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McCormick G, Mohr NM, Ablordeppey E, Stephens RJ, Fuller BM, Roberts BW. Partial pressure of carbon dioxide/pH interaction and its association with mortality among patients mechanically ventilated in the emergency department. Am J Emerg Med 2024; 79:105-110. [PMID: 38417220 DOI: 10.1016/j.ajem.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/29/2024] [Accepted: 02/18/2024] [Indexed: 03/01/2024] Open
Abstract
OBJECTIVES There is currently conflicting data as to the effects of hypercapnia on clinical outcomes among mechanically ventilated patients in the emergency department (ED). These conflicting results may be explained by the degree of acidosis. We sought to test the hypothesis that hypercapnia is associated with increased in-hospital mortality and decreased ventilator-free days at lower pH, but associated with decreased in-hospital mortality and increased ventilator-free days at higher pH, among patients requiring mechanical ventilation in the emergency department (ED). METHODS Secondary analysis of patient level data from prior clinical trials and cohort studies that enrolled adult patients who required mechanical ventilation in the ED. Patients who had a documented blood gas while on mechanical ventilation in the ED were included in these analyses. The primary outcome was in-hospital mortality, and secondary outcome was ventilator-free days. Mixed-effects logistic, linear, and survival-time regression models were used to test if pH modified the association between partial pressure of carbon dioxide (pCO2) and outcome measures. RESULTS Of the 2348 subjects included, the median [interquartile range (IQR)] pCO2 was 43 (35-54) and pH was 7.31 (7.22-7.39). Overall, in-hospital mortality was 27%. We found pH modified the association between pCO2 and outcomes, with higher pCO2 associated with increased probability of in-hospital mortality when pH is below 7.00, and decreased probability of in-hospital mortality when pH is above 7.10. These results remained consistent across multiple sensitivity and subgroup analyses. A similar relationship was found with ventilator-free days. CONCLUSIONS Higher pCO2 is associated with decreased mortality and greater ventilator-free days when pH is >7.10; however, it is associated with increased mortality and fewer ventilator-free days when the pH is below 7.00. Targeting pCO2 based on pH in the ED may be a potential intervention target for future clinical trials to improve clinical outcomes.
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Affiliation(s)
- Gregory McCormick
- The Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesia, Division of Critical Care Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, United States of America
| | - Enyo Ablordeppey
- Departments of Emergency Medicine and Anesthesia, Division of Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Robert J Stephens
- Department of Medicine, Division of Critical Care, University of Maryland School of Medicine, United States of America
| | - Brian M Fuller
- Departments of Emergency Medicine and Anesthesia, Division of Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Brian W Roberts
- The Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States of America.
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Mosier JM, Tidswell M, Wang HE. Noninvasive respiratory support in the emergency department: Controversies and state-of-the-art recommendations. J Am Coll Emerg Physicians Open 2024; 5:e13118. [PMID: 38464331 PMCID: PMC10920951 DOI: 10.1002/emp2.13118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/21/2024] [Accepted: 01/26/2024] [Indexed: 03/12/2024] Open
Abstract
Acute respiratory failure is a common reason for emergency department visits and hospital admissions. Diverse underlying physiologic abnormalities lead to unique aspects about the most common causes of acute respiratory failure: acute decompensated heart failure, acute exacerbation of chronic obstructive pulmonary disease, and acute de novo hypoxemic respiratory failure. Noninvasive respiratory support strategies are increasingly used methods to support work of breathing and improve gas exchange abnormalities to improve outcomes relative to conventional oxygen therapy or invasive mechanical ventilation. Noninvasive respiratory support includes noninvasive positive pressure ventilation and nasal high flow, each with unique physiologic mechanisms. This paper will review the physiology of respiratory failure and noninvasive respiratory support modalities and offer data and guideline-driven recommendations in the context of key clinical controversies.
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Affiliation(s)
- Jarrod M. Mosier
- Department of Emergency MedicineThe University of Arizona College of MedicineTucsonArizonaUSA
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Department of MedicineThe University of Arizona College of MedicineTucsonArizonaUSA
| | - Mark Tidswell
- Division of Pulmonary and Critical Care, Department of MedicineUniversity of Massachusetts Chan Medical School – Baystate Medical CenterSpringfieldMassachusettsUSA
| | - Henry E. Wang
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
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Fuller BM, Mohr NM, Ablordeppey E, Roman O, Mittauer D, Yan Y, Kollef MH, Carpenter CR, Roberts BW. The Practice Change and Clinical Impact of Lung-Protective Ventilation Initiated in the Emergency Department: A Secondary Analysis of Individual Patient-Level Data From Prior Clinical Trials and Cohort Studies. Crit Care Med 2023; 51:279-290. [PMID: 36374044 PMCID: PMC10907984 DOI: 10.1097/ccm.0000000000005717] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Mechanically ventilated emergency department (ED) patients experience high morbidity and mortality. In a prior trial at our center, ED-based lung-protective ventilation was associated with improved care delivery and outcomes. Whether this strategy has persisted in the years after the trial remains unclear. The objective was to assess practice change and clinical outcomes associated with ED lung-protective ventilation. DESIGN Secondary analysis of individual patient-level data from prior clinical trials and cohort studies. SETTING ED and ICUs of a single academic center. PATIENTS Mechanically ventilated adults. INTERVENTIONS A lung-protective ventilator protocol used as the default approach in the ED. MEASUREMENTS AND MAIN RESULTS The primary ventilator-related outcome was tidal volume, and the primary clinical outcome was hospital mortality. Secondary outcomes included ventilator-, hospital-, and ICU-free days. Multivariable logistic regression, propensity score (PS)-adjustment, and multiple a priori subgroup analyses were used to evaluate outcome as a function of the intervention. A total of 1,796 patients in the preintervention period and 1,403 patients in the intervention period were included. In the intervention period, tidal volume was reduced from 8.2 mL/kg predicted body weight (PBW) (7.3-9.1) to 6.5 mL/kg PBW (6.1-7.1), and low tidal volume ventilation increased from 46.8% to 96.2% ( p < 0.01). The intervention period was associated with lower mortality (35.9% vs 19.1%), remaining significant after multivariable logistic regression analysis (adjusted odds ratio [aOR], 0.43; 95% CI, 0.35-0.53; p < 0.01). Similar results were seen after PS adjustment and in subgroups. The intervention group had more ventilator- (18.8 [10.1] vs 14.1 [11.9]; p < 0.01), hospital- (12.2 [9.6] vs 9.4 [9.5]; p < 0.01), and ICU-free days (16.6 [10.1] vs 13.1 [11.1]; p < 0.01). CONCLUSIONS ED lung-protective ventilation has persisted in the years since implementation and was associated with improved outcomes. These data suggest the use of ED-based lung-protective ventilation as a means to improve outcome.
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Affiliation(s)
- Brian M Fuller
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Enyo Ablordeppey
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Olivia Roman
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Dylan Mittauer
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, Division of Biostatistics, Washington University School of Medicine, St. Louis, MO
| | - Marin H Kollef
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ
| | - Christopher R Carpenter
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Brian W Roberts
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
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Fuller BM, Pappal RD, Mohr NM, Roberts BW, Faine B, Yeary J, Sewatsky T, Johnson NJ, Driver BE, Ablordeppey E, Drewry AM, Wessman BT, Yan Y, Kollef MH, Carpenter CR, Avidan MS. Awareness With Paralysis Among Critically Ill Emergency Department Patients: A Prospective Cohort Study. Crit Care Med 2022; 50:1449-1460. [PMID: 35866657 PMCID: PMC10040234 DOI: 10.1097/ccm.0000000000005626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES In mechanically ventilated patients, awareness with paralysis (AWP) can have devastating consequences, including post-traumatic stress disorder (PTSD), depression, and thoughts of suicide. Single-center data from the emergency department (ED) demonstrate an event rate for AWP factors higher than that reported from the operating room. However, there remains a lack of data on AWP among critically ill, mechanically ventilated patients. The objective was to assess the proportion of ED patients experiencing AWP and investigate modifiable variables associated with its occurrence. DESIGN An a priori planned secondary analysis of a multicenter, prospective, before-and-after clinical trial. SETTING The ED of three academic medical centers. PATIENTS Mechanically ventilated adult patients that received neuromuscular blockers. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All data related to sedation and analgesia were collected. AWP was the primary outcome, assessed with the modified Brice questionnaire, and was independently adjudicated by three expert reviewers. Perceived threat, in the causal pathway for PTSD, was the secondary outcome. A total of 388 patients were studied. The proportion of patients experiencing AWP was 3.4% ( n = 13), the majority of whom received rocuronium ( n = 12/13; 92.3%). Among patients who received rocuronium, 5.5% ( n = 12/230) experienced AWP, compared with 0.6% ( n = 1/158) among patients who did not receive rocuronium in the ED (odds ratio, 8.64; 95% CI, 1.11-67.15). Patients experiencing AWP had a higher mean ( sd ) threat perception scale score, compared with patients without AWP (15.6 [5.8] vs 7.7 [6.0]; p < 0.01). CONCLUSIONS AWP was present in a concerning proportion of mechanically ventilated ED patients, was associated with rocuronium exposure in the ED, and led to increased levels of perceived threat, placing patients at greater risk for PTSD. Studies that aim to further quantify AWP in this vulnerable population and eliminate its occurrence are urgently needed.
