Mechanical Ventilation and ARDS in the ED

Abstract

BACKGROUND:Th ere are few data regarding mechanical ventilation and ARDS in the ED. Th is could be a vital arena for prevention and treatment.

A Quasi-Experimental, Before-After Trial Examining the Impact of an Emergency Department Mechanical Ventilator Protocol on Clinical Outcomes and Lung-Protective Ventilation in Acute Respiratory Distress Syndrome

“…Seven days was chosen because the great majority of patients that develop ARDS after admission from the ED will do so within this time period. (14, 19, 21) Exclusion criteria were: 1) extubation within 24 hours; 2) death in the ED or within 24 hours; 3) chronic mechanical ventilation; 4) presence of tracheostomy; and 5) transfer to another hospital.…”

“…(14, 19) To improve these practices, the intervention aimed to address: 1) low tidal volume to prevent volutrauma; 2) appropriate PEEP setting to limit atelectrauma; 3) limitation of hyperoxia with rapid oxygen weaning; and 4) head-of-bed elevation for aspiration precautions. After intubation, the ED respiratory therapist obtained patient height with a tape measure, and tidal volume was indexed to PBW.…”

“…(11–13) Ventilator settings prior to intensive care unit (ICU) arrival influence initial ventilator settings in the ICU; this may be critically important, as delayed initiation of low tidal volume after ARDS onset appears especially influential, both for adherence to LPV and mortality. (6, 14, 15) Even if delivered for comparatively brief periods, LPV can impart significant benefit, as demonstrated by data from the operating room (OR) and in lung donation. (16, 17) Finally, cohort studies have demonstrated that adherence to LPV in the ED is poor and that ED mechanical ventilation is associated with ARDS development.…”

“…(16, 17) Finally, cohort studies have demonstrated that adherence to LPV in the ED is poor and that ED mechanical ventilation is associated with ARDS development. (14, 18, 19) Therefore, a pre-ICU intervention aiming to improve mechanical ventilation in the ED may be an effective strategy to improve adherence to LPV and reduce ARDS mortality.…”

Ventilator Strategies and Rescue Therapies for Management of Acute Respiratory Failure in the Emergency Department

“…A recent multicenter observation study showed that a concerning number of patients receive suboptimal mechanical ventilation while in the ED. 8 The goals of the ED management of acute respiratory failure include minimizing work of breathing, appropriately using noninvasive positive-pressure ventilation (NIPPV), improving gas exchange, optimizing patient-ventilator synchrony, and limiting risk of ventilator-induced lung injury. Controversy remains about the role of noninvasive ventilation, timing of intubation, pharmacologic and nonpharmacologic rescue therapies and their role in the ED, and the role of extracorporeal membrane oxygenation (ECMO).…”