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Intensive Care Medicine

, Volume 43, Issue 7, pp 957–970 | Cite as

A multi-faceted strategy to reduce ventilation-associated mortality in brain-injured patients. The BI-VILI project: a nationwide quality improvement project

  • Karim AsehnouneEmail author
  • Ségolène Mrozek
  • Pierre François Perrigault
  • Philippe Seguin
  • Claire Dahyot-Fizelier
  • Sigismond Lasocki
  • Anne Pujol
  • Mathieu Martin
  • Russel Chabanne
  • Laurent Muller
  • Jean Luc Hanouz
  • Emmanuelle Hammad
  • Bertrand Rozec
  • Thomas Kerforne
  • Carole Ichai
  • Raphael Cinotti
  • Thomas Geeraerts
  • Djillali Elaroussi
  • Paolo Pelosi
  • Samir Jaber
  • Marie Dalichampt
  • Fanny Feuillet
  • Véronique Sebille
  • Antoine Roquilly
  • The BI-VILI study group
Seven-Day Profile Publication

Abstract

Purpose

We assessed outcomes in brain-injured patients after implementation of a multi-faceted approach to reduce respiratory complications in intensive care units.

Methods

Prospective nationwide before–after trial. Consecutive adults with acute brain injury requiring mechanical ventilation for ≥24 h in 20 French intensive care units (ICUs) were included. The management of invasive ventilation in brain-injured patients admitted between 1 July 2013 and 31 October 2013 (4 months) was monitored and analysed. After the baseline period (1 November 2013–31 December 2013), ventilator settings and decision to extubate were selected as targets to hasten weaning from invasive ventilation. During the intervention period, low tidal volume (≤7 ml/kg), moderate positive end-expiratory pressure (PEEP, 6–8 cm H2O) and an early extubation protocol were recommended. The primary endpoint was the number of days free of invasive ventilation at day 90. Comparisons were performed between the two periods and between the compliant and non-compliant groups.

Results

A total of 744 patients from 20 ICUs were included (391 pre-intervention; 353 intervention). No difference in the number of invasive ventilation-free days at day 90 was observed between the two periods [71 (0–80) vs. 67 (0–80) days; P = 0.746]. Compliance with the complete set of recommendations increased from 8 (2%) to 52 (15%) patients after the intervention (P < 0.001). At day 90, the number of invasive ventilation-free days was higher in the 60 (8%) patients whose care complied with recommendations than in the 684 (92%) patients whose care deviated from recommendations [77 (66–82) and 71 (0–80) days, respectively; P = 0.03]. The mortality rate was 10% in the compliant group and 26% in the non-compliant group (P = 0.023). Both multivariate analysis [hazard ratio (HR) 1.78, 95% confidence interval (95% CI) 1.41–2.26; P < 0.001] and propensity score-adjusted analysis (HR 2.25, 95% CI 1.56–3.26, P < 0.001) revealed that compliance was an independent factor associated with the reduction in the duration of mechanical ventilation.

Conclusions

Adherence to recommendations for low tidal volume, moderate PEEP and early extubation seemed to increase the number of ventilator-free days in brain-injured patients, but inconsistent adoption limited their impact.

Trail registration number: NCT01885507.

Keywords

Ventilator weaning Brain injuries Airway extubation Tidal volume PEEP 

Notes

Acknowledgements

The authors thank Delphine Flattres Duchaussoy, Sabrina Lebouter-Banon and the nurses of the participating ICUs for technical support.

BI-VILI study group

Dr. L. Thioliere L, Angers University Hospital; Dr. G. Zamparini G, Caen University Hospital; Dr. M. Leone, Marseille University Hospital; Drs. P.J. Mahe, D. Demeure dit latte and A. Delater, Nantes University Hospital, Hôtel Dieu; Drs. K. Lakhal K and L. Brisard, Nantes University Hospital, HGRL; Drs. R. Drilleau and O. Mimoz, Poitiers University Hospital; Drs. Y. Malledant, S. Isslame, Y. Launey and N. Nesseler, Rennes University Hospital; Dr. M. Ferrandière. Tours University Hospital.

Author contributions

RA was the principle investigator who oversaw the study conduct, helped develop all study materials including the trial protocol, assisted with participant recruitment and data collection at the Nantes site, participated in data analysis and interpretation of the results and drafted and revised the manuscript. AK provided oversight on trial design, helped develop study materials including the trial protocol, provided oversight on trial conduct, participated in data analysis and the interpretation of the results and revised the manuscript. FF, DM and SV were the trial statisticians and provided advice and input related to all statistical issues, completed final data analysis and interpretation of the results and revised the manuscript. MS, PFP, SP, DFC, LS, PA, MM, CR, ML, HJL, HE, RB, KT, IC, CR, GT and LM were the principal investigators at research sites and assisted with the development of the protocol and other study materials, referred or actively recruited participants at sites, assessed participant eligibility and delivered formal training. JS provided oversight on trial design, participated in data analysis and the interpretation of the results and revised the manuscript. FFV, LM, JPE and PP participated in the realisation of the meta-analysis and in the interpretation of the results and revised the manuscript.