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Affiliation(s)
- Brian M Fuller
- Departments of Anesthesiology and Emergency Medicine, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Ryan D Pappal
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Brian W Roberts
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ
| | - Brett Faine
- Departments of Emergency Medicine and Pharmacy, Roy J. and Lucille A. Carver College of Medicine, University of Iowa College of Pharmacy, Iowa City, IA
| | - Julianne Yeary
- Emergency Department, Charles F. Knight Emergency and Trauma Center, Barnes Jewish Hospital, St. Louis, MO
| | - Thomas Sewatsky
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ
| | - Nicholas J Johnson
- Departments of Emergency Medicine and Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington/Harborview Medical Center, Seattle, WA
| | - Brian E Driver
- Department of Emergency Medicine, University of Minnesota School of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Enyo Ablordeppey
- Departments of Anesthesiology and Emergency Medicine, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Anne M Drewry
- Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Brian T Wessman
- Departments of Anesthesiology and Emergency Medicine, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, Division of Biostatistics, Washington University School of Medicine, St. Louis, MO
| | - Marin H Kollef
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Christopher R Carpenter
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Michael S Avidan
- Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO
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Stephens RJ, Evans EM, Pajor MJ, Pappal RD, Egan HM, Wei M, Hayes H, Morris JA, Becker N, Roberts BW, Kollef MH, Mohr NM, Fuller BM. A dual-center cohort study on the association between early deep sedation and clinical outcomes in mechanically ventilated patients during the COVID-19 pandemic: The COVID-SED study. Crit Care 2022; 26:179. [PMID: 35705989 PMCID: PMC9198202 DOI: 10.1186/s13054-022-04042-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/25/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Mechanically ventilated patients have experienced greater periods of prolonged deep sedation during the coronavirus disease (COVID-19) pandemic. Multiple studies from the pre-COVID era demonstrate that early deep sedation is associated with worse outcome. Despite this, there is a lack of data on sedation depth and its impact on outcome for mechanically ventilated patients during the COVID-19 pandemic. We sought to characterize the emergency department (ED) and intensive care unit (ICU) sedation practices during the COVID-19 pandemic, and to determine if early deep sedation was associated with worse clinical outcomes. STUDY DESIGN AND METHODS Dual-center, retrospective cohort study conducted over 6 months (March-August, 2020), involving consecutive, mechanically ventilated adults. All sedation-related data during the first 48 h were collected. Deep sedation was defined as Richmond Agitation-Sedation Scale of - 3 to - 5 or Riker Sedation-Agitation Scale of 1-3. To examine impact of early sedation depth on hospital mortality (primary outcome), we used a multivariable logistic regression model. Secondary outcomes included ventilator-, ICU-, and hospital-free days. RESULTS 391 patients were studied, and 283 (72.4%) experienced early deep sedation. Deeply sedated patients received higher cumulative doses of fentanyl, propofol, midazolam, and ketamine when compared to light sedation. Deep sedation patients experienced fewer ventilator-, ICU-, and hospital-free days, and greater mortality (30.4% versus 11.1%) when compared to light sedation (p < 0.01 for all). After adjusting for confounders, early deep sedation remained significantly associated with higher mortality (adjusted OR 3.44; 95% CI 1.65-7.17; p < 0.01). These results were stable in the subgroup of patients with COVID-19. CONCLUSIONS The management of sedation for mechanically ventilated patients in the ICU has changed during the COVID pandemic. Early deep sedation is common and independently associated with worse clinical outcomes. A protocol-driven approach to sedation, targeting light sedation as early as possible, should continue to remain the default approach.
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Affiliation(s)
- Robert J. Stephens
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, Campus Box 8054, St. Louis, MO 63110 USA
| | - Erin M. Evans
- Division of Critical Care, Departments of Emergency Medicine and Anesthesia, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, 200 Hawkins Drive, 1008 RCP, Iowa City, IA 52242 USA
| | - Michael J. Pajor
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, Campus Box 8054, St. Louis, MO 63110 USA
| | - Ryan D. Pappal
- Washington University School of Medicine in St. Louis, St. Louis, MO 63110 USA
| | - Haley M. Egan
- Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Max Wei
- Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Hunter Hayes
- Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Jason A. Morris
- Department of Emergency Medicine, Harvard-Affiliated Emergency Medicine Residency, Mass General Brigham, Boston, MA 02115 USA
| | - Nicholas Becker
- Department of Emergency Medicine, Mount Sinai Morningside/West, New York, NY 10025 USA
| | - Brian W. Roberts
- Department of Emergency Medicine, Cooper University Hospital, One Cooper Plaza, Camden, NJ K152 USA
| | - Marin H. Kollef
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO 63110 USA
| | - Nicholas M. Mohr
- Division of Critical Care, Departments of Emergency Medicine and Anesthesia, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, 200 Hawkins Drive, 1008 RCP, Iowa City, IA 52242 USA
| | - Brian M. Fuller
- Division of Critical Care, Departments of Anesthesiology and Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO 63110 USA
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Moy HP, Nayman BD, Olvera D, Monnin KD, Pappal RD, Hayes JM, Mohr NM, Kollef MH, Palmer CM, Ablordeppey E, Roberts BW, Fuller BM. Mechanical Ventilation Practices and Low Tidal Volume Ventilation in Air Medical Transport Patients: The AIR-VENT Study. Respir Care 2022; 67:647-656. [PMID: 35440496 PMCID: PMC9994187 DOI: 10.4187/respcare.09824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The management of mechanical ventilation critically impacts outcome for patients with acute respiratory failure. Ventilator settings in the early post-intubation period may be especially influential on outcome. Low tidal volume ventilation in the prehospital setting has been shown to impact the provision of low tidal volume after admission and influence outcome. However, there is an overall paucity of data on mechanical ventilation for air medical transport patients. The objectives of this study were to characterize air medical transport ventilation practices and assess variables associated with nonprotective ventilation. METHODS This was a multi-center, nationwide (approximately 130 bases) retrospective cohort study conducted on consecutive, adult mechanically ventilated air medical transport patients treated in the prehospital environment. Descriptive statistics were used to assess the cohort; the chi-square test compared categorical variables, and continuous variables were compared using independent samples t test or Mann-Whitney U test. To assess for predictors of nonprotective ventilation, a multivariable logistic regression model was constructed to adjust for potentially confounding variables. Low tidal volume ventilation was defined as a tidal volume of ≤ 8 mL/kg predicted body weight (PBW). RESULTS A total of 68,365 subjects were studied. Height was documented in only 4,186 (6.1%) subjects. Significantly higher tidal volume/PBW (8.6 [8.3-9.2] mL vs 6.5 [6.1-7.0] mL) and plateau pressure (20.0 [16.5-25.0] cm H2O vs 18.0 [15.0-22.0] cm H2O) were seen in the nonpro-tective ventilation group (P < .001 for both). According to sex, females received higher tidal volume/PBW compared to males (7.4 [6.6-8.0] mL vs 6.4 [6.0-6.8] mL, P < .001) and composed 75% of those subjects with nonprotective ventilation compared to 25% male, P < .001. After multivariable logistic regression, female sex was an independent predictor of nonprotective ventilation (adjusted odds ratio 6.79 [95% CI 5.47-8.43], P < .001). CONCLUSIONS The overwhelming majority of air medical transport subjects had tidal volume set empirically, which may be exposing patients to nonprotective ventilator settings. Given a lack of PBW assessments, the frequency of low tidal volume use remains unknown. Performance improvement initiatives aimed at indexing tidal volume to PBW are easy targets to improve the delivery of mechanical ventilation in the prehospital arena, especially for females.
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Affiliation(s)
- Hawnwan P Moy
- Department of Emergency Medicine, Division of Emergency Medical Services, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | | | | | - Karlee De Monnin
- Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Ryan D Pappal
- Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Jane M Hayes
- Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Marin H Kollef
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Christopher M Palmer
- Departments of Anesthesiology and Emergency Medicine, Division of Critical Care, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Enyo Ablordeppey
- Departments of Anesthesiology and Emergency Medicine, Division of Critical Care, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Brian W Roberts
- Department of Emergency Medicine, Cooper University Hospital, Camden, New Jersey
| | - Brian M Fuller
- Departments of Anesthesiology and Emergency Medicine, Division of Critical Care, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri.
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Granados-Bolivar ME, Quesada-Caballero M, Suleiman-Martos N, Romero-Béjar JL, Albendín-García L, Cañadas-De la Fuente GA, Caballero-Vázquez A. Evolution of Acute Respiratory Distress Syndrome in Emergency and Critical Care: Therapeutic Management before and during the Pandemic Situation. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:726. [PMID: 35743989 PMCID: PMC9229826 DOI: 10.3390/medicina58060726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/23/2022] [Accepted: 05/25/2022] [Indexed: 11/23/2022]
Abstract
Background and Objectives: Acute respiratory distress syndrome is a life-threatening lung condition that prevents enough oxygen from getting to the lungs and blood. The causes can be varied, although since the COVID-19 pandemic began there have been many cases related to this virus. The management and evolution of ARDS in emergency situations in the last 5 years was analyzed. Materials and Methods: A systematic review was carried out in the PubMed and Scopus databases. Using the descriptors Medical Subject Headings (MeSH), the search equation was: "Emergency health service AND acute respiratory distress syndrome". The search was conducted in December 2021. Quantitative primary studies on the care of patients with ARDS in an emergency setting published in the last 5 years were included. Results: In the initial management, adherence to standard treatment with continuous positive airway pressure (CPAP) is recommended. The use of extracorporeal membrane reduces the intensity of mechanical ventilation or as rescue therapy in acute respiratory distress syndrome (ARDS). The prone position in both intubated and non-intubated patients with severe ARDS is associated with a better survival of these patients, therefore, it is very useful in these moments of pandemic crisis. Lack of resources forces triage decisions about which patients are most likely to survive to start mechanical ventilation and this reflects the realities of intensive care and emergency care in a resource-limited setting. Conclusions: adequate prehospital management of ARDS and in emergency situations can improve the prognosis of patients. The therapeutic options in atypical ARDS due to COVID-19 do not seem to vary substantially from conventional ARDS.
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Affiliation(s)
- Monserrat E. Granados-Bolivar
- Iznalloz Health Center, Granada Metropolitan District, Andalusian Health Service, Calle Virgen de la Consolación, 12, 18015 Granada, Spain;
| | - Miguel Quesada-Caballero
- Albayda La Cruz Health Center, Granada Metropolitan District, Andalusian Health Service, Calle Virgen de la Consolación, 12, 18015 Granada, Spain;
| | - Nora Suleiman-Martos
- Faculty of Health Sciences, University of Granada, Campus Universitario de Ceuta, C/Cortadura del Valle SN, 51001 Ceuta, Spain;
| | - José L. Romero-Béjar
- Statistics and Operational Research Department, University of Granada, Avda. Fuentenueva S/N, 18071 Granada, Spain
| | - Luis Albendín-García
- Casería de Montijo Health Center, Granada Metropolitan District, Andalusian Health Service, Calle Virgen de la Consolación, 12, 18015 Granada, Spain;
| | | | - Alberto Caballero-Vázquez
- Diagnostic Lung Cancer Unit, Broncopleural Techniques and Interventional Pulmonology Departament, Hospital Universitario Virgen de las Nieves, 18014 Granada, Spain;
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Initiation of a Lung Protective Ventilation Strategy in the Emergency Department: Does an Emergency Department-Based ICU Make a Difference? Crit Care Explor 2022; 4:e0632. [PMID: 35156050 PMCID: PMC8826963 DOI: 10.1097/cce.0000000000000632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND: Lung protective ventilation (LPV) is a key component in the management of acute respiratory distress syndrome and other acute respiratory pathology. Initiation of LPV in the emergency department (ED) is associated with improved patient-centered and system outcomes, but adherence to LPV among ED patients is low. The impact of an ED-based ICU (ED-ICU) on LPV adherence is not known. METHODS: This single-center, retrospective, cohort study analyzed rates of adherence to a multifaceted LPV strategy pre- and post-implementation of an ED-ICU. LPV strategy components included low tidal volume ventilation, avoidance of severe hyperoxia and high plateau pressures, and positive end-expiratory pressure settings in alignment with best-evidence recommendations. The primary outcome was adherence to the LPV strategy at time of ED departure. RESULTS AND CONCLUSIONS: A total of 561 ED visits were included in the analysis, of which 60.0% received some portion of their emergency care in the ED-ICU. Adherence to the LPV strategy was statistically significantly higher in the ED-ICU cohort compared with the pre-ED-ICU cohort (65.8% vs 41.4%; p < 0.001) and non-ED-ICU cohort (65.8% vs 43.1%; p < 0.001). Among the ED-ICU cohort, 92.8% of patients received low tidal volume ventilation. Care in the ED-ICU was also associated with shorter ICU and hospital length of stay. These findings suggest improved patient and resource utilization outcomes for mechanically ventilated ED patients receiving care in an ED-ICU.
