically ill - patients .
the trial was stopped early as more patients in the conventional group developed ali ( 13.5% vs. 2.6% p = 0.01 ) .
we recommend a protective ventilation strategy in critical care patients who require mechanical ventilation for over 48 h and have or are at risk for ards .
the aim of this audit was to assess compliance with a safe ventilation strategy for mechanically ventilated patients on icu with or at risk of ards .
the mechanical ventilation protocol set out by ards clinical network was used as the standard for both audits in the management of patients requiring mechanical ventilation .
these recommend a vt of 6 ml / kg of ibw and a plateau airway pressure of 30 cm h2o .
the aim of this audit was to assess compliance with a safe ventilation strategy for mechanically ventilated patients on icu with or at risk of ards .
the mechanical ventilation protocol set out by ards clinical network was used as the standard for both audits in the management of patients requiring mechanical ventilation .
these recommend a vt of 6 ml / kg of ibw and a plateau airway pressure of 30 cm h2o . the survey was carried out alongside the initial audit .
the aim of this audit was to assess compliance with a safe ventilation strategy for mechanically ventilated patients on icu with or at risk of ards .
the mechanical ventilation protocol set out by ards clinical network was used as the standard for both audits in the management of patients requiring mechanical ventilation .
these recommend a vt of 6 ml / kg of ibw and a plateau airway pressure of 30 cm h2o . the survey was carried out alongside the initial audit .
data were collected prospectively for both phases of the audit over an 8-week period , data collection were anonymous and only nonidentifiable information was used .
the initial audit was carried out from december 2010 to january 2011 , and the re - audit was carried out from january 2012 to february 2012 .
all critical care patients who were mechanically ventilated for over 48 h and who were at risk of developing ards were included in the audit .
risk factors for ards included : sepsis , trauma , high - risk surgery , pneumonia , aspiration , and blood transfusion .
exclusion criteria were : patients ventilated for < 48 h , patients ' breathing spontaneously and patients ' using noninvasive ventilation .
data collection for each patient included : admission diagnosis , age , sex , height , and ibw .
patients ' height was measured on admission and recorded on the icu chart ; this along with the patient 's sex , was used to calculate ibw [ table 1 ] . a reference sheet with
ibw calculated using this formula was available for a range of heights at each icu bed space .
ibw was then used to calculate a vt of 6 ml / kg as part of a protective ventilation strategy .
ibw calculated using a patient 's sex and height in the following formula ventilation parameters collected included mean daily vt , plateau airway pressure and the lowest partial pressure of arterial oxygen ( p)/fraction of inspired oxygen ( f ) ratio ( p / f ratio ) for each ventilated day recorded .
the p / f ratio is used as an indicator of disease severity in ards .
data were collected on a spreadsheet using microsoft excel for windows and analyzed using statistical package for the social sciences ( spss ) .
student 's t - test was used for continuous data and fischer 's exact test for categorical data . an anonymous survey in the form of a short questionnaire
was carried out prospectively over a 2-day period in january 2011 alongside the initial audit .
the questionnaire was distributed to a random sample of 30 nurses working at our critical care unit .
questions assessed their understanding regarding definitions of ards , and their knowledge of how to calculate ibw and the ideal vt for patients with or at risk of ards . following the initial audit , an education program targeted at junior doctors and icu nurses
education focused on the importance of using safe ventilation parameters in patients at risk of ards , how to calculate ibw and deliver vt 's of 6 ml / kg of ibw at the bedside .
these displayed recommended ventilation parameters including ibw for a range of heights and ideal vt 's for a range of ibw 's .
data were collected for a total of 141 ventilated days in the first audit and 125 ventilated days in the re - audit .
there were no differences between the two audit cohorts at baseline [ table 2 ] .
overall mean vt 's was 9.5 ml / kg of ibw in the initial audit compared to 6.6 ml / kg ibw ( p < 0.0001 ) following the implementation of the intervention [ figure 1 ] . no difference was seen in mean plateau airway pressures between the two phases of the audit ( 29.5 cm h2o vs. 30.2 cm h2o ) .
the lowest mean p / f ratio for the initial and re - audit were 131 and 173 mmhg , respectively ( p < 0.0002 ) [ table 2 ] .
outcome measures included 30 days mortality , which was the same in both cohorts , 5 ( 35.7% ) patients died in each cohort [ table 2 ] .
demographics and data between the two audit groups mean tidal volumes between the two audits .
the nursing survey was distributed to 30 nurses , of whom 24 ( 80% ) responded .
about 16 ( 67% ) of the nurses in the survey were a band five , 4 ( 17% ) were band six , and 3 ( 13% ) were a band seven .
20 ( 83% ) responders knew the meaning of ards , and 22 ( 92% ) used the hospitals ventilation protocol for patients with or at risk of ards .
the majority of nurses in the survey 16 ( 70% ) stated they were aware of how to calculate a safe vt for patients ' with ards .
