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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 to ARDS 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 treatment with low‐Vt ventilation, they initiated low‐Vt ventilation for 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.