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9
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Low Tidal Volume Ventilation for Emergency Department Patients: A Systematic Review and Meta-Analysis on Practice Patterns and Clinical Impact. Crit Care Med 2022; 50:986-998. [PMID: 35120042 DOI: 10.1097/ccm.0000000000005459] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Data suggest that low tidal volume ventilation (LTVV) initiated in the emergency department (ED) has a positive impact on outcome. This systematic review and meta-analysis quantify the impact of ED-based LTVV on outcomes and ventilator settings in the ED and ICU. DATA SOURCES We systematically reviewed MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, references, conferences, and ClinicalTrials.gov. STUDY SELECTION Randomized and nonrandomized studies of mechanically ventilated ED adults were eligible. DATA EXTRACTION Two reviewers independently screened abstracts. The primary outcome was mortality. Secondary outcomes included ventilation duration, lengths of stay, and occurrence rate of acute respiratory distress syndrome (ARDS). We assessed impact of ED LTVV interventions on ED and ICU tidal volumes. DATA SYNTHESIS The search identified 1,023 studies. Eleven studies (n = 12,912) provided outcome data and were meta-analyzed; 10 additional studies (n = 1,863) provided descriptive ED tidal volume data. Overall quality of evidence was low. Random effect meta-analytic models revealed that ED LTVV was associated with lower mortality (26.5%) versus non-LTVV (31.1%) (odds ratio, 0.80 [0.72-0.88]). ED LTVV was associated with shorter ICU (mean difference, -1.0; 95% CI, -1.7 to -0.3) and hospital (mean difference, -1.2; 95% CI, -2.3 to -0.1) lengths of stay, more ventilator-free days (mean difference, 1.4; 95% CI, 0.4-2.4), and lower occurrence rate (4.5% vs 8.3%) of ARDS (odds ratio, 0.57 [0.44-0.75]). ED LTVV interventions were associated with reductions in ED (-1.5-mL/kg predicted body weight [PBW] [-1.9 to -1.0]; p < 0.001) and ICU (-1.0-mL/kg PBW [-1.8 to -0.2]; p = 0.01) tidal volume. CONCLUSIONS The use of LTVV in the ED is associated with improved clinical outcomes and increased use of lung protection, recognizing low quality of evidence in this domain. Interventions aimed at implementing and sustaining LTVV in the ED should be explored.
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Baez AA, Qasim Z, Wilcox S, Weir WB, Loeffler P, Golden BM, Schwartz D, Levy M. Prehospital Mechanical Ventilation: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:88-95. [PMID: 35001824 DOI: 10.1080/10903127.2021.1994676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Airway emergencies and respiratory failure frequently occur in the prehospital setting. Patients undergoing advanced airway management customarily receive manual ventilations. However, manual ventilation is associated with hypo- and hyperventilation, variable tidal volumes, and barotrauma, among other potential complications. Portable mechanical ventilators offer an important strategy for optimizing ventilation and mitigating ventilatory complications.EMS clinicians, including those performing emergency response as well as interfacility transports, should consider using mechanical ventilation after advanced airway insertion.Prehospital mechanical ventilation techniques, strategies, and parameters should be disease-specific and should mirror in-hospital best practices.EMS clinicians must receive training in the general principles of mechanical ventilation as well as detailed training in the operation of the specific system(s) used by the EMS agency.Patients undergoing mechanical ventilation must receive appropriate sedation and analgesia.
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11
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Roginski MA, Burney CP, Husson EG, Harper KR, Atchinson PRA, Munson JC. Influence of Critical Care Transport Ventilator Management on Intensive Care Unit Care. Air Med J 2022; 41:96-102. [PMID: 35248352 DOI: 10.1016/j.amj.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/16/2021] [Accepted: 10/13/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE High tidal volume ventilation is associated with ventilator-induced lung injury. Early introduction of lung protective ventilation improves patient outcomes. This study describes ventilator management during critical care transport and the association between transport ventilator settings and ventilator settings in the intensive care unit (ICU). METHODS This was a retrospective review of mechanically ventilated adult patients transported to an academic medical center via a critical care transport program between January 2018 and April 2019. Ventilator settings during transport were compared with the initial and 6- and 12-hour postadmission ventilator settings. RESULTS Three hundred eighty patients were identified; 114 (30%) received tidal volumes > 8 mL/kg predicted body weight at the time of transfer. The transport handoff tidal volume strongly correlated with the ICU tidal volume (Pearson r = 0.7). Patients receiving high tidal volumes during transport were more likely to receive high tidal volumes initially upon transfer (relative risk [RR] = 4.6; 95% confidence interval [CI], 3.3-6.5) and at 6 and 12 hours after admission (RR = 2.6; 95% CI, 1.8-3.8 and RR = 2.7; 95% CI, 1.7-4.3, respectively). CONCLUSION Exposure to high tidal volumes during transport is associated with high tidal volume ventilation in the ICU, even up to 12 hours after admission. This study identifies opportunities for improving patient care through the application of lung protective ventilation strategies during transport.
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Affiliation(s)
- Matthew A Roginski
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Medicine, Section of Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | - Charles P Burney
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | | | | | - Patricia Ruth A Atchinson
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Medicine, Section of Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jeffrey C Munson
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
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12
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Utility of solar-powered oxygen delivery in a resource-constrained setting. Pulmonology 2021:S2531-0437(21)00224-5. [PMID: 34937668 DOI: 10.1016/j.pulmoe.2021.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 11/10/2021] [Accepted: 11/20/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Pneumonia is a leading cause of childhood mortality globally. Children with severe pneumonia associated with hypoxaemia require oxygen (O2) therapy, which is scarce across resource-constrained countries. Solar-powered oxygen (SPO2) is a novel technology developed for delivering therapeutic O2 in resource-constrained environments. RESEARCH QUESTION Is the introduction of SPO2 associated with a reduction in mortality, relative to the existing practice? STUDY DESIGN This was a pragmatic, quasi-experimental study comparing mortality amongst children < 5 years of age with hypoxaemic respiratory illness before and after the installation of SPO2 in two resource-constrained hospitals. METHODS Participants were children < 5 years old admitted with acute hypoxaemic respiratory illness. The intervention was SPO2, installed at two resource-constrained hospitals. The primary outcome was 30-day mortality. Secondary outcomes included in-hospital mortality (time to death), length of hospital stay among survivors, duration of O2 therapy (time to wean O2), and O2 delivery system failure(s). RESULTS Mortality amongst children admitted with acute hypoxaemic respiratory illness decreased from 30/50 (60%) pre-SPO2 to 15/50 (30%) post-SPO2 (relative risk reduction 50%, 95%CI 19 - 69, p = 0.0049). The post-SPO2 period was consistently associated with decreased mortality in statistical models adjusting for potential confounding factors. Likewise, survival curves pre- and post- SPO2 differed significantly (hazard ratio 0.39, 95% CI 0.20 - 0.74, p = 0.0043). A reduction in the frequency of O2 delivery interruptions due to fuel shortages and multiple patients needing the concentrator at once was observed, explaining the mortality reduction. INTERPRETATION Solar-powered oxygen installation was associated with decreased mortality in resource-constrained settings.
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13
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A Target for Increased Mortality Risk in Critically Ill Patients: The Concept of Perpetuity. J Clin Med 2021; 10:jcm10173971. [PMID: 34501419 PMCID: PMC8432225 DOI: 10.3390/jcm10173971] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 08/24/2021] [Accepted: 08/25/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Emergency medicine is acuity-based and focuses on time-sensitive treatments for life-threatening diseases. Prolonged time in the emergency department, however, is associated with higher mortality in critically ill patients. Thus, we explored management after an acuity-based intervention, which we call perpetuity, as a potential mechanism for increased risk. To explore this concept, we evaluated the impact of each hour above a lung-protective tidal volume on risk of mortality. Methods: This cohort analysis includes all critically ill, non-trauma, adult patients admitted to two academic EDs between 1 November 2013 and 30 April 2017. Cox models with time-varying covariates were developed with time in perpetuity as a time-varying covariate, defined as hours above 8 mL/kg ideal body weight, adjusted for covariates. The primary outcome was the time to in-hospital death. Results: Our analysis included 2025 patients, 321 (16%) of whom had at least 1 h of perpetuity time. A partial likelihood-ratio test comparing models with and without hours in perpetuity was statistically significant (χ2(3) = 13.83, p = 0.0031). There was an interaction between age and perpetuity (Relative risk (RR) 0.9995; 95% Confidence interval (CI95): 0.9991–0.9998). For example, for each hour above 8 mL/kg ideal body weight, a 20-year-old with 90% oxygen saturation has a relative risk of death of 1.02, but a 40-year-old with 90% oxygen saturation has a relative risk of 1.01. Conclusions: Perpetuity, illustrated through the lens of mechanical ventilation, may represent a target for improving outcomes in critically ill patients, starting in the emergency department. Research is needed to evaluate the types of patients and interventions in which perpetuity plays a role.
