Annals of the American Thoracic Society

To the Editor:

Nearly 1 million patients per year require invasive mechanical ventilation for acute respiratory failure in the United States (1). Among those who recover to the point of passing a spontaneous breathing trial, many remain at high risk for recurrent respiratory failure and reintubation after extubation (2). Multiple randomized trials demonstrate that treatment of high-risk patients with preventive noninvasive ventilation (NIV) immediately after planned extubation can prevent these adverse events (36). On the basis of these data, two recent clinical practice guidelines recommended that high-risk patients be extubated directly to NIV to prevent postextubation respiratory failure (7, 8). Yet despite these recommendations, the use of preventive postextubation NIV in routine practice remains limited (9, 10). We therefore conducted a survey to better understand provider perspectives on postextubation NIV and to identify perceived barriers to use.

Methods

In October 2017, we surveyed nurses, respiratory therapists, and physicians (including fellows) working in 33 intensive care units (ICUs) across 15 hospitals within the UPMC Health System in southwestern Pennsylvania; 14 participating ICUs were general ICUs, 6 were cardiac or cardiothoracic ICUs, 4 were medical ICUs, 4 were neurologic ICUs, 3 were trauma ICUs, and 2 were surgical ICUs. We sent up to three e-mail invitations to 2,223 potential respondents using a commercially available Web-based survey tool (Qualtrics). No incentives were offered. The survey was reviewed by the University of Pittsburgh Institutional Review Board and found to be exempt under 45 CFR 46.101(b) (2).

Our goals were to assess perspectives regarding the need for and effectiveness of postextubation NIV and to identify barriers to use. After pilot testing a draft survey with five nurses, five respiratory therapists, and two physicians, we revised the instrument for readability and clarity. The final survey addressed three domains: respondent demographics, attitudes regarding identification and treatment of patients at high risk for extubation failure, and barriers to use of postextubation NIV. We defined extubation failure as “reintubation within 48 hours of a planned extubation.” To distinguish preventive postextubation NIV from rescue NIV used to treat postextubation respiratory failure, we described “the practice of extubating high-risk patients directly to non-invasive ventilation (e.g., BiPAP) to prevent extubation failure.” We measured attitudes using a 5-point Likert scale and barriers using a 4-point Likert scale.

We excluded respondents who reported not providing care for a mechanically ventilated ICU patient in the preceding 2 months; who did not identify as a nurse, respiratory therapist, or physician; and who did not respond to questions about postextubation NIV. We considered responses of “strongly agree” and “somewhat agree” to indicate agreement with our attitudinal questions and responses of “extremely important” and “very important” to indicate that a barrier was perceived to be important. We used chi-square tests to determine whether nurses, respiratory therapists, and physicians have different perspectives. We used STATA (version 14.2) for statistical analyses.

Results

Of the 2,223 individuals contacted, we received 487 (22%) eligible responses from 278 nurses, 125 respiratory therapists, and 84 physicians; 159 (37%) respondents worked primarily at UPMC Presbyterian, 81 (17%) at UPMC Mercy, 68 (14%) at UPMC Shadyside, 30 (6%) at UPMC Hamot, 27 (6%) at UPMC Passavant, 26 (5%) at UPMC Altoona, 23 (5%) at UPMC Magee-Womens, and the remaining 54 (11%) in 8 other UPMC hospitals. Nurses and respiratory therapists were less likely to respond than physicians (21% vs. 20% vs. 38% response rate; P < 0.001). The median (interquartile range) years in practice was 6 (3–13) among nurses, 14 (7–28) among respiratory therapists, and 3 (1–12) among physicians (P = 0.001). Among the 84 physician respondents, 49 (58%) where trained in internal medicine, 13 (15%) in emergency medicine, 7 (8%) in surgery, 7 (8%) in pediatrics, 6 (7%) in anesthesiology, and 2 (2%) in neurology.

Only 20% of respondents agreed with the statement that extubation failure is a common problem in their ICU (Table 1), whereas 84% reported confidence in their ability to identify patients who are at high risk of extubation failure. Half (54%) of respondents agreed that extubation directly to NIV reduces extubation failure in high-risk patients, and a similar percentage agreed that extubation to high-flow oxygen reduces extubation failure. Agreement varied by provider type, with physicians most likely to agree that postextubation NIV reduces the risk of extubation failure (79% of physicians vs. 42% of nurses vs. 59% of respiratory therapists; P < 0.001) and least confident in their ability to identify high-risk patients (72% of physicians vs. 85% of nurses vs. 85% of respiratory therapists; P = 0.02).

Table 1. Provider perspectives regarding the need for and effectiveness of postextubation noninvasive ventilation

StatementStrongly Agree or Somewhat AgreeP Value
AllRNRTMD
Extubation failure is common in my ICU.99/487 (20)63/278 (23)16/125 (13)19/84 (23)0.06
Extubation failure causes them harm.303/485 (62)165/278 (59)69/123 (56)63/84 (75)0.01
I can tell when patients are high risk for extubation failure.406/482 (84)235/277 (85)104/122 (85)60/83 (72)0.02
I regularly use a scoring system to assess risk for extubation failure.108/485 (22)40/277 (14)45/124 (36)19/84 (23)<0.001
Extubating high-risk patients to NIV can reduce risk of extubation failure.263/486 (54)118/278 (42)73/124 (59)66/84 (79)<0.001
Extubating high-risk patients to high-flow oxygen can reduce risk of extubation failure.251/484 (52)126/276 (46)66/124 (53)55/84 (65)0.005

Definition of abbreviations: ICU = intensive care unit; MD = medical doctor; NIV = noninvasive ventilation; RN = registered nurse; RT = respiratory therapist.

