LOV- ED Trial

Dr. Hannah Yang

Background




  • 250,000 patients annually are mechanically ventilated in US Emergency Departments (ED).

  • Of these patients, 20% 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


Parameters


  • Tidal volume

  • PEEP

  • FiO2

  • Respiratory Rate

  • Head of bed elevation to 30 degrees

Study Design


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

  • 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.