Determinants influencing use of lower tidal volumes, lower inspiratory pressures, and prone positioning in ARDS: A systematic review

Abstract Background: Lower tidal volumes and lower inspiratory pressures for patients with acute respiratory distress syndrome (ARDS) and prone positioning in severe ARDS are evidence-based practices that improve patient survival but are inconsistently applied. The objective of this systematic review is to identify what barriers, facilitators, and factors (together called determinants) influence the use of lower tidal volumes and lower inspiratory pressures for adult intensive care unit patients with ARDS and prone positioning for those with severe ARDS.Methods: We performed a systematic review employing PubMed, Embase, and CINAHL for studies published between January 1, 2000 and February 1, 2020. Studies reporting qualitative, quantitative, or mixed-methods data about determinants of implementation of the three strategies of interest were identified. We extracted determinants of implementation, study type, and evidence-based practice(s) studied. We assigned determinants to the Consolidated Framework for Implementation Research (CFIR) to organize contextual factors influencing implementation.Results: 4,578 studies were screened and 32 manuscripts were included and analyzed. Lower tidal volumes was the most studied evidence-based practice (27 of 32 studies). 86 determinants were extracted. We assigned 62 (72%) of determinants to the CFIR, with Characteristics of Individuals and Inner Setting most represented. The other 24 (28%) determinants were related to the patient’s clinical condition and demographic factors. We assigned these to a domain developed through inductive reasoning, “Patient Factors,” with 15 (63%) assigned to the construct “Dynamic Patient Attributes” and 9 (38%) to “Static Patient Attributes.” 5 of 86 (6%) determinants related to prone positioning.Conclusions: Multiple determinants impact the delivery of lower tidal volumes and lower inspiratory pressures in patients with ARDS, but we identified few determinants for prone positioning in severe ARDS. Our application of implementation science theory enables clinicians to identify factors influencing this evidence-to-practice gap and may support investigations and interventions to improve guideline-concordant care in ARDS.Systematic Review Registration: We registered this systematic review on PROSPERO (PROSPERO 2019 CRD42019135160).