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What Differs from Theory to 
Practice? 
Emel Eryüksel 
Marmara University, Pulmonary and 
Critical Care
Intrathoracic Pressures and Breathing
Salon a 13 kasim 15.45 17.00 emel eryüksel-ing
Ventilation Strategies 
• Improved safety 
• Improved patient comfort 
• Rapid response to change in patient condition
Ventilation Strategies 
• Improved safety 
• Improved patient comfort 
• Rapid response to change in patient condition
Lung Injury Caused by Forces 
at Low and High Lung Volumes 
n engl j med 369;22
Salon a 13 kasim 15.45 17.00 emel eryüksel-ing
Salon a 13 kasim 15.45 17.00 emel eryüksel-ing
Salon a 13 kasim 15.45 17.00 emel eryüksel-ing
adherence to lung protective 
ventilation?
• -Of the 485 patients, 417 (86%) received 50% or less and 68 (14%) 
received more than 50% of their twice daily ventilator settings adherent 
to lung protective ventilation. A total of 180 (37%) patients never received 
lung protective ventilation during any of their twice daily ventilator 
settings.-
WHY? 
What causes physicians to change 
the way they practice?
Changes in practice are 
sometimes rapid and dramatic. 
laparoscopic cholecystectomy …..
education 
• Why are most physicians not influenced by 
practice guidelines?
Salon a 13 kasim 15.45 17.00 emel eryüksel-ing
scientific knowledge to specific patients
SUMMARIZE THE EVIDENCE 
• To change practice, the evidence must be 
summarized concisely into several key 
interventions….
• For ALI, the evidence supports LPV, which can be defined as 
providing a tidal volume less than or equal to 6 ml/kg of 
predicted body weight and a plateau pressure of less than or 
equal to 30 cm H2O….
IDENTIFY LOCAL BARRIERS TO PRACTICE COMPLIANCE
diagnostic uncertainty
Salon a 13 kasim 15.45 17.00 emel eryüksel-ing
Severity
Salon a 13 kasim 15.45 17.00 emel eryüksel-ing
Patient’s Weight.. 
• 50+ 0.91(centimeters of height-152.4) male 
• 45.5+0.91(centimeters of height-152.4) 
female
Salon a 13 kasim 15.45 17.00 emel eryüksel-ing
ICU TEAM
• Overall, organizational 
barriers and perceived 
barriers related to 
clinician attitudes and 
behaviors were lower 
among physicians 
compared with nurses 
and respiratory 
therapists.
• Physicians specializing in internal medicine 
(including pulmonary/critical care) perceived 
lower barriers and scored higher on the 
Knowledge Test compared with surgery
• Barriers were lower and Knowledge Test 
scores higher among fellows and attending 
physicians vs. interns and residents, who have 
much less experience working in the ICU.
MEASURE PERFORMANCE
• Clinicians can measure performance using 
processes of care (e.g., LPV use), outcomes of 
care (in-hospital mortality)or both.
ENSURE THAT ALL PATIENTS RECEIVE THE THERAPY
Salon a 13 kasim 15.45 17.00 emel eryüksel-ing
Salon a 13 kasim 15.45 17.00 emel eryüksel-ing
Educating clinicians 
• that they are aware of the evidence, agree 
with it, and understand the actions needed to 
comply with the evidence.
Executing
Salon a 13 kasim 15.45 17.00 emel eryüksel-ing

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Salon a 13 kasim 15.45 17.00 emel eryüksel-ing

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