A multi-faceted strategy to reduce ventilation-associated mortality in brain-injured patients. The BI-VILI project: a nationwide quality improvement project
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We assessed outcomes in brain-injured patients after implementation of a multi-faceted approach to reduce respiratory complications in intensive care units.
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.
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.
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.
KeywordsVentilator weaning Brain injuries Airway extubation Tidal volume PEEP
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.
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.
Non-profit organization “Gueules Cassées”.
To access to the study date, please contact the corresponding author (AK) who has the full access to the raw data.
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