Results indicate the n/N (%) who selected a 4 (somewhat agree) or 5 (strongly agree) on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree).

Barriers to postextubation NIV that were most frequently cited as important were contraindications to use and difficulty identifying high-risk patients (Table 2)—both were more likely to be cited as important barriers by nurses and respiratory therapists than by physicians (63% and 55% of nurses, respectively, vs. 70% and 57% of respiratory therapists vs. 43% and 23% of physicians; P < 0.001 for both). In addition, nurses were more likely than both respiratory therapists and physicians to report that other team members do not suggest (50% of nurses vs. 27% of physicians vs. 15% of respiratory therapists; P < 0.001) or are opposed to postextubation NIV (45% of nurses vs. 27% of physicians vs. 23% of respiratory therapists; P < 0.001).

Table 2. Provider perspectives regarding barriers to postextubation noninvasive ventilation

Potential BarrierExtremely Important or Very ImportantP Value
AllRNRTMD
It is often contraindicated.268/438 (61)151/239 (63)82/117 (70)35/82 (43)<0.001
It is too difficult to identify high-risk patients.217/438 (50)132/241 (55)66/116 (57)19/81 (23)<0.001
Other team members do not suggest it.163/440 (37)119/240 (50)32/118 (27)12/82 (15)<0.001
Other team members are opposed to it.159/441 (36)108/241 (45)32/118 (27)19/82 (23)<0.001
It may make patients uncomfortable.157/440 (36)95/241 (39)44/117 (38)18/82 (22)0.02
It is too difficult to administer well.132/438 (30)83/240 (35)29/118 (25)20/82 (24)0.07
Other team members are not comfortable using it.77/437 (18)43/239 (18)20/117 (17)13/81 (16)0.92
I am not comfortable using it.56/438 (13)32/239 (13)21/117 (18)3/82 (4)0.01
It takes too much time.30/440 (7)20/240 (8)9/118 (7)1/82 (1)0.08
It is too costly.28/440 (6)23/241 (10)5/117 (4)0/82 (0)0.005

Definition of abbreviations: MD = medical doctor; RN = registered nurse; RT = respiratory therapist.

Results indicate the n/N (%) who selected a 3 (very important) or 4 (extremely important) on a 4-point Likert scale ranging from 1 (not at all important) to 5 (extremely important).

Discussion

In a survey of nearly 500 ICU providers across 15 hospitals, many respondents expressed skepticism about the effectiveness of postextubation NIV despite multiple randomized controlled trials demonstrating efficacy (36) and clinical practice guidelines recommending use. Respondents identified many important barriers to use, some of which relate to the intervention itself (e.g., concerns about whether it is indicated) and some of which relate to role of the interprofessional care team in NIV delivery (e.g., concerns about the perceptions of other team members).

Previous studies that examined barriers to the use of NIV in general found that lack of awareness of the evidence and concerns about the time required to implement NIV are key barriers to use (1114). We similarly found that lack of awareness of evidence is a barrier. Yet, we also demonstrate that opinions about postextubation NIV (as well as high-flow oxygen) differ between various members of the interprofessional ICU team. This lack of agreement among key members of the team may be a major impediment to implementation.

We hypothesize that differences in perspectives are an important reason that common approaches to translating evidence into practice—which have traditionally targeted individual providers rather than the ICU team as a whole—have been ineffective. Most evidence-based practices in critical care are complex and multifaceted, requiring ongoing coordination within a dynamic interprofessional care team (15). Implementation strategies that account not only for the complexity of intensive care but also for the complexity of the ICU team may be more effective.

Our study has several limitations. We conducted our survey <1 year after clinical practice guidelines recommending postextubation NIV were published (7, 8). Although the clinical trials that supported these recommendations were published between 2005 and 2013, our survey may have yielded different results if administered at a later date. We surveyed providers from multiple hospitals (large and small, academic and community), but respondents from the largest hospitals (e.g., UPMC Presbyterian) may skew results, and including hospitals from multiple geographic regions could have improved the generalizability of results. Although our response rate was not low for an e-mail–based survey, nonresponse bias could have affected results if, for example, clinicians who use NIV less often were more likely to respond than those who use NIV frequently or if less-experienced clinicians were more likely to respond than those with more experience. Finally, we did not provide respondents with a specific definition of “high risk,” and responses may differ depending on the definition used. Despite these limitations, our finding that perspectives on the effectiveness of and barriers to postextubation NIV vary significantly by provider type may provide an important road map for improving use of preventive postextubation NIV by targeting the interprofessional care team.

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*Corresponding author (e-mail: ).

Supported by National Institutes of Health grants HL143507 and HL133444.

Author Contributions: J.M.K. and T.D.G. conceived and designed the study and acquired the data. All authors analyzed the data and interpreted the results. E.A.N. drafted the manuscript, and all authors critically revised the manuscript and approved the final version.

Author disclosures are available with the text of this letter at www.atsjournals.org.

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