CORRESPONDENCE
Lung-protective Ventilation in Emergency Department Patients With Severe Sepsis To the Editor: Lung-protective ventilation (LPV) is a cornerstone of management for patients with established acute respiratory distress syndrome (ARDS) to limit ventilatorinduced lung injury and improve clinical outcomes. While the use of LPV for prevention of ARDS remains controversial, a growing body of evidence supports its use. Fuller and colleagues1 recently described the limited implementation of LPV for ARDS prevention in emergency department (ED) patients with severe sepsis. While the authors were appropriately cautious in their interpretation of the literature, emergency medicine and critical care physicians must continue to make clinical decisions on ventilator management—what should be recommended? The physiology and biologic plausibility of LPV in patients at risk for ARDS make sense. Numerous studies in multiple animal models have demonstrated that mechanical ventilation with higher tidal volumes damages the previously uninjured lung and causes pulmonary and systemic inflammation. More recently, clinical studies have provided evidence for the use