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Evidence-based medical education: caution.

We read with interest the study by Cox and coworkers (1). It is indeed crucial to assess the residents’ knowledge of medical literature. The online supplement provides us with the questionnaire given to the medical residents. Interestingly, the second least correctly answered question is No. 12, which relates to the most appropriate next measure to take when arterial blood gas analysis of a woman mechanically ventilated under 0.6 FiO2 and 5 cm H2O positive end-expiratory pressure (PEEP) reveals: pH 7.28, Pco2 36, PaO2 55 mm Hg, and SaO2 85%. The list of possible answers is as follows: (a) Increase the FiO2 to 0.80; (b) Increase the tidal volume by 100 ml from your initial setting; (c) Increase the rate by 4 breaths per minute from your initial setting; and (d) increase the PEEP to 10 cm H2O. Only 56% of the residents provided the required answer: (d) increase PEEP to 10 cm H2O. It would have been interesting to know the percentage of residents answering the other different propositions. Our contention is that medical residents who had first increased FiO2 (and only after that increased PEEP) would have put their patient at a much lesser risk for persistent hypoxemia (and cardiac compromise) than those who had first increased PEEP. Indeed, patients may not always respond to PEEP, may sometimes increase their PaO2 only several hours after PEEP augmentation, or may even decrease their PaO2 if their cardiac output decreases as a result of increased PEEP (2). Our first concern as clinicians when treating patients with severe hypoxemia (as is the case in this vignette with PaO2/FiO2 92) is to avoid prolonged hypoxemia. In addition, even if one wishes to apply evidence-based medicine, then one may wish to refer to a very recent review of evidencebased medicine on adult respiratory distress syndrome (ARDS) treatment that made a grade C recommendation for the use of PEEP in ARDS treatment (3). Then it may be worthwhile to rely on physiology and consider, as stated by Lodato (4), that “the known immediate risks of systemic hypoxia and barotrauma are clearly more rapid and devastating than the potential and future risk of hyperoxia-induced lung injury.” In the area of ARDS, the same caveat may be addressed to evidence-based medical education as to evidence-based medicine (5). However important it may be to assess the knowledge of medical literature of senior residents, assessing their understanding of physiology may prove to be at least as beneficial to the patient.