Elucidating the fuzziness in physician decision making in ARDS

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• 作者：David B. Bernstein (1) <br> Binh Nguyen (2) (3) <br> Gilman B. Allen (2) (3) <br> Jason H. T. Bates (1) (3) <br>
• 关键词：Acute respiratory distress syndrome ; Mechanical ventilation ; Fuzzy logic ; Low tidal volume ventilation ; Clinical decision making
• 刊名：Journal of Clinical Monitoring and Computing
• 出版年：2013
• 出版时间：June 2013
• 年：2013
• 卷：27
• 期：3
• 页码：357-363
• 全文大小：351KB
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• 作者单位：David B. Bernstein (1) <br> Binh Nguyen (2) (3) <br> Gilman B. Allen (2) (3) <br> Jason H. T. Bates (1) (3) <br><br>1. School of Engineering, University of Vermont, 149 Beaumont Avenue, HSRF 228, Burlington, VT, 05405-0075, USA <br> 2. Fletcher Allen Health Care, Burlington, VT, 05405, USA <br> 3. Department of Medicine, University of Vermont, Burlington, VT, 05405, USA <br>
• ISSN：1573-2614

文摘

The current standard of care for patients suffering from acute respiratory distress syndrome (ARDS) is ventilation with a tidal volume of 6?ml/kg predicted body weight (PBW), but variability remains in the tidal volumes that are actually used. This study aims to identify patient scenarios for which there is discordance between physicians in choice of tidal volume and positive end-expiratory pressure (PEEP) in ARDS patients. We developed an algorithm based on fuzzy logic for encapsulating the expertise of individual physicians regarding their use of tidal volume and PEEP in ARDS patients. The algorithm uses three input measurements: (1) peak airway pressure (PAP), (2) PEEP, and (3) arterial oxygen saturation (SaO2b>). It then generates two output parameters: (1) the deviation of tidal volume from 6?ml/kg PBW, and (2) the change in PEEP from its current value. We captured 6 realizations of intensivist expertise in this algorithm and assessed their degree of concordance using a Monte Carlo simulation. Variability in the tidal volume recommended by the algorithm increased for PAP?>?30?cmH2b>O and PEEP?>?5?cmH2b>O. Tidal volume variability decreased for SaO2b>?>?90?%. Variability in the recommended change in PEEP increased for PEEP?>?5 cmH2b>O and for SaO2b> near 90?%. Intensivists vary in their management of ARDS patients when peak airway pressures and PEEP are high, suggesting that the current goal of 6?ml/kg PBW may need to be revisited under these conditions.