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OBJECTIVE:: No studies have explored the barriers to implementing lung-protective ventilation in patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Our objective was to identify barriers to using lung-protective ventilation in patients with ALI/ARDS. DESIGN:: Survey with content analysis of open-ended responses. SETTING:: Medical center. PARTICIPANTS:: Experienced intensive care unit nurses and respiratory therapists network identified through purposive sampling at hospitals from the ARDS Network, a National Institutes of Health-sponsored research consortium. INTERVENTIONS:: Survey. RESULTS:: Fifty-five surveys representing all ten ARDS Network sites were received. Twenty-seven (49%) of the respondents were intensive care unit nurses, 24 (44%) were respiratory therapists, and four did not indicate their profession. Clinicians had used lung-protective ventilation in a median of 20 (interquartile range, 10'''50) patients with ALI/ARDS. Respondents identified physician willingness to relinquish control of ventilator, physician recognition of ALI/ARDS, and physician perceptions of patient contraindications to low tidal volumes as important barriers to initiating lung-protective ventilation. Important barriers to continuing patients on lung-protective ventilation were concerns over patient discomfort and tachypnea and concerns over hypercapnia, acidosis, and hypoxemia. Techniques for overcoming barriers were identified including specific ventilator setup recommendations, clinician education, and tools to assess patient discomfort. CONCLUSIONS:: Experienced bedside clinicians perceive important barriers to implementing lung-protective ventilation. Successful strategies to increase use of lung-protective ventilation should target these barriers. [ABSTRACT FROM AUTHOR]

OBJECTIVESTo review the challenges of providing mechanical ventilatory support for respiratory failure while avoiding ventilator-associated lung injury in patients with acute lung injury. To review the results of several randomized clinical trials of lung-protective ventilation strategies using conventional mechanical ventilators.DATA SOURCESPublished reports of clinical trials comparing clinical outcomes of patients with acute lung injury, randomized to mechanical ventilation with either a lung-protective or a control, conventional, standard, or traditional approach.DATA EXTRACTION AND SYNTHESISLung-protective mechanical ventilation strategies are designed to prevent injury from overdistention by using lower tidal volumes and lower inspiratory pressures (volume- and pressure-limited ventilation) or injury from ventilation with atelectasis and alveolar flooding at end-expiration (open-lung ventilation). In one trial, clinical outcomes were better in the study group that received combined volume- and pressure-limited and open-lung strategies compared with the study group that received a conventional approach. Of four trials focusing on volume- and pressure-limited ventilation alone, three did not demonstrate improvements in clinical outcomes, whereas one demonstrated a substantial reduction in mortality and an increase in ventilator-free days. The different results in these four trials may be attributable to differences in tidal volumes between the study groups, chance variation, or differences in the management of respiratory acidosis.CONCLUSIONSEvidence supports the use of a volume- and pressure-limited approach to mechanical ventilation in patients with acute lung injury. It is not yet clear whether the open-lung approach will further reduce mortality in patients receiving volume- and pressure-limited ventilation support. [ABSTRACT FROM AUTHOR]

OBJECTIVETo review the epidemiology of acute lung injury (ALI) with particular emphasis on its effect on public health.DATA SOURCESPublished studies on the definitions, incidence, and outcomes of ALI.DATA SUMMARYALI is a syndrome of acute hypoxemic respiratory failure that is not primarily cardiac in origin. The diagnostic criteria for the syndrome have not been well studied for their reliability or validity. The lack of a gold standard for the diagnosis of ALI is a challenge to clinical investigation. Recent data on the incidence of ALI (20-50 cases/105 person-years) indicate that it is more common than previous estimates for the incidence of acute respiratory distress syndrome (3-8 cases/105 person-years). There is conflicting evidence as to whether the mortality rate in the broader patient population with ALI is different from the mortality rate in acute respiratory distress syndrome. Mortality attributable to and associated with ALI in the United States is comparable to HIV infection, breast cancer, and asthma. Morbidity from impaired cognitive function, functional status, and psychiatric complications has been reported in survivors of ALI.CONCLUSIONSRecent studies of the epidemiology of ALI have reported higher incidence rates for this syndrome than previously described. The mortality and morbidity rates associated with ALI are considerable, with significant impact on public health. [ABSTRACT FROM AUTHOR]