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14
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The Society of Critical Care Medicine at 50 Years: Interprofessional Practice in Critical Care: Looking Back and Forging Ahead. Crit Care Med 2021; 49:2017-2032. [PMID: 34387239 PMCID: PMC8594495 DOI: 10.1097/ccm.0000000000005276] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Abstract
OBJECTIVES: Prior studies have demonstrated suboptimal adherence to lung protective ventilation among patients with acute respiratory distress syndrome. A common barrier to providing this evidence-based practice is diagnostic uncertainty. We sought to test the hypothesis that patients with acute respiratory distress syndrome due to coronavirus disease 2019, in whom acute respiratory distress syndrome is easily recognized, would be more likely to receive low tidal volume ventilation than concurrently admitted acute respiratory distress syndrome patients without coronavirus disease 2019. DESIGN: Retrospective cohort study. SETTING: Five hospitals of a single health system. PATIENTS: Mechanically ventilated patients with coronavirus disease 2019 or noncoronavirus disease 2019 acute respiratory distress syndrome as identified by an automated, electronic acute respiratory distress syndrome finder in clinical use at study hospitals. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among 333 coronavirus disease 2019 patients and 234 noncoronavirus disease 2019 acute respiratory distress syndrome patients, the average initial tidal volume was 6.4 cc/kg predicted body weight and 6.8 cc/kg predicted body weight, respectively. Patients had tidal volumes less than or equal to 6.5 cc/kg predicted body weight for a mean of 70% of the first 72 hours of mechanical ventilation in the coronavirus disease 2019 cohort, compared with 52% in the noncoronavirus disease 2019 cohort (unadjusted p < 0.001). After adjusting for height, gender, admitting hospital, and whether or not the patient was admitted to a medical specialty ICU, coronavirus disease 2019 diagnosis was associated with a 21% higher percentage of time receiving tidal volumes less than or equal to 6.5 cc/kg predicted body weight within the first 72 hours of mechanical ventilation (95% CI, 14–28%; p < 0.001). CONCLUSIONS: Adherence to low tidal volume ventilation during the first 72 hours of mechanical ventilation is higher in patients with coronavirus disease 2019 than with acute respiratory distress syndrome without coronavirus disease 2019. This population may present an opportunity to understand facilitators of implementation of this life-saving evidence-based practice.
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16
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See KC, Sahagun J, Taculod J. Patient characteristics and outcomes associated with adherence to the low PEEP/FIO2 table for acute respiratory distress syndrome. Sci Rep 2021; 11:14619. [PMID: 34272453 PMCID: PMC8285534 DOI: 10.1038/s41598-021-94081-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 07/01/2021] [Indexed: 11/24/2022] Open
Abstract
It remains uncertain how best to set positive end-expiratory pressure (PEEP) for mechanically ventilated patients with the acute respiratory distress syndrome (ARDS). Among patients on low tidal volume ventilation (LTVV), we investigated if further adherence to the low PEEP/FIO2 (inspired oxygen fraction) table would be associated with better survival compared to nonadherence. Patients with ARDS, admitted directly from the Emergency Department to our 20-bed Medical Intensive Care Unit (ICU) from August 2016 to July 2017, were retrospectively studied. To determine adherence to the low PEEP/FIO2 table, PEEP and FIO2 12 h after ICU admission were used, to reflect ventilator adjustments by ICU clinicians after initial stabilization. Logistic regression was used to analyze hospital mortality as an outcome with adherence to the low PEEP/FIO2 as the key independent variable, adjusted for age, APACHE II score, initial P/F ratio and initial systolic blood pressure. 138 patients with ARDS were analysed. Overall adherence to the low PEEP/FIO2 table was 75.4%. Among patients on LTVV, nonadherence to the low PEEP/FIO2 table was associated with increased mortality compared to adherence (adjusted odds ratio 4.10, 95% confidence interval 1.68–9.99, P = 0.002). Patient characteristics at baseline were not associated with adherence to the low PEEP/FIO2 table.
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Affiliation(s)
- Kay Choong See
- Division of Respiratory & Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, NUHS Tower Block Level 10, Singapore, 119228, Singapore. .,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
| | - Juliet Sahagun
- Division of Critical Care-Respiratory Therapy, National University Hospital, Singapore, Singapore
| | - Juvel Taculod
- Division of Critical Care-Respiratory Therapy, National University Hospital, Singapore, Singapore
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Promoting Evidence-Based Practice in Acute Respiratory Distress Syndrome: A Systematic Review. Crit Care Explor 2021; 3:e0391. [PMID: 33912832 PMCID: PMC8078296 DOI: 10.1097/cce.0000000000000391] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Supplemental Digital Content is available in the text. OBJECTIVE: Low tidal volume ventilation and prone positioning are recommended therapies yet underused in acute respiratory distress syndrome. We aimed to assess the role of interventions focused on implementation of low tidal volume ventilation and prone positioning in mechanically ventilated adult patients with acute respiratory distress syndrome. DATA SOURCES: PubMed, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials. STUDY SELECTION: We searched the four databases from January 1, 2001, to January 28, 2021, for studies that met the predefined search criteria. Selected studies focused on interventions to improve implementation of low tidal volume ventilation and prone positioning in mechanically ventilated patients with acute respiratory distress syndrome. DATA EXTRACTION: Two authors independently performed study selection and data extraction using a standardized form. DATA SYNTHESIS: Due to methodological heterogeneity of included studies, meta-analysis was not feasible; thus, we provided a narrative summary and assessment of the literature. Eight nonrandomized studies met our eligibility criteria. Most studies looked at interventions to improve adherence to low tidal volume ventilation. Most interventions focused on education for providers. Studies were primarily conducted in the ICU and involved trainees, intensivists, respiratory therapists, and critical care nurses. Although overall quality of the studies was very low, the primary outcomes of interest suggest that interventions could improve adherence to or implementation of low tidal volume ventilation and prone positioning in acute respiratory distress syndrome. Measurements and Main Results: Two authors independently performed study selection and data extraction using a standardized form. Due to methodologic heterogeneity of included studies, meta-analysis was not feasible; thus, we provided a narrative summary and assessment of the literature. Eight nonrandomized studies met our eligibility criteria. Most studies looked at interventions to improve adherence to low tidal volume ventilation. Most interventions focused on education for providers. Studies were primarily conducted in the ICU and involved trainees, intensivists, respiratory therapists, and critical care nurses. Although overall quality of the studies was very low, the primary outcomes of interest suggest that interventions could improve adherence to or implementation of low tidal volume ventilation and prone positioning in acute respiratory distress syndrome. Conclusions: There is a dearth of literature addressing interventions to improve implementation of evidence-based practices in acute respiratory distress syndrome. Existing interventions to improve clinician knowledge and facilitate application of low tidal volume ventilation and prone positioning may be effective, but supporting studies have significant limitations.
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18
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Duggal A, Panitchote A, Siuba M, Krishnan S, Torbic H, Hastings A, Mehkri O, Hanane T, Hatipoglu U, Hite RD, Mireles-Cabodevila E. Implementation of Protocolized Care in ARDS Improves Outcomes. Respir Care 2021; 66:600-609. [PMID: 33051253 PMCID: PMC9993996 DOI: 10.4187/respcare.07999] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Treatments for ARDS that improve patient outcomes include use of lung-protective ventilation, prone ventilation, and conservative fluid management. Implementation of ARDS protocols via educational programs might improve adherence and outcomes. The objective of this study was to investigate the effects of an ARDS protocol implementation on outcomes and adherence with ARDS guidelines. METHODS This was a single-center, interventional, comparative study before and after protocol implementation. Staff education for the ARDS protocol was implemented between June 2014 and May 2015. A retrospective cohort analysis was conducted during between January 2012 and May 2014 (pre-protocol) and between June 2015 and June 2017 (post-protocol). A total of 450 subjects with ARDS were included. After propensity score matching, 432 subjects were analyzed. Of those, 330 subjects were treated after protocol implementation. RESULTS The median (interquartile range [IQR]) plateau pressure and tidal volume over the first 3 d decreased significantly after protocol implementation (30.5 [IQR 24.2-33] vs 25.5 [IQR 21.7-30], P = .01 and 7.65 vs 7.4 mL/kg predicted body weight, P = .032, respectively). The percentage of subjects with unsafe tidal volume (> 10 mL/kg predicted body weight) decreased (14.4% vs 5.8%, P = .02). The percentage of subjects with safe plateau pressure (≤ 30 cm H2O) increased (47.4% vs 76.5%, P < .001). PEEP deviation from the ARDSNet PEEP/[Formula: see text] table was significantly lower after the implementation. Mortality at 28 and 90 days improved after implementation (53.9% vs 41.8% and 61.8% vs 48.2%, respectively). Adjusted odds ratios for 28-d and 90-d mortality were 0.47 (95% CI 0.28-0.78) and 0.45 (95% CI 0.27-0.76), respectively. CONCLUSIONS ARDS protocol implementation was associated with improved survival and rate of adherence.
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Affiliation(s)
- Abhijit Duggal
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Anupol Panitchote
- Division of Critical Care Medicine, Department of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Matthew Siuba
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sudhir Krishnan
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Heather Torbic
- Department of Pharmacology, Cleveland Clinic, Cleveland, Ohio
| | - Andrei Hastings
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Omar Mehkri
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Tarik Hanane
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Umur Hatipoglu
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - R Duncan Hite
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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19
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McGinn R, Fergusson DA, Stewart DJ, Kristof AS, Barron CC, Thebaud B, McIntyre L, Stacey D, Liepmann M, Dodelet-Devillers A, Zhang H, Renlund R, Lilley E, Downey GP, Brown EG, Côté L, Dos Santos CC, Fox-Robichaud AE, Hussain SNA, Laffey JG, Liu M, MacNeil J, Orlando H, Qureshi ST, Turner PV, Winston BW, Lalu MM. Surrogate Humane Endpoints in Small Animal Models of Acute Lung Injury: A Modified Delphi Consensus Study of Researchers and Laboratory Animal Veterinarians. Crit Care Med 2021; 49:311-323. [PMID: 33332817 DOI: 10.1097/ccm.0000000000004734] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In many jurisdictions, ethical concerns require surrogate humane endpoints to replace death in small animal models of acute lung injury. Heterogenous selection and reporting of surrogate endpoints render interpretation and generalizability of findings between studies difficult. We aimed to establish expert-guided consensus among preclinical scientists and laboratory animal veterinarians on selection and reporting of surrogate endpoints, monitoring of these models, and the use of analgesia. DESIGN A three-round consensus process, using modified Delphi methodology, with researchers who use small animal models of acute lung injury and laboratory animal veterinarians who provide care for these animals. Statements on the selection and reporting of surrogate endpoints, monitoring, and analgesia were generated through a systematic search of MEDLINE and Embase. Participants were asked to suggest any additional potential statements for evaluation. SETTING A web-based survey of participants representing the two stakeholder groups (researchers, laboratory animal veterinarians). Statements were rated on level of evidence and strength of support by participants. A final face-to-face meeting was then held to discuss results. SUBJECTS None. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Forty-two statements were evaluated, and 29 were rated as important, with varying strength of evidence. The majority of evidence was based on rodent models of acute lung injury. Endpoints with strong support and evidence included temperature changes and body weight loss. Behavioral signs and respiratory distress also received support but were associated with lower levels of evidence. Participants strongly agreed that analgesia affects outcomes in these models and that none may be necessary following nonsurgical induction of acute lung injury. Finally, participants strongly supported transparent reporting of surrogate endpoints. A prototype composite score was also developed based on participant feedback. CONCLUSIONS We provide a preliminary framework that researchers and animal welfare committees may adapt for their needs. We have identified knowledge gaps that future research should address.
