Promoting Evidence-Based Practice in Acute Respiratory Distress Syndrome: A Systematic Review

Abstract

OBJECTIVE: Low tidal volume ventilation and prone positioning are recommended therapies yet underused in acute respiratory distress syndrome. We aimed to assess the role of interventions focused on implementation of low tidal volume ventilation and prone positioning in mechanically ventilated adult patients with acute respiratory distress syndrome. DATA SOURCES: PubMed, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials. STUDY SELECTION: We searched the four databases from January 1, 2001, to January 28, 2021, for studies that met the predefined search criteria. Selected studies focused on interventions to improve implementation of low tidal volume ventilation and prone positioning in mechanically ventilated patients with acute respiratory distress syndrome. DATA EXTRACTION: Two authors independently performed study selection and data extraction using a standardized form. DATA SYNTHESIS: Due to methodological heterogeneity of included studies, meta-analysis was not feasible; thus, we provided a narrative summary and assessment of the literature. Eight nonrandomized studies met our eligibility criteria. Most studies looked at interventions to improve adherence to low tidal volume ventilation. Most interventions focused on education for providers. Studies were primarily conducted in the ICU and involved trainees, intensivists, respiratory therapists, and critical care nurses. Although overall quality of the studies was very low, the primary outcomes of interest suggest that interventions could improve adherence to or implementation of low tidal volume ventilation and prone positioning in acute respiratory distress syndrome. Measurements and Main Results: Two authors independently performed study selection and data extraction using a standardized form. Due to methodologic heterogeneity of included studies, meta-analysis was not feasible; thus, we provided a narrative summary and assessment of the literature. Eight nonrandomized studies met our eligibility criteria. Most studies looked at interventions to improve adherence to low tidal volume ventilation. Most interventions focused on education for providers. Studies were primarily conducted in the ICU and involved trainees, intensivists, respiratory therapists, and critical care nurses. Although overall quality of the studies was very low, the primary outcomes of interest suggest that interventions could improve adherence to or implementation of low tidal volume ventilation and prone positioning in acute respiratory distress syndrome. Conclusions: There is a dearth of literature addressing interventions to improve implementation of evidence-based practices in acute respiratory distress syndrome. Existing interventions to improve clinician knowledge and facilitate application of low tidal volume ventilation and prone positioning may be effective, but supporting studies have significant limitations.

Factors Influencing the Implementation of Prone Positioning during the COVID-19 Pandemic: A Qualitative Study

“…There are few published reports of interventions designed to increase the use of evidence-based ARDS interventions, highlighting the need for effective implementation strategies ( 35 ). The successful expansion of proning in ARDS from COVID-19 can serve as a model for designing such interventions.…”

Mortality associated with acute respiratory distress syndrome, 2009-2019: a systematic review and meta-analysis

“…In a systematic review published in 2021, in which more than two decades literature had been searched, fewer than ten studies on interventions aimed to increase adherence to the use of lung-protective ventilation and prone positioning were identified. 43 Given the availability of evidence-based interventions conferring a survival benefit, we had expected to see a larger focus on implementation and subsequent reduction in mortality. This has become of greater importance given the ongoing COVID-19 pandemic.…”

Assessing Evidence-Based Practice Knowledge, Self-Efficacy, and Use Among Respiratory Therapists

“…4,5 Quality evidence is lacking that focuses on interventions to improve implementation of lung protective strategies. 6 Like other health professions, respiratory therapists have relied on clinical experience, peers, and expert opinion to form the basis of most clinical decisions. [7][8][9] Many health professions have made EBP a desired competency and professional responsibility, which has resulted in the adoption of a similar set of the EBP principles considered essential to the clinical decision-making process.…”