Managing Safely the Complexity in Critical Care: Are Protocols for Artificial Ventilation in Pediatric Acute Respiratory Distress Syndrome Beneficial in Searching for Reliable Biomarkers?*

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Mechanical ventilation can be a double-edged sword in children with, or at high risk of, pediatric acute respiratory distress syndrome (PARDS). Mechanical ventilation, if improperly set, can increase the extent of lung injury and be the cause of secondary ventilator-induced lung injury (VILI). On the other hand, artificial ventilator settings can be adjusted to minimize VILI and this can reduce mortality in ARDS (1).
When considering the characterizing elements of patient-centered quality of care and patient safety practices, it is important to stress certain aspects of relevance to the decisions taken by the individual care provider and to the interventions carried out through teamwork in critical and intensive care.
Foremost among these is the degree of discretionality to be given to the provider in setting the therapy. Studies revealed an inconsistent use of mechanical ventilation practices and adjunctive therapies in patients with lung diseases, with subjective thresholds for mechanical ventilation also differing among centers and practitioners (2, 3).
In intensive care medicine, where the validity of a protocol-based approach would seem indisputable, it is often the case that treatment is left to the discretion of the provider who is thus free to indulge personal “preferences.” These sometimes include therapies of no proven efficacy, which may in some cases be harmful, particularly if their validity is unsupported by evidence-based studies (4). Although the adoption of clinical guidelines is the object of debate, the challenge is to translate complex guidelines into meaningful changes in behavior and clinical outcomes. This increases the reliability of patient care, eliminates personnel turnover errors, and decreases variation in clinical practice (5–8).
Patient-centered care is best guaranteed in ICUs where team-based care and protocols are implemented. The benefits of protocols for teamwork can be maximized by careful development and implementation strategies, proper identification of suitable patient populations, transparency, and accountability.
Optimal teamwork and communication are essential to provide high-quality care and promote patient safety, and failings in these areas are the leading causes of medical errors in critical and intensive care (7, 9–11).
In this issue of Critical Care Medicine, Yehya and Thomas (12) present the results of their study of the relevance of lung mechanics and oxygenation metrics in PARDS. Their main finding is that an improvement in oxygenation (rather than respiratory mechanics) is associated with lower mortality. The study introduces a novel concept among the prognostic variables associated with PARDS outcomes in children. The findings of this study are thus likely to stimulate a debate about the role of pressure/volume variables compared with oxygenation and prognosis in PARDS. Peak inspiratory pressure (PIP) does not merely correlate with the pathologic condition of the lung but is widely influenced by treatment variables (such as endotracheal tube size, the ventilator connecting circuit, and the humidifier dead space), as well as by nursing interventions (such as cuff inflation control, patient mobilization, efficient humidification and gas system warming, and errors such as excessive suction depth in bronchial suctioning and applying too high elevated negative pressure in deep bronchial suctioning).
Pressure variables are static measurements adjusted by the healthcare team, and in a nonprotocolled study, these variations depend upon the clinicians and are not necessarily related to changes in lung pathology. Oxygenation, rather than pressure variables, is the primary metric associated with outcome.
Oxygenation and the PaO2/FIO2 ratio specifically address the real condition of the alveoli and their diffusion capacity. Thus, oxygenation appears to be the assessment method of indication to evaluate both initial parenchymal injury and improvement following the application of a specific treatment.

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