We continue on with the series with Knowledge Bomb #15. The purpose and motivation for this series is outlined in the first entry and extensively in an ALiEM IDEA series blog entry.

Background:

Annually, 250,000 patients are mechanically ventilated in US Emergency Departments (ED). Of these patients, 20% will develop complications such as Acute Respiratory Distress Syndrome (ARDS) or other ventilator associated conditions (VACs) like pneumonia. It has been shown that ventilator associated injury can occur shortly after initiating mechanical ventilation.  Can we prevent these complications and improve patient outcomes in the ICU by initiating a lung protective strategy in the ED?

Article:

Fuller BM, Ferguson I, Mohr NM et al. Lung-protective ventilation initiated in the emergency department (LOV-ED): a study protocol for a quasi-experimental, before-after trial aimed at reducing pulmonary complications. Annals of Emergency Medicine. 2017; 70(3): 406-418

Study Design:

This quasi-experimental study implemented an ED targeted strategy for lung-protective mechanical ventilation.

The parameters set included:

  • Tidal volume
  • PEEP
  • FiO2
  • Respiratory Rate
  • Head of bed elevation to 30 degrees

Tape measures were used to accurately measure the height for the patients before referencing the ARDSnet table to adequately set a tidal volume. They then used the ARDSnet ventilator protocol to adequately set a PEEP and FiO2 for the patient.

RR was set at 20-30 breaths per minute (unless a different rate was deemed appropriate by the emergency physician).   After these settings were established in the ED, the patient’s hospital course was followed prospectively.

Results:

-In this study’s intervention group, Lung-protective ventilation increased by 48.8%.
-The primary outcomes studied were ARDS and other VACs.
-Primary outcomes seen in 14.5% of the pre-intervention group compared to 7.4% of the intervention group.
-Absolute risk reduction of ARDS and VACs of 7.1%.
-Mortality rate was 34.1% in the pre-intervention group, compared to 19.6% in the intervention group.
-Increase in ventilator-free days, ICU-free days and hospital-free days in the intervention group.

Final Thoughts:

Will this study change my clinical practice?  Yes

This study helped me see the following:

  1. A tape measure is a necessary item in the ED so that adequate tidal volumes can be delivered, rather than guessing an inadequate tidal volume.
  2. Start with a lower FiO2 and adjust to the patient’s needs rather than starting at 100% and titrating down. (Adjust PEEP too as needed to help with oxygenation)
  3. I may be underestimating the respiratory rate needs of my patients.

 

Hannah Yang is a PGY2 Emergency Resident at UIC