Mechanical Ventilation Protocol in the ED

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    Mechanical Ventilation Protocol in the ED

    Citation

    Fuller BM, Ferguson IT, Mohr NM, et al. Lung-Protective Ventilation Initiated in the Emergency Department (LOV-ED): A Quasi-Experimental, Before-After Trial. Ann Emerg Med. 2017;

    Clinical Question
    Does a multifaceted, 4-part, ED-based mechanical ventilator protocol improve respiratory and ventilator-associated outcomes?

    The Short Version:

    Using a mechanical ventilation protocol (i.e., protective tidal volumes, appropriate PEEP, low FiO2, and elevating HOB) post-intubation in the ED has beneficial effects in the patient’s downstream hospital course.

    The Long Version:

    Design
    Before-and-after study with a preintervention period followed by a prospective intervention period.

    Setting
    The study was conducted in the ED (intervention) and ICUs (pertinent data and outcomes assessment) of an academic, tertiary medical center.

    Population
    The preintervention group consisted of consecutive, mechanically ventilated patients in the ED identified by validated electronic query method. The intervention group was followed and enrolled consecutively. Propensity score-matched cohorts of 490 patients in each group were compared.

    Intervention
    Multifaceted ED-based 4-part mechanical ventilator protocol targeting
    – lung-protective tidal volume
    – appropriate setting of positive end-expiratory pressure
    – rapid oxygen weaning
    – head-of-bed elevation

    Control
    Propensity score matched cohort

    Outcome
    Primary outcome was the composite incidence of respiratory distress syndrome and ventilator-associated conditions; secondary outcomes were ventilator-free days, ICU-free days, hospital free days, and mortality. The composite outcome decreased after protocol implementation (14.5% to 7.4%). Mortality also decreased after protocol implementation (34.1% to 19.6%). Propensity score-matched analysis showed absolute risk reduction for the primary outcome of 7.1% (aOR 0.47;95%CI 0.31-0.71). Secondary outcomes of mortality (aOR 0.47;95%CI 0.35-0.63) and ventilator-free days (aOR 3.69; 95%CI 2.30-5.07) were improved.

    Conclusion
    Although outcome improvement caused by factors other than the intervention cannot be excluded, these data support the feasibility and potential efficacy of a 4-part lung-protective mechanical ventilation protocol for emergency department patients.

    Strengths
    This pragmatic trial performed a realistic and straightforward intervention. The data behind the 4-part intervention protocol is supported by prior research in line with standard of care. Acute respiratory distress syndrome was adjudicated by blinded assessments.

    Weaknesses
    Causation between protocol and outcomes cannot be proven given possible improved overall care during intervention period. The primary outcome was a composite outcome which tends to equate the two component outcomes. After the propensity score matching, there was still a significant difference between the two study groups with dialysis dependence and those intubated as a result of congestive heart failure or pulmonary edema.

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