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Affiliation(s)
- Ryan McGinn
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Faculty of Medicine, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Blueprint Translational Research Group, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Blueprint Translational Research Group, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Duncan J Stewart
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Arnold S Kristof
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Faculty of Medicine, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Blueprint Translational Research Group, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
- Meakins-Christie Laboratories, McGill University, Montreal, QC, Canada
- Department of Critical Care and Translational Research in Respiratory Diseases Program, McGill University Health Centre, Montreal, QC, Canada
- Division of Respirology, Departments of Critical Care and Medicine, McGill University, Montreal, QC, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
- Division of Critical Care, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- Faculty of Health Sciences, University of Ottawa, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- The Research Institute of the McGill University Health Center, McGill University, Montreal, QC, Canada
- Departments of Anesthesia, Medicine and Physiology, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Keenan Research Centre - Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Research Animals Department, Royal Society for the Prevention of Cruelty to Animals, Southwater, United Kingdom
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO
- Departments of Medicine and Immunology and Microbiology, University of Colorado, Denver, CO
- Neurosciences Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Biochemistry Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Interdepartmental Division of Critical Care, and Keenan Research Center, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Animal & Veterinary Sciences, University of Ottawa, Ottawa, ON, Canada
- Department of Pathobiology, University of Guelph, Guelph, ON, Canada
- Departments of Critical Care Medicine, Medicine and Biochemistry and Molecular Biology, Cumming School and Medicine and the University of Calgary, Calgary, AB, Canada
| | - Carly C Barron
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Bernard Thebaud
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Lauralyn McIntyre
- Division of Critical Care, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Dawn Stacey
- Faculty of Health Sciences, University of Ottawa, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Mark Liepmann
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Faculty of Medicine, University of Ottawa, ON, Canada
| | - Aurore Dodelet-Devillers
- The Research Institute of the McGill University Health Center, McGill University, Montreal, QC, Canada
| | - Haibo Zhang
- Departments of Anesthesia, Medicine and Physiology, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Richard Renlund
- Keenan Research Centre - Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Elliot Lilley
- Research Animals Department, Royal Society for the Prevention of Cruelty to Animals, Southwater, United Kingdom
| | - Gregory P Downey
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO
- Departments of Medicine and Immunology and Microbiology, University of Colorado, Denver, CO
| | - Earl G Brown
- Neurosciences Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Biochemistry Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Lucie Côté
- The Research Institute of the McGill University Health Center, McGill University, Montreal, QC, Canada
| | - Claudia C Dos Santos
- Interdepartmental Division of Critical Care, and Keenan Research Center, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Alison E Fox-Robichaud
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - Sabah N A Hussain
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Faculty of Medicine, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Blueprint Translational Research Group, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
- Meakins-Christie Laboratories, McGill University, Montreal, QC, Canada
- Department of Critical Care and Translational Research in Respiratory Diseases Program, McGill University Health Centre, Montreal, QC, Canada
- Division of Respirology, Departments of Critical Care and Medicine, McGill University, Montreal, QC, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
- Division of Critical Care, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- Faculty of Health Sciences, University of Ottawa, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- The Research Institute of the McGill University Health Center, McGill University, Montreal, QC, Canada
- Departments of Anesthesia, Medicine and Physiology, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Keenan Research Centre - Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Research Animals Department, Royal Society for the Prevention of Cruelty to Animals, Southwater, United Kingdom
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO
- Departments of Medicine and Immunology and Microbiology, University of Colorado, Denver, CO
- Neurosciences Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Biochemistry Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Interdepartmental Division of Critical Care, and Keenan Research Center, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Animal & Veterinary Sciences, University of Ottawa, Ottawa, ON, Canada
- Department of Pathobiology, University of Guelph, Guelph, ON, Canada
- Departments of Critical Care Medicine, Medicine and Biochemistry and Molecular Biology, Cumming School and Medicine and the University of Calgary, Calgary, AB, Canada
| | - John G Laffey
- Departments of Anesthesia, Medicine and Physiology, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Mingyao Liu
- Departments of Anesthesia, Medicine and Physiology, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Jenna MacNeil
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Holly Orlando
- Animal & Veterinary Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Salman T Qureshi
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Faculty of Medicine, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Blueprint Translational Research Group, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
- Meakins-Christie Laboratories, McGill University, Montreal, QC, Canada
- Department of Critical Care and Translational Research in Respiratory Diseases Program, McGill University Health Centre, Montreal, QC, Canada
- Division of Respirology, Departments of Critical Care and Medicine, McGill University, Montreal, QC, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
- Division of Critical Care, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- Faculty of Health Sciences, University of Ottawa, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- The Research Institute of the McGill University Health Center, McGill University, Montreal, QC, Canada
- Departments of Anesthesia, Medicine and Physiology, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Keenan Research Centre - Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Research Animals Department, Royal Society for the Prevention of Cruelty to Animals, Southwater, United Kingdom
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO
- Departments of Medicine and Immunology and Microbiology, University of Colorado, Denver, CO
- Neurosciences Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Biochemistry Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Interdepartmental Division of Critical Care, and Keenan Research Center, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Animal & Veterinary Sciences, University of Ottawa, Ottawa, ON, Canada
- Department of Pathobiology, University of Guelph, Guelph, ON, Canada
- Departments of Critical Care Medicine, Medicine and Biochemistry and Molecular Biology, Cumming School and Medicine and the University of Calgary, Calgary, AB, Canada
| | - Patricia V Turner
- Department of Pathobiology, University of Guelph, Guelph, ON, Canada
| | - Brent W Winston
- Departments of Critical Care Medicine, Medicine and Biochemistry and Molecular Biology, Cumming School and Medicine and the University of Calgary, Calgary, AB, Canada
| | - Manoj M Lalu
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Faculty of Medicine, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Blueprint Translational Research Group, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
- Meakins-Christie Laboratories, McGill University, Montreal, QC, Canada
- Department of Critical Care and Translational Research in Respiratory Diseases Program, McGill University Health Centre, Montreal, QC, Canada
- Division of Respirology, Departments of Critical Care and Medicine, McGill University, Montreal, QC, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
- Division of Critical Care, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- Faculty of Health Sciences, University of Ottawa, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- The Research Institute of the McGill University Health Center, McGill University, Montreal, QC, Canada
- Departments of Anesthesia, Medicine and Physiology, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Keenan Research Centre - Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Research Animals Department, Royal Society for the Prevention of Cruelty to Animals, Southwater, United Kingdom
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO
- Departments of Medicine and Immunology and Microbiology, University of Colorado, Denver, CO
- Neurosciences Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Biochemistry Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Interdepartmental Division of Critical Care, and Keenan Research Center, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Animal & Veterinary Sciences, University of Ottawa, Ottawa, ON, Canada
- Department of Pathobiology, University of Guelph, Guelph, ON, Canada
- Departments of Critical Care Medicine, Medicine and Biochemistry and Molecular Biology, Cumming School and Medicine and the University of Calgary, Calgary, AB, Canada
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Emergency Department Management of Severe Hypoxemic Respiratory Failure in Adults With COVID-19. J Emerg Med 2020; 60:729-742. [PMID: 33526308 PMCID: PMC7836534 DOI: 10.1016/j.jemermed.2020.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 11/14/2020] [Accepted: 12/13/2020] [Indexed: 01/19/2023]
Abstract
Background While emergency physicians are familiar with the management of hypoxemic respiratory failure, management of mechanical ventilation and advanced therapies for oxygenation in the emergency department have become essential during the coronavirus disease 2019 (COVID-19) pandemic. Objective We review the current evidence on hypoxemia in COVID-19 and place it in the context of known evidence-based management of hypoxemic respiratory failure in the emergency department. Discussion COVID-19 causes mortality primarily through the development of acute respiratory distress syndrome (ARDS), with hypoxemia arising from shunt, a mismatch of ventilation and perfusion. Management of patients developing ARDS should focus on mitigating derecruitment and avoiding volutrauma or barotrauma. Conclusions High flow nasal cannula and noninvasive positive pressure ventilation have a more limited role in COVID-19 because of the risk of aerosolization and minimal benefit in severe cases, but can be considered. Stable patients who can tolerate repositioning should be placed in a prone position while awake. Once intubated, patients should be managed with ventilation strategies appropriate for ARDS, including targeting lung-protective volumes and low pressures. Increasing positive end-expiratory pressure can be beneficial. Inhaled pulmonary vasodilators do not decrease mortality but may be given to improve refractory hypoxemia. Prone positioning of intubated patients is associated with a mortality reduction in ARDS and can be considered for patients with persistent hypoxemia. Neuromuscular blockade should also be administered in patients who remain dyssynchronous with the ventilator despite adequate sedation. Finally, patients with refractory severe hypoxemic respiratory failure in COVID-19 should be considered for venovenous extracorporeal membrane oxygenation.
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Fuller BM, Roberts BW, Mohr NM, Pappal RD, Stephens RJ, Yan Y, Carpenter C, Kollef MH, Avidan MS. A study protocol for a multicentre, prospective, before-and-after trial evaluating the feasibility of implementing targeted SEDation after initiation of mechanical ventilation in the emergency department (The ED-SED Pilot Trial). BMJ Open 2020; 10:e041987. [PMID: 33328261 PMCID: PMC7745689 DOI: 10.1136/bmjopen-2020-041987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Sedation is a cornerstone therapy in the management of patients receiving mechanical ventilation and is highly influential on outcome. Early sedation depth appears especially influential, as early deep sedation is associated with worse outcome when compared with light sedation. Our research group has shown that patients receiving mechanical ventilation in the emergency department (ED) are exposed to deep sedation commonly, and ED sedation depth is impactful on intensive care unit (ICU) care and clinical outcomes. While extensive investigation has occurred for patients in the ICU, comparatively little data exist from the ED. Given the influence that ED sedation seems to carry, as well as a lack of ED-based sedation trials, there is significant rationale to investigate ED-based sedation as a means to improve outcome. METHODS AND ANALYSIS This is a multicentre (n=3) prospective, before-and-after pilot trial examining the feasibility of implementing targeted sedation in the immediate postintubation period in the ED. A cohort of 344 patients receiving mechanical ventilation in ED will be included. Feasibility outcomes include: (1) participant recruitment; (2) proportion of Richmond Agitation-Sedation Scale (RASS) scores in the deep sedation range; (3) reliability (agreement) of RASS measurements performed by bedside ED nurses; and (4) adverse events. The proportion of deep sedation measurements before and after the intervention will be compared using the χ2 test. Logistic regression will be used to compare before-and-after differences, adjusting for potential confounders. The inter-rater correlation coefficient will be used to assess paired observations between a study team member and bedside ED nurses, and to describe reliability of RASS measurements. ETHICS AND DISSEMINATION The Human Research Protection Office at Washington University in St. Louis School of Medicine has approved the study. The publication of peer-reviewed manuscripts and the presentation of abstracts at scientific meetings will be used to disseminate the work. REGISTRATION ClinicalTrials.gov identifier NCT04410783; Pre-results.