Compliance with ethical standards

Conflicts of interest

The authors declare that they have no conflict of interest.

Funding

Non-profit organization “Gueules Cassées”.

Data sharing

To access to the study date, please contact the corresponding author (AK) who has the full access to the raw data.

Supplementary material

134_2017_4764_MOESM1_ESM.pdf (417 kb)
Supplementary material 1 (PDF 416 kb)
134_2017_4764_MOESM2_ESM.docx (101 kb)
Supplementary material 2 (DOCX 101 kb)
134_2017_4764_MOESM3_ESM.docx (61 kb)
Supplementary material 3 (DOCX 60 kb)
134_2017_4764_MOESM4_ESM.docx (14 kb)
Supplementary material 4 (DOCX 15 kb)

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Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2017

Authors and Affiliations

  • Karim Asehnoune
    • 1
    • 20
    Email author
  • Ségolène Mrozek
    • 2
  • Pierre François Perrigault
    • 3
  • Philippe Seguin
    • 4
  • Claire Dahyot-Fizelier
    • 5
  • Sigismond Lasocki
    • 6
  • Anne Pujol
    • 7
  • Mathieu Martin
    • 8
  • Russel Chabanne
    • 9
  • Laurent Muller
    • 10
  • Jean Luc Hanouz
    • 11
  • Emmanuelle Hammad
    • 12
  • Bertrand Rozec
    • 13
  • Thomas Kerforne
    • 14
  • Carole Ichai
    • 15
  • Raphael Cinotti
    • 1
  • Thomas Geeraerts
    • 2
  • Djillali Elaroussi
    • 7
  • Paolo Pelosi
    • 16
  • Samir Jaber
    • 17
  • Marie Dalichampt
    • 18
  • Fanny Feuillet
    • 19
  • Véronique Sebille
    • 18
    • 19
  • Antoine Roquilly
    • 1
  • The BI-VILI study group
  1. 1.Intensive Care Unit, Anesthesia and Critical Care Department, Hôtel Dieu-HME–University Hospital of Nantes Centre Hospitalier Universitaire (CHU) de NantesNantesFrance
  2. 2.Department of Anesthesiology and Critical Care DepartmentUniversity Hospital of ToulouseToulouseFrance
  3. 3.Intensive Care Unit, Anesthesia and Critical Care DepartmentGui Chauliac University Hospital of MontpellierMontpellierFrance
  4. 4.Intensive Care Unit, Anesthesia and Critical Care DepartmentPontchaillou–University Hospital of RennesRennesFrance
  5. 5.Neuro-Intensive Care Unit, Anesthesia and Critical Care DepartmentUniversity Hospital of PoitiersPoitiersFrance
  6. 6.Intensive Care Unit, Anesthesia and Critical Care DepartmentUniversity Hospital of AngersAngersFrance
  7. 7.Intensive Care Unit, Anesthesia and Critical Care DepartmentUniversity Hospital of ToursToursFrance
  8. 8.Intensive Care Unit, Anesthesia and Critical Care Department, University Hospital of Créteil–CHU Henri MondorAssistance publique–Hôpitaux de Paris (AP-HP)CréteilFrance
  9. 9.Department of Anesthesiology and Intensive CareUniversity Hospital of Clermont FerrandClermont FerrandFrance
  10. 10.Department of Anesthesiology and Intensive CareUniversity Hospital of NimesNimesFrance
  11. 11.Department of Anesthesiology and Intensive CareUniversity Hospital of CaenCaenFrance
  12. 12.Department of Anesthesiology and Intensive CareUniversity Hospital of MarseilleMarseilleFrance
  13. 13.Intensive Care Unit, Anesthesia and Critical Care DepartmentLaennec–University Hospital of NantesNantesFrance
  14. 14.Surgical Intensive Care Unit, Anesthesia and Critical Care DepartmentUniversity Hospital of PoitiersPoitiersFrance
  15. 15.Intensive Care Unit Pasteur 2–University Hospital of NiceNiceFrance
  16. 16.Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino–IST National Cancer Research InstituteUniversity of GenoaGenoaItaly
  17. 17.Intensive Care Unit, Anesthesia and Critical Care DepartmentSaint Eloi University Hospital of MontpellierMontpellierFrance
  18. 18.Plateforme de Biométrie, Département Promotion de la Recherche CliniqueUniversity Hospital of NantesNantesFrance
  19. 19.EA 4275, MethodS for Patients-centered Outcomes and HEalth REsearch (SPHERE), UFR des Sciences PharmaceutiquesNantes UniversityNantesFrance
  20. 20.Service d’Anesthésie RéanimationCHU de NantesNantes Cedex 1France

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