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Original Research: Critical Care |

Mechanical Ventilation and ARDS in the EDMechanical Ventilation and ARDS in the ED: A Multicenter, Observational, Prospective, Cross-sectional Study

Brian M. Fuller, MD; Nicholas M. Mohr, MD; Christopher N. Miller, MD; Andrew R. Deitchman, MD; Brian J. Levine, MD; Nicole Castagno, MS; Elizabeth C. Hassebroek, MD; Adam Dhedhi, BA; Nicholas Scott-Wittenborn, BA; Edward Grace; Courtney Lehew, MD; Marin H. Kollef, MD, FCCP
Author and Funding Information

From the Department of Emergency Medicine (Drs Fuller and Lehew) and the Department of Anesthesiology (Dr Fuller), Division of Critical Care, and the Department of Medicine (Dr Kollef), Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, MO; the Departments of Emergency Medicine and Anesthesiology (Dr Mohr), Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA; the Department of Emergency Medicine (Dr Miller), University of Cincinnati Medical Center, Cincinnati, OH; the Department of Emergency Medicine (Drs Deitchman and Levine), Christiana Care Health System, Newark, DE; the University of Michigan Medical School (Ms Castagno), Ann Arbor, MI; the Department of Critical Care Medicine (Dr Hassebroek), Mayo Clinic, Rochester, MN; Saint Louis University School of Medicine (Mr Dhedhi), St. Louis, MO; Washington University in St. Louis (Mr Scott-Wittenborn), St. Louis, MO; and Middlebury College (Mr Grace), Middlebury, VT.

CORRESPONDENCE TO: Brian M. Fuller, MD, Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Washington University School of Medicine in St. Louis, 660 S Euclid Ave, Campus Box 8072, St. Louis, MO 63110; e-mail: fullerb@wusm.wustl.edu


FUNDING/SUPPORT: Dr Fuller was supported by an Emergency Medicine Grant-in-Aid from the Department of Emergency Medicine, Washington University School of Medicine in St. Louis, and by the KL2 Career Development Award. Dr Mohr was supported by the Emergency Medicine Foundation Research Fellowship. Ms Castagno was funded by the University of Cincinnati Department of Emergency Medicine. Mr Grace was supported by the ASPIRE Program at Washington University in St. Louis. Dr Kollef was supported by the Barnes Jewish Hospital Foundation. This publication was supported by the Washington University Institute of Clinical and Translational Sciences [Grants UL1 TR000448 and KL2 TR000450] from the National Center for Advancing Translational Sciences.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(2):365-374. doi:10.1378/chest.14-2476
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BACKGROUND:  There are few data regarding mechanical ventilation and ARDS in the ED. This could be a vital arena for prevention and treatment.

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

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

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

TRIAL REGISTRY:  ClinicalTrials.gov; No.: NCT01628523; URL: www.clinicaltrials.gov

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