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Affiliation(s)
- Brian M Fuller
- Department of Anesthesiology, Division of Critical Care, Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Brian W Roberts
- Department of Emergency Medicine, Cooper University Hospital, One Cooper Plaza, Camden, New Jersey, USA
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Ryan D Pappal
- Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Robert J Stephens
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Chris Carpenter
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Marin H Kollef
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Michael Simon Avidan
- Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
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Standardized Management for Hypoxemic Respiratory Failure and ARDS: Systematic Review and Meta-analysis. Chest 2020; 158:2358-2369. [PMID: 32629038 DOI: 10.1016/j.chest.2020.05.611] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/30/2020] [Accepted: 05/29/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Treatment of hypoxemic respiratory failure (HRF) and ARDS is complex. Standardized management of HRF and ARDS may improve adherence to evidence-informed practice and improve outcomes. RESEARCH QUESTION What is the effect of standardized treatment compared with usual care on survival of patients with HRF and ARDS? STUDY DESIGN AND METHODS MEDLINE, EMBASE, Cochrane, CINAHL, Scopus, and Web-of-Science were searched (inception to 2018). Included studies were randomized clinical trials or quasi-experimental studies that examined the effect of standardized treatment (care-protocol, care-pathway, or bundle) compared with usual treatment among mechanically ventilated adult patients admitted to an ICU with HRF or ARDS. Study characteristics, pathway components, and patient outcomes were abstracted independently by two reviewers. RESULTS From 15,932 unique citations, 14 studies were included in the systematic review (three randomized clinical trials and 11 quasi-experimental studies). Twelve studies (including 5,767 patients) were included in the meta-analysis. Standardized management of HRF was associated with a 23% relative reduction in mortality (relative risk, 0.77; 95% CI, 0.65-0.91; I2, 70%; P = .002). In studies targeting patients with ARDS (n = 8), a 21% pooled mortality reduction was observed (relative risk, 0.79; 95% CI, 0.71-0.88; I2, 3.1%). Standardized management was associated with increased 28-day ventilator-free days (weighted mean difference, 3.48 days; 95% CI, 2.43-4.54 days; P < .001). Standardized management was also associated with a reduction in tidal volume (weighted mean difference, -1.80 mL/kg predicted body weight; 95% CI, -2.80 to -0.80 mL/kg predicted body weight; P < .001). Meta-regression demonstrated that the reduction in mortality was associated with provision of lower tidal volume (P = .045). INTERPRETATION When compared with usual treatment, standardized treatment of patients with HRF and ARDS is associated with increased ventilator-free days, lower tidal volume ventilation, and lower mortality. ICUs should consider the use of standardized treatment to improve the processes and outcomes of care for patients with HRF and ARDS. CLINICAL TRIAL REGISTRATION PROSPERO; No.: CRD42019099921; URL: www.crd.york.ac.uk/prospero/.
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Mouli TC, Davuluri A, Vijaya S, Priyanka ADY, Mishra SK. Effectiveness of simulation based teaching of ventilatory management among non-anaesthesiology residents to manage COVID 19 pandemic - A Quasi experimental cross sectional pilot study. Indian J Anaesth 2020; 64:S136-S140. [PMID: 32773853 PMCID: PMC7293371 DOI: 10.4103/ija.ija_452_20] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 05/04/2020] [Accepted: 05/15/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND AIMS Simulation is one of the important learning tools when it comes to skill acquisition and as a supplemental tool for training in high stake situations like COVID-19. The aim of this study is to meet the global requirements of knowledge on ventilatory management, prepare and to evaluate the effectiveness of the teaching module for non-anesthesiology trainees on COVID-19 patients. METHODS Quasi experimental cross sectional pilot study was conducted with a sample of twenty-six trainees. A teaching module was prepared and validated which consisted of lectures, audio-video sessions, demonstrations with hands-on training, debriefing, analytical-phase and reflection. Pre and Post evaluations from student t-test and direct observation of procedural skills (DOPS) were used for knowledge and skill assessment respectively and feedback obtained from Likert's score. RESULTS Pre- and Post-tests had a mean score of 7.42 ± 2.12 and 14.92 ± 2.9 respectively (P value 0.00001). DOPS included 16 point score, in which 23 trainees (88.4%) met the expectations and above expectations as per training objectives. A five-point Likert's score feedback revealed satisfactory and highly satisfactory scores of 100% (ABG), 96.1% (mechanical ventilation), and 84.6% (ventilation in COVID-19 patients). Overall satisfaction for the workshop among respondents was 100 per cent. Confidences of handling scores were 84.5% (interpreting ABG), 65.3% (maneuvering mechanical ventilation), and 96.15% (intubation in COVID-19 patients). CONCLUSION A planned teaching module in ventilation management helps to train non-anaesthesiologists more effectively as a part of COVID-19 preparedness. Simulation with debriefing based training to the medical fraternity is the best alternative in the present pandemic and it will also ensure the safety of health care professionals.
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Affiliation(s)
- Tatikonda Chandra Mouli
- Department of Anaesthesiology And Critical Care, GSL Medical College, Rajahmundry, Andhra Pradesh, India
| | - Anjani Davuluri
- Department of Anaesthesiology And Critical Care, GSL Medical College, Rajahmundry, Andhra Pradesh, India
| | - Sana Vijaya
- Department of General Surgery, GSL Medical College, Rajahmundry, Andhra Pradesh, India
| | - Avala Devi Yamini Priyanka
- Department of Anaesthesiology And Critical Care, GSL Medical College, Rajahmundry, Andhra Pradesh, India
| | - Sushant Kumar Mishra
- Department of Community Medicine, GSL Medical College, Rajahmundry, Andhra Pradesh, India
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Pappal RD, Roberts BW, Mohr NM, Ablordeppey E, Wessman BT, Drewry AM, Yan Y, Kollef MH, Avidan MS, Fuller BM. Protocol for a prospective, observational cohort study of awareness in mechanically ventilated patients admitted from the emergency department: the ED-AWARENESS study. BMJ Open 2019; 9:e033379. [PMID: 31594905 PMCID: PMC6797343 DOI: 10.1136/bmjopen-2019-033379] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Awareness with paralysis is a complication with potentially devastating psychological consequences for mechanically ventilated patients. While rigorous investigation into awareness has occurred for operating room patients, little attention has been paid outside of this domain. Mechanically ventilated patients in the emergency department (ED) have been historically managed in a way that predisposes them to awareness events: high incidence of neuromuscular blockade use, underdosing of analgesia and sedation, delayed administration of analgesia and sedation after intubation, and a lack of monitoring of sedation targets and depth. These practice patterns are discordant to recommendations for reducing the incidence of awareness, suggesting there is significant rationale to examine awareness in the ED population. METHODS AND ANALYSIS This is a single centre, prospective cohort study examining the incidence of awareness in mechanically ventilated ED patients. A cohort of 383 mechanically ventilated ED patients will be included. The primary outcome is awareness with paralysis. Qualitative reports of all awareness events will be provided. Recognising the potential problem with conventional multivariable analysis arising from a small number of events (expected less than 10-phenomenon of separation), Firth penalised method, exact logistic regression model or penalised maximum likelihood estimation shrinkage (Ridge, LASSO) will be used to assess for predictors of awareness. ETHICS AND DISSEMINATION Approval of the study by the Human Research Protection Office has been obtained. This work will be disseminated by publication of peer-reviewed manuscripts, presentation in abstract form at scientific meetings and data sharing with other investigators through academically established means.
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Affiliation(s)
- Ryan D Pappal
- Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Brian W Roberts
- Emergency Medicine, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Nicholas M Mohr
- Emergency Medicine and Anesthesiology, Roy J. and Lucille A. Carver College of Medicine University of Iowa, Iowa City, Iowa, USA
| | - Enyo Ablordeppey
- Anesthesiology and Emergency Medicine, Washington University, Saint Louis, Missouri, USA
| | - Brian T Wessman
- Anesthesiology and Emergency Medicine, Washington University, Saint Louis, Missouri, USA
| | - Anne M Drewry
- Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Yan Yan
- Clinical Epidemiology Center, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Public Health Sciences, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Marin H Kollef
- Medicine, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Michael Simon Avidan
- Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Brian M Fuller
- Anesthesiology and Emergency Medicine, Washington University, Saint Louis, Missouri, USA
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Bayram B, Şancı E. Invasive mechanical ventilation in the emergency department. Turk J Emerg Med 2019; 19:43-52. [PMID: 31065603 PMCID: PMC6495062 DOI: 10.1016/j.tjem.2019.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 03/13/2019] [Indexed: 10/29/2022] Open
Abstract
Emergency department (ED) lenght of stay of the patients requiring admission to the intensive care units has increased gradually in recent years. Mechanical ventilation is an integral part of critical care and mechanically ventilated patients have to be managed and monitored by emergency physicians for longer than expected in EDs. This early period of care has significant impact on the outcomes of these patients. Therefore, emergency physicians should have comprehensive knowledge of mechanical ventilation. This review will summarize the current literature of the basic concepts, appropriate clinical applications, monitoring parameters, components and mechanisms of mechanical ventilation in the ED.
