Brian M Fuller1, Nicholas M Mohr2, Christopher N Miller3, Andrew R Deitchman4, Brian J Levine4, Nicole Castagno5, Elizabeth C Hassebroek6, Adam Dhedhi7, Nicholas Scott-Wittenborn8, Edward Grace9, Courtney Lehew10, Marin H Kollef11. 1. Department of Emergency Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, MO; Department of Anesthesiology, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, MO. Electronic address: fullerb@wusm.wustl.edu. 2. Department of Emergency Medicine and Anesthesiology, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA. 3. Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH. 4. Department of Emergency Medicine, Christiana Care Health System, Newark, DE. 5. University of Michigan Medical School, Ann Arbor, MI. 6. Department of Critical Care Medicine, Mayo Clinic, Rochester, MN. 7. Saint Louis University School of Medicine, St. Louis, MO. 8. Washington University in St. Louis, St. Louis, MO. 9. Middlebury College, Middlebury, VT. 10. Department of Emergency Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, MO. 11. Division of Critical Care, and the Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, MO.
Abstract
BACKGROUND: There are few data regarding mechanical ventilation and ARDS in the ED. This could be a vital arena for prevention and treatment. METHODS: This study was a multicenter, observational, prospective, cohort study aimed at analyzing ventilation practices in the ED. The primary outcome was the incidence of ARDS after admission. Multivariable logistic regression was used to determine the predictors of ARDS. RESULTS: We analyzed 219 patients receiving mechanical ventilation to assess ED ventilation practices. Median tidal volume was 7.6 mL/kg predicted body weight (PBW) (interquartile range, 6.9-8.9), with a range of 4.3 to 12.2 mL/kg PBW. Lung-protective ventilation was used in 122 patients (55.7%). The incidence of ARDS after admission from the ED was 14.7%, with a mean onset of 2.3 days. Progression to ARDS was associated with higher illness severity and intubation in the prehospital environment or transferring facility. Of the 15 patients with ARDS in the ED (6.8%), lung-protective ventilation was used in seven (46.7%). Patients who progressed to ARDS experienced greater duration in organ failure and ICU length of stay and higher mortality. CONCLUSIONS: Lung-protective ventilation is infrequent in patients receiving mechanical ventilation in the ED, regardless of ARDS status. Progression to ARDS is common after admission, occurs early, and worsens outcome. Patient- and treatment-related factors present in the ED are associated with ARDS. Given the limited treatment options for ARDS, and the early onset after admission from the ED, measures to prevent onset and to mitigate severity should be instituted in the ED. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01628523; URL: www.clinicaltrials.gov.
BACKGROUND: There are few data regarding mechanical ventilation and ARDS in the ED. This could be a vital arena for prevention and treatment. METHODS: This study was a multicenter, observational, prospective, cohort study aimed at analyzing ventilation practices in the ED. The primary outcome was the incidence of ARDS after admission. Multivariable logistic regression was used to determine the predictors of ARDS. RESULTS: We analyzed 219 patients receiving mechanical ventilation to assess ED ventilation practices. Median tidal volume was 7.6 mL/kg predicted body weight (PBW) (interquartile range, 6.9-8.9), with a range of 4.3 to 12.2 mL/kg PBW. Lung-protective ventilation was used in 122 patients (55.7%). The incidence of ARDS after admission from the ED was 14.7%, with a mean onset of 2.3 days. Progression to ARDS was associated with higher illness severity and intubation in the prehospital environment or transferring facility. Of the 15 patients with ARDS in the ED (6.8%), lung-protective ventilation was used in seven (46.7%). Patients who progressed to ARDS experienced greater duration in organ failure and ICU length of stay and higher mortality. CONCLUSIONS: Lung-protective ventilation is infrequent in patients receiving mechanical ventilation in the ED, regardless of ARDS status. Progression to ARDS is common after admission, occurs early, and worsens outcome. Patient- and treatment-related factors present in the ED are associated with ARDS. Given the limited treatment options for ARDS, and the early onset after admission from the ED, measures to prevent onset and to mitigate severity should be instituted in the ED. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01628523; URL: www.clinicaltrials.gov.
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