Short Attention Span Summary
I LOV-ED this study mnemonic!
Initiation of a mechanical ventilation protocol in the ED using a low tidal volume strategy, PEEP protocols, rapid FiO2 weaning, and head-of-bed elevation resulted in dramatic clinical improvement in the composite primary outcome: ARDS or ventilator-associated conditions; NNT = 14. And a secondary outcome, mortality, was also improved, NNT = 7. There is no way to account for all the confounders or other process improvements that may have also led to better outcomes, but the use of propensity analysis makes this association very believable.
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Simply starting a lung-protective mechanical ventilation strategy in the ED appeared to make a big difference in important clinical outcomes in this study. Learn to manage the vent like a pro. REBEL EM has a great deep-dive on this article by Anand Swaminathan.
Abstract
Ann Emerg Med. 2017 Mar 1. pii: S0196-0644(17)30028-8. doi: 10.1016/j.annemergmed.2017.01.013. [Epub ahead of print]
Fuller BM1, Ferguson IT2, Mohr NM3, Drewry AM4, Palmer C5, Wessman BT5, Ablordeppey E5, Keeperman J5, Stephens RJ6, Briscoe CC6, Kolomiets AA7, Hotchkiss RS4, Kollef MH8.
Author information:
1 Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO. Electronic address: [email protected].
2 School of Medicine and Medical Science, University College Dublin, Dublin, Ireland.
3 Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA.
4 Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO.
5 Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO.
6 Washington University School of Medicine in St. Louis, St. Louis, MO.
7 School of Public Health and Social Justice, Saint Louis University, St. Louis, MO.
8 Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO.
Abstract
STUDY OBJECTIVE:
We evaluated the efficacy of an emergency department (ED)-based lung-protective mechanical ventilation protocol for the prevention of pulmonary complications.
METHODS:
This was a quasi-experimental, before-after study that consisted of a preintervention period, a run-in period of approximately 6 months, and a prospective intervention period. The intervention was a multifaceted ED-based mechanical ventilator protocol targeting lung-protective tidal volume, appropriate setting of positive end-expiratory pressure, rapid oxygen weaning, and head-of-bed elevation. A propensity score-matched analysis was used to evaluate the primary outcome, which was the composite incidence of acute respiratory distress syndrome and ventilator-associated conditions.
RESULTS:
A total of 1,192 patients in the preintervention group and 513 patients in the intervention group were included. Lung-protective ventilation increased by 48.4% in the intervention group. In the propensity score-matched analysis (n=490 in each group), the primary outcome occurred in 71 patients (14.5%) in the preintervention group compared with 36 patients (7.4%) in the intervention group (adjusted odds ratio 0.47; 95% confidence interval [CI] 0.31 to 0.71). There was an increase in ventilator-free days (mean difference 3.7; 95% CI 2.3 to 5.1), ICU-free days (mean difference 2.4; 95% CI 1.0 to 3.7), and hospital-free days (mean difference 2.4; 95% CI 1.2 to 3.6) associated with the intervention. The mortality rate was 34.1% in the preintervention group and 19.6% in the intervention group (adjusted odds ratio 0.47; 95% CI 0.35 to 0.63).
CONCLUSION:
Implementing a mechanical ventilator protocol in the ED is feasible and is associated with significant improvements in the delivery of safe mechanical ventilation and clinical outcome.
Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