10 ( 42% ) of the nurses surveyed knew the ideal vt for patients with ards .
this completed audit cycle demonstrated a significant improvement in clinical practice through the implementation of a simple education program aimed at junior doctors and nursing staff through increased awareness surrounding a protective ventilation strategy on icu .
the standards of this audit were to comply with a protective ventilation strategy for patients at risk of ards , in accordance with evidence based guidelines set out by ardsnet .
the initial and re - audit both met the standards for pressure limited ventilation as part of a protective ventilation strategy ; however , the initial audit failed to meet standards for a protective volume ventilation strategy .
patients were ventilated with large vt 's similar to conventional ventilation strategies of 10 ml / kg / ibw . following implementation of interventions , the re - audit demonstrated a significant improvement in compliance to this standard .
there is good evidence from both animal and human studies to suggest that a high vt strategy can cause volutrauma and is associated with a significant risk of vili .
lower vt of 6 ml / kg improves clinical outcome in patients with and at risk of ards .
this evidence is further enhanced by a randomized controlled trail by pinheiro de oliveira et al .
this suggests that high vt may induce lung injury in mechanically ventilated patients ' with normal lungs .
reasons for high vt include poor nurse education on how to implement a safe ventilation protocol in these patients as highlighted in the survey and a failure to recognize patients at risk of ards amongst intensive care staff .
many of the junior doctors were foundation level or medical core trainees with limited icu experience . the lowest
mean p / f ratio was significantly lower in the initial audit than the re - audit ; this may have contributed to higher observed vts in this group .
larger vt observed in patients with lower p / f ratios suggests that these patients may be particularly difficult to ventilate using a safe ventilation strategy .
the nursing survey identified an educational need amongst nursing staff regarding ards and appropriate ventilation strategies for these patients .
most responders claimed to use the ards ventilation protocol and were aware of how to calculate a safe vt for these patients .
the majority of responders did not know the ideal vt value of 6 ml / kg , without this knowledge , the ventilation protocol can not be implemented .
our survey found that most nurses had not undergone formal training on ards and its management , and when questioned , most felt they would benefit from further training .
there are many challenges to the effective implementation of a protective ventilation strategy on icu .
this audit demonstrated that simple interventions in combination with a targeted education program can improve compliance with a safe ventilation protocol .
these changes have improved our management of patients at risk of , and with established ards at the bedside .
we hope that a simple education program can be implemented across other icu 's to help optimize the management of patients with or at risk of ards . a mandatory half day training session on ards and lung - protective ventilation for critical care nursing staff and regular teaching on ards for junior doctors at the start of each rotation . more consultant led focus on safe ventilation strategy during ward rounds .
this should include a vt prescription box on the bedside chart of every patient , to be filled out on the daily consultant ward round .
ventilation strategy to be assessed as part of the protocol when setting up ventilation for a new icu admission , and to be recorded in the notes with a sticker . increased tolerance of permissive hypercapnia .
a mandatory half day training session on ards and lung - protective ventilation for critical care nursing staff and regular teaching on ards for junior doctors at the start of each rotation .
this should include a vt prescription box on the bedside chart of every patient , to be filled out on the daily consultant ward round .
ventilation strategy to be assessed as part of the protocol when setting up ventilation for a new icu admission , and to be recorded in the notes with a sticker . increased tolerance of permissive hypercapnia .
a mandatory half day training session on ards and lung - protective ventilation for critical care nursing staff and regular teaching on ards for junior doctors at the start of each rotation .
this should include a vt prescription box on the bedside chart of every patient , to be filled out on the daily consultant ward round .
ventilation strategy to be assessed as part of the protocol when setting up ventilation for a new icu admission , and to be recorded in the notes with a sticker . increased tolerance of permissive hypercapnia .
there is clear evidence for the use of a protective ventilation protocol in patients with acute respiratory distress syndrome ( ards ) . 
 there is evidence to suggest that protective ventilation is beneficial in patients at risk of ards . 
 a protective ventilation strategy was implemented on our intensive care unit in critical care patients who required mechanical ventilation for over 48 h , with and at risk for ards . 
 a complete audit cycle was performed over 13 months to assess compliance with a safe ventilation protocol in intensive care . 
 the ards network mechanical ventilation protocol was used as the standard for our protective ventilation strategy . 
 this recommends ventilation with a tidal volume ( vt ) of 6 ml / kg of ideal body weight ( ibw ) and plateau airway pressure of 30 cm h2o . the initial audit failed to meet this standard with vt 's of 9.5 ml / kg of ibw . 
 following the implementation of a ventilation strategy and an educational program , we demonstrate a significant improvement in practice with vt 's of 6.6 ml / kg of ibw in the re - audit . 
 this highlights the importance of simple interventions and continuous education in maintaining high standards of care .