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Affiliation(s)
- Başak Bayram
- Dokuz Eylul University, School of Medicine, Department of Emergency Medicine, Izmir, Turkey
| | - Emre Şancı
- Darıca Farabi Education and Research Hospital, Department of Emergency Medicine, Kocaeli, Turkey
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The effect of emergency department crowding on lung-protective ventilation utilization for critically ill patients. J Crit Care 2019; 52:40-47. [PMID: 30954692 DOI: 10.1016/j.jcrc.2019.03.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/16/2019] [Accepted: 03/21/2019] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To measure effects of ED crowding on lung-protective ventilation (LPV) utilization in critically ill ED patients. METHODS This is a retrospective cohort study of adult mechanically ventilated ED patients admitted to the medical intensive care unit (MICU), over a 3.5-year period at a single academic tertiary care hospital. Clinical data, including reason for intubation, severity of illness (MPM0-III), acute respiratory distress syndrome (ARDS) risk score (EDLIPS), and ventilator settings were extracted via electronic query of electronic health record and standardized chart abstraction. Crowding metrics were obtained at 5-min intervals and averaged over the ED stay, stratified by acuity and disposition. Multivariate logistic regression was used to predict likelihood of LPV prior to ED departure. RESULTS Mechanical ventilation was used in 446 patients for a median ED duration of 3.7 h (interquartile ratio, IQR, 2.3, 5.6). Mean MPM0-III score was 32.5 ± 22.7, with high risk for ARDS (EDLIPS ≥5) seen in 373 (82%) patients. Initial and final ED ventilator settings differed in 134 (30.0%) patients, of which only 47 (35.1%) involved tidal volume changes. Higher percentages of active ED patients (workup in-progress) and those requiring eventual admission were associated with lower odds of LPV utilization by ED departure (OR 0.97, 95%CI 0.94-1.00; OR 0.97, 95%CI 0.94-1.00, respectively). In periods of high volume, ventilator adjustments to settings other than the tidal volume were associated with higher odds of LPV utilization. Reason for intubation, MPM0-III, and EDLIPS were not associated with LPV utilization, with no interactions detected in times of crowding. CONCLUSIONS ED patients remain on suboptimal tidal volume settings with infrequent ventilator adjustments during the ED stay. Hospitals should focus on both systemic factors and bedside physician and/or respiratory therapist interventions to increase LPV utilization in times of ED boarding and crowding for all patients.
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Gao Y, He YL. Ventilator for the treatment of acute respiratory distress syndrome: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e13686. [PMID: 30572492 PMCID: PMC6320076 DOI: 10.1097/md.0000000000013686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 11/22/2018] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Ventilator has been reported to treat acute respiratory distress syndrome (ARDS). However, its efficacy is still inconclusive. This systematic review and meta-analysis study aims to evaluate its efficacy and safety for the treatment of patients with ARDS. METHODS The electronic databases of Cochrane central register of controlled trials (CENTRAL), EMBASE, MEDILINE, CINAHL, allied and complementary medicine database (AMED) and 4 Chinese databases will be used to search relevant literature from their inception to the present to evaluate the efficacy and safety of ventilator for ARDS without the language restrictions. This study will only consider randomized controlled trials (RCTs) of ventilator for the treatment of ARDS. The Cochrane risk of bias tool will be utilized to assess the quality of the included RCTs studies. The primary outcomes include arterial blood gases values (recorded once a day) and ventilator settings. The secondary outcomes will include the Acute Physiology and Chronic Health Evaluation II, Simplified Acute Physiology Score, quality of life, cost, death, and any other adverse events. The summary results will be performed by using the models of random-effects or fixed-effects based on the heterogeneity of the included RCTs. RESULTS The results will be disseminated to peer-reviewed journals for publication. This study does not need ethics approval, because of no individual data will be involved. The results of this study will help clinicians and health policy-makers to refer for the policy or guideline making. CONCLUSION The results of this systematic review and meta-analysis study may provide helpful evidence for the efficacy and safety of ventilator for ARDS. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018 115409.
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Tuteja G, Uppal A, Strong J, Nguyen T, Pope K, Jenkins R, Al Rebh H, Gatz D, Chang WT, Tran QK. Interventions affecting blood pressure variability and outcomes after intubating patients with spontaneous intracranial hemorrhage. Am J Emerg Med 2018; 37:1665-1671. [PMID: 30528041 DOI: 10.1016/j.ajem.2018.11.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/23/2018] [Accepted: 11/28/2018] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Spontaneous intracranial hemorrhage (sICH) that increases intracranial pressure (ICP) is a life-threatening emergency often requiring intubation in Emergency Departments (ED). A previous study of intubated ED patients found that providing ≥5 interventions after initiating mechanical ventilation (pMVI) reduced mortality rate. We hypothesized that pMVIs would lower blood pressure variability (BPV) in patients with sICH and thus improve survival rates and neurologic outcomes. METHOD We performed a retrospective study of adults, who were transferred to a quaternary medical center between 01/01/2011 and 09/30/2015 for sICH, received an extraventricular drain during hospitalization. They were identified by International Classification of Diseases, version 9 (430.XX, 431.XX), and procedure code 02.21. Outcomes were BPV indices, death, and being discharged home. RESULTS We analyzed records from 147 intubated patients transferred from 40 EDs. Forty-one percent of patients received ≥5 pMVIs and was associated with lower median successive variation in systolic blood pressure (BPSV) (31,[IQR 18-45) compared with those receiving 4 or less pMVIs (38[IQR 16-70]], p = 0.040). Three pMVIs, appropriate tidal volume, sedative infusion, and capnography were significantly associated with lower BPV. In addition to clinical factors, BPSV (OR 26; 95% CI 1.2, >100) and chest radiography (OR 0.3; 95% CI 0.09, 0.9) were associated with mortality rate. Use of quantitative capnography (OR 8.3; 95%CI, 4.7, 8.8) was associated with increased likelihood of being discharged home. CONCLUSIONS In addition to disease severity, individual pMVIs were significantly associated with BPV and patient outcomes. Emergency physicians should perform pMVIs more frequently to prevent BPV and improve patients' outcomes.
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Affiliation(s)
- Gurshawn Tuteja
- John Hopkins University, Baltimore, MD, United States of America.
| | - Angad Uppal
- John Hopkins University, Baltimore, MD, United States of America.
| | - Jonathan Strong
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America.
| | - Tina Nguyen
- University of Maryland at College Park, College Park, MD, United States of America.
| | - Kanisha Pope
- University of Maryland at College Park, College Park, MD, United States of America
| | - Ryne Jenkins
- R Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, United States of America.
| | - Heba Al Rebh
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America.
| | - David Gatz
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America.
| | - Wan-Tsu Chang
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America; R Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, United States of America.
| | - Quincy K Tran
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America; R Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, United States of America.
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Silva PL, Rocco PRM. The basics of respiratory mechanics: ventilator-derived parameters. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:376. [PMID: 30460250 DOI: 10.21037/atm.2018.06.06] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Mechanical ventilation is a life-support system used to maintain adequate lung function in patients who are critically ill or undergoing general anesthesia. The benefits and harms of mechanical ventilation depend not only on the operator's setting of the machine (input), but also on their interpretation of ventilator-derived parameters (outputs), which should guide ventilator strategies. Once the inputs-tidal volume (VT), positive end-expiratory pressure (PEEP), respiratory rate (RR), and inspiratory airflow (V')-have been adjusted, the following outputs should be measured: intrinsic PEEP, peak (Ppeak) and plateau (Pplat) pressures, driving pressure (ΔP), transpulmonary pressure (PL), mechanical energy, mechanical power, and intensity. During assisted mechanical ventilation, in addition to these parameters, the pressure generated 100 ms after onset of inspiratory effort (P0.1) and the pressure-time product per minute (PTP/min) should also be evaluated. The aforementioned parameters should be seen as a set of outputs, all of which need to be strictly monitored at bedside in order to develop a personalized, case-by-case approach to mechanical ventilation. Additionally, more clinical research to evaluate the safe thresholds of each parameter in injured and uninjured lungs is required.
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Affiliation(s)
- Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Affiliation(s)
- Brian M Fuller
- Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Nicholas M Mohr
- Department of Anesthesia, Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri
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O'Reilly-Shah VN, Easton GS, Jabaley CS, Lynde GC. Variable effectiveness of stepwise implementation of nudge-type interventions to improve provider compliance with intraoperative low tidal volume ventilation. BMJ Qual Saf 2018; 27:1008-1018. [PMID: 29776982 DOI: 10.1136/bmjqs-2017-007684] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 03/13/2018] [Accepted: 04/28/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Identifying mechanisms to improve provider compliance with quality metrics is a common goal across medical disciplines. Nudge interventions are minimally invasive strategies that can influence behavioural changes and are increasingly used within healthcare settings. We hypothesised that nudge interventions may improve provider compliance with lung-protective ventilation (LPV) strategies during general anaesthesia. METHODS We developed an audit and feedback dashboard that included information on both provider-level and department-level compliance with LPV strategies in two academic hospitals, two non-academic hospitals and two academic surgery centres affiliated with a single healthcare system. Dashboards were emailed to providers four times over the course of the 9-month study. Additionally, the default setting on anaesthesia machines for tidal volume was decreased from 700 mL to 400 mL. Data on surgical cases performed between 1 September 2016 and 31 May 2017 were examined for compliance with LPV. The impact of the interventions was assessed via pairwise logistic regression analysis corrected for multiple comparisons. RESULTS A total of 14 793 anaesthesia records were analysed. Absolute compliance rates increased from 59.3% to 87.8%preintervention to postintervention. Introduction of attending physician dashboards resulted in a 41% increase in the odds of compliance (OR 1.41, 95% CI 1.17 to 1.69, p=0.002). Subsequently, the addition of advanced practice provider and resident dashboards lead to an additional 93% increase in the odds of compliance (OR 1.93, 95% CI 1.52 to 2.46, p<0.001). Lastly, modifying ventilator defaults led to a 376% increase in the odds of compliance (OR 3.76, 95% CI 3.1 to 4.57, p<0.001). CONCLUSION Audit and feedback tools in conjunction with default changes improve provider compliance.
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Affiliation(s)
| | - George S Easton
- Department of Information Systems and Operations Management, Emory University, Goizueta Business School, Atlanta, Georgia, USA
| | - Craig S Jabaley
- Department of Anesthesiology, Emory University, Atlanta, Georgia, USA
| | - Grant C Lynde
- Department of Anesthesiology, Emory University, Atlanta, Georgia, USA
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Page DB, Drewry AM, Ablordeppey E, Mohr NM, Kollef MH, Fuller BM. Thirty-day hospital readmissions among mechanically ventilated emergency department patients. Emerg Med J 2018; 35:252-256. [PMID: 29305381 DOI: 10.1136/emermed-2017-206651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 10/15/2017] [Accepted: 11/30/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND Unplanned 30-day readmissions have a negative impact on patients and healthcare systems. Mechanically ventilated ED patients are at high risk for complications, but factors associated with readmission are unknown. OBJECTIVE (1) Determine the rate of 30-day hospital readmission for ED patients receiving mechanical ventilation. (2) Identify associations between ED-based risk factors and readmission. DESIGN Retrospective cohort study. SETTING Tertiary-care, academic medical centre. PATIENTS Adult ED patients receiving mechanical ventilation. MEASUREMENTS Baseline demographics, comorbid conditions, illness severity and treatment variables were collected, as were clinical outcomes occurring during the index hospitalisation. The primary outcome was 30-day hospital readmission rate. Multivariable logistic regression was used to evaluate factors associated with the primary outcome. RESULTS A total of 1262 patients were studied. The primary outcome occurred in 287 (22.7%) patients. There was no association between care in the ED and readmission. During the index hospitalisation, readmitted patients had shorter ventilator, hospital and intensive care unit duration (P<0.05 for all). The primary outcome was associated with African-American race (adjusted OR 1.34 (95% CI 1.02 to 1.78)), chronic obstructive pulmonary disease (adjusted OR 1.52 (95% CI 1.12 to 2.06)), diabetes mellitus (adjusted OR 1.34 (95% CI 1.02 to 1.78)) and higher illness severity (adjusted OR 1.03 (95% CI 1.01 to 1.05)). CONCLUSIONS Almost one in four mechanically ventilated ED patients are readmitted within 30 days, and readmission is associated with patient-level and institutional-level factors. Strategies must be developed to identify, treat and coordinate care for the most at-risk patients.
