• Brian M Fuller, Ian T Ferguson, Nicholas M Mohr, Anne M Drewry, Christopher Palmer, Brian T Wessman, Enyo Ablordeppey, Jacob Keeperman, Robert J Stephens, Cristopher C Briscoe, Angelina A Kolomiets, Richard S Hotchkiss, and Marin H Kollef.
• 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. Electronic address: fullerb@wustl.edu.
• Ann Emerg Med. 2017 Sep 1; 70 (3): 406-418.e4.

Study ObjectiveWe evaluated the efficacy of an emergency department (ED)-based lung-protective mechanical ventilation protocol for the prevention of pulmonary complications.MethodsThis 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.ResultsA 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).ConclusionImplementing 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.Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

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