A critical care clinician survey comparing attitudes and perceived barriers to low tidal volume ventilation with actual practice

Rationale: Low-VT ventilation lowers mortality in patients with acute respiratory distress syndrome (ARDS) but is underused. Little is known about clinician attitudes toward and perceived barriers to low-VT ventilation use and their association with actual low-VT ventilation use. Objectives: The objectives of this study were to assess clinicians' attitudes toward and perceived barriers to low-VT ventilation (VT ,6.5 ml/kg predicted body weight) in patients with ARDS, to identify differences in attitudes and perceived barriers among clinician types, and to compare attitudes toward and perceived barriers to actual low- VT ventilation use in patients with ARDS. Methods: We conducted a survey of critical care physicians, nurses, and respiratory therapists at four non-ARDS Network hospitals in the Chicago region. We compared survey responses with performance in a cohort of 362 patients with ARDS. Results: Survey responses included clinician attitudes toward and perceived barriers to low-VT ventilation use. We also measured low-VT ventilation initiation by these clinicians in 347 patients with ARDS initiated after ARDS onset as well as correlation with clinician attitudes and perceived barriers. Of 674 clinicians surveyed, 467 (69.3%) responded. Clinicians had positive attitudes toward and perceived few process barriers toARDS diagnosis or initiation of low-VT ventilation. Physicians had more positive attitudes and perceived fewer barriers than nurses or respiratory therapists. However, use of low-VT ventilation by all three clinician groups was low. For example, whereas physicians believed that 92.5% of their patients with ARDS warranted treatmentwith low-VT ventilation, they initiated low-VT ventilationfor a median (interquartile range) of 7.4% (0 to 14.3%) of their eligible patients with ARDS. Clinician attitudes and perceived barriers were not correlated with low-VT ventilation initiation. Conclusions: Clinicians had positive attitudes toward low-VT ventilation and perceived few barriers to using it, but attitudes and perceived process barriers were not correlated with actual low-VT ventilation use, which was low. Implementation strategies should be focused on examining other issues, such as ARDS recognition and process solutions, to improve low-VT ventilation use.