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Affiliation(s)
- David B Page
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Anne M Drewry
- Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Enyo Ablordeppey
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Washington University School of Medicine, St Louis, Missouri, USA
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Roy J and Lucille A Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Marin H Kollef
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Brian M Fuller
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Washington University School of Medicine, St Louis, Missouri, USA
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Alencar R, D'Angelo V, Carmona R, Schultz MJ, Serpa Neto A. Patients with uninjured lungs may also benefit from lung-protective ventilator settings. F1000Res 2017; 6:2040. [PMID: 29250319 PMCID: PMC5701436 DOI: 10.12688/f1000research.12225.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2017] [Indexed: 12/21/2022] Open
Abstract
Although mechanical ventilation is a life-saving strategy in critically ill patients and an indispensable tool in patients under general anesthesia for surgery, it also acts as a double-edged sword. Indeed, ventilation is increasingly recognized as a potentially dangerous intrusion that has the potential to harm lungs, in a condition known as ‘ventilator-induced lung injury’ (VILI). So-called ‘lung-protective’ ventilator settings aiming at prevention of VILI have been shown to improve outcomes in patients with acute respiratory distress syndrome (ARDS), and, over the last few years, there has been increasing interest in possible benefit of lung-protective ventilation in patients under ventilation for reasons other than ARDS. Patients without ARDS could benefit from tidal volume reduction during mechanical ventilation. However, it is uncertain whether higher levels of positive end-expiratory pressure could benefit these patients as well. Finally, recent evidence suggests that patients without ARDS should receive low driving pressures during ventilation.
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Affiliation(s)
- Roger Alencar
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Vittorio D'Angelo
- School of Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Rachel Carmona
- School of Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Marcus J Schultz
- Deptartment of Intensive Care, Academic Medical Center, Amsterdam, Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, Netherlands.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok , Thailand
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Deptartment of Intensive Care, Academic Medical Center, Amsterdam, Netherlands
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Angotti LB, Richards JB, Fisher DF, Sankoff JD, Seigel TA, Al Ashry HS, Wilcox SR. Duration of Mechanical Ventilation in the Emergency Department. West J Emerg Med 2017; 18:972-979. [PMID: 28874952 PMCID: PMC5576636 DOI: 10.5811/westjem.2017.5.34099] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 05/24/2017] [Accepted: 05/26/2017] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Due to hospital crowding, mechanically ventilated patients are increasingly spending hours boarding in emergency departments (ED) before intensive care unit (ICU) admission. This study aims to evaluate the association between time ventilated in the ED and in-hospital mortality, duration of mechanical ventilation, ICU and hospital length of stay (LOS). METHODS This was a multi-center, prospective, observational study of patients ventilated in the ED, conducted at three academic Level I Trauma Centers from July 2011 to March 2013. All consecutive adult patients on invasive mechanical ventilation were eligible for enrollment. We performed a Cox regression to assess for a mortality effect for mechanically ventilated patients with each hour of increasing LOS in the ED and multivariable regression analyses to assess for independently significant contributors to in-hospital mortality. Our primary outcome was in-hospital mortality, with secondary outcomes of ventilator days, ICU LOS and hospital LOS. We further commented on use of lung protective ventilation and frequency of ventilator changes made in this cohort. RESULTS We enrolled 535 patients, of whom 525 met all inclusion criteria. Altered mental status without respiratory pathology was the most common reason for intubation, followed by trauma and respiratory failure. Using iterated Cox regression, a mortality effect occurred at ED time of mechanical ventilation > 7 hours, and the longer ED stay was also associated with a longer total duration of intubation. However, adjusted multivariable regression analysis demonstrated only older age and admission to the neurosciences ICU as independently associated with increased mortality. Of interest, only 23.8% of patients ventilated in the ED for over seven hours had changes made to their ventilator. CONCLUSION In a prospective observational study of patients mechanically ventilated in the ED, there was a significant mortality benefit to expedited transfer of patients into an appropriate ICU setting.
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Affiliation(s)
- Lauren B Angotti
- Medical University of South Carolina, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Charleston, South Carolina
| | - Jeremy B Richards
- Medical University of South Carolina, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Charleston, South Carolina
| | - Daniel F Fisher
- Massachusetts General Hospital, Respiratory Care Services, Boston, Massachusetts
| | - Jeffrey D Sankoff
- University of Colorado at Denver, School of Medicine, Department of Emergency Medicine, Denver, Colorado
| | - Todd A Seigel
- Kaiser Permanente East Bay, Oakland and Richmond Medical Centers, Department of Emergency Medicine and Critical Care, Oakland, California
| | - Haitham S Al Ashry
- Medical University of South Carolina, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Charleston, South Carolina
| | - Susan R Wilcox
- Medical University of South Carolina, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Charleston, South Carolina.,Medical University of South Carolina, Division of Emergency Medicine, Charleston, South Carolina
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Stephens RJ, Dettmer MR, Roberts BW, Fowler SA, Fuller BM. Practice patterns and outcomes associated with early sedation depth in mechanically ventilated patients: a systematic review protocol. BMJ Open 2017; 7:e016437. [PMID: 28600379 PMCID: PMC5726115 DOI: 10.1136/bmjopen-2017-016437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Mechanical ventilation is a commonly performed intervention in critically ill patients. Frequently, these patients experience deep sedation early in their clinical course. Emerging data suggest that the practice of early deep sedation may negatively impact patient outcomes. The purpose of this review is to assess the world's literature to describe and determine the impact of early deep sedation on the outcomes of mechanically ventilated patients. METHODS AND ANALYSIS Randomised controlled trials and non-randomised studies will be eligible for inclusion in this systematic review. With the assistance of a medical librarian, we will comprehensively search MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews and Effects, and Cochrane Database of Systematic Reviews for peer-reviewed literature. Grey literature from appropriate professional society conferences, held from 2010 to 2017, will be reviewed manually. Two authors will independently review all search results, and disagreements will be resolved through arbitration by a third author. If appropriate, meta-analysis will be used for quantitative analysis of the data. Heterogeneity between studies will be assessed using the I2 statistic. ETHICS AND DISSEMINATION The proposed systematic review will not collect data that are associated with individual patients and does not require ethical approval. Results of this study will contribute to the understanding of early sedation, identify future research targets and guide early care in mechanically ventilated patients. TRIAL REGISTRATION NUMBER This systematic review has been registered in the international prospective register of systematic reviews (PROSPERO #CRD42017057264).
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Affiliation(s)
| | - Matthew R Dettmer
- Emergency Services Institute, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Brian W Roberts
- Department of Emergency Medicine, Cooper University Hospital, Camden, New Jersey, USA
| | - Susan A Fowler
- Bernard Becker Medical Library, Washington University, St Louis, Missouri, USA
| | - Brian M Fuller
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine, St Louis, Missouri, USA
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Fuller BM, Ferguson IT, Mohr NM, Drewry AM, Palmer C, Wessman BT, Ablordeppey E, Keeperman J, Stephens RJ, Briscoe CC, Kolomiets AA, Hotchkiss RS, Kollef MH. Lung-Protective Ventilation Initiated in the Emergency Department (LOV-ED): A Quasi-Experimental, Before-After Trial. Ann Emerg Med 2017; 70:406-418.e4. [PMID: 28259481 DOI: 10.1016/j.annemergmed.2017.01.013] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 01/06/2017] [Accepted: 01/10/2017] [Indexed: 01/31/2023]
Abstract
STUDY OBJECTIVE We evaluated the efficacy of an emergency department (ED)-based lung-protective mechanical ventilation protocol for the prevention of pulmonary complications. METHODS This was a quasi-experimental, before-after study that consisted of a preintervention period, a run-in period of approximately 6 months, and a prospective intervention period. The intervention was a multifaceted ED-based mechanical ventilator protocol targeting lung-protective tidal volume, appropriate setting of positive end-expiratory pressure, rapid oxygen weaning, and head-of-bed elevation. A propensity score-matched analysis was used to evaluate the primary outcome, which was the composite incidence of acute respiratory distress syndrome and ventilator-associated conditions. RESULTS A total of 1,192 patients in the preintervention group and 513 patients in the intervention group were included. Lung-protective ventilation increased by 48.4% in the intervention group. In the propensity score-matched analysis (n=490 in each group), the primary outcome occurred in 71 patients (14.5%) in the preintervention group compared with 36 patients (7.4%) in the intervention group (adjusted odds ratio 0.47; 95% confidence interval [CI] 0.31 to 0.71). There was an increase in ventilator-free days (mean difference 3.7; 95% CI 2.3 to 5.1), ICU-free days (mean difference 2.4; 95% CI 1.0 to 3.7), and hospital-free days (mean difference 2.4; 95% CI 1.2 to 3.6) associated with the intervention. The mortality rate was 34.1% in the preintervention group and 19.6% in the intervention group (adjusted odds ratio 0.47; 95% CI 0.35 to 0.63). CONCLUSION Implementing a mechanical ventilator protocol in the ED is feasible and is associated with significant improvements in the delivery of safe mechanical ventilation and clinical outcome.
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Affiliation(s)
- Brian M Fuller
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO.
| | - Ian T Ferguson
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Anne M Drewry
- Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Christopher Palmer
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Brian T Wessman
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Enyo Ablordeppey
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Jacob Keeperman
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Robert J Stephens
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | - Angelina A Kolomiets
- School of Public Health and Social Justice, Saint Louis University, St. Louis, MO
| | - Richard S Hotchkiss
- Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Marin H Kollef
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
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