Mechanical Ventilation and ARDS in the ED: A Multicenter, Observational, Prospective, Cross-sectional Study.
BACKGROUND
There are few data regarding mechanical ventilation and ARDS in the ED. This could be a vital arena for prevention and treatment.


METHODS
This study was a multicenter, observational, prospective, cohort study aimed at analyzing ventilation practices in the ED. The primary outcome was the incidence of ARDS after admission. Multivariable logistic regression was used to determine the predictors of ARDS.


RESULTS
We analyzed 219 patients receiving mechanical ventilation to assess ED ventilation practices. Median tidal volume was 7.6 mL/kg predicted body weight (PBW) (interquartile range, 6.9-8.9), with a range of 4.3 to 12.2 mL/kg PBW. Lung-protective ventilation was used in 122 patients (55.7%). The incidence of ARDS after admission from the ED was 14.7%, with a mean onset of 2.3 days. Progression to ARDS was associated with higher illness severity and intubation in the prehospital environment or transferring facility. Of the 15 patients with ARDS in the ED (6.8%), lung-protective ventilation was used in seven (46.7%). Patients who progressed to ARDS experienced greater duration in organ failure and ICU length of stay and higher mortality.


CONCLUSIONS
Lung-protective ventilation is infrequent in patients receiving mechanical ventilation in the ED, regardless of ARDS status. Progression to ARDS is common after admission, occurs early, and worsens outcome. Patient- and treatment-related factors present in the ED are associated with ARDS. Given the limited treatment options for ARDS, and the early onset after admission from the ED, measures to prevent onset and to mitigate severity should be instituted in the ED.


BACKGROUND
ClinicalTrials.gov; No.: NCT01628523; URL: www.clinicaltrials.gov.
Department of Emergency Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, MO; Department of Anesthesiology, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, MO. Electronic address: fullerb@wusm.wustl.edu.
Brian M
BM
Fuller
Department of Emergency Medicine and Anesthesiology, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA.
Nicholas M
NM
Mohr
Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH.
Christopher N
CN
Miller
Department of Emergency Medicine, Christiana Care Health System, Newark, DE.
Andrew R
AR
Deitchman
Department of Emergency Medicine, Christiana Care Health System, Newark, DE.
Brian J
BJ
Levine
University of Michigan Medical School, Ann Arbor, MI.
Nicole
N
Castagno
Department of Critical Care Medicine, Mayo Clinic, Rochester, MN.
Elizabeth C
EC
Hassebroek
Saint Louis University School of Medicine, St. Louis, MO.
Adam
A
Dhedhi
Washington University in St. Louis, St. Louis, MO.
Nicholas
N
Scott-Wittenborn
Middlebury College, Middlebury, VT.
Edward
E
Grace
Department of Emergency Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, MO.
Courtney
C
Lehew
Division of Critical Care, and the Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, MO.
Marin H
MH
Kollef
D000328:Adult; D000368:Aged; D015331:Cohort Studies; D003430:Cross-Sectional Studies; D018450:Disease Progression; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011446:Prospective Studies; D012121:Respiration, Artificial / Q000379:methods*; D012128:Respiratory Distress Syndrome / Q000628:therapy*; D012131:Respiratory Insufficiency / Q000628:therapy*; D055397:Ventilator-Induced Lung Injury / Q000517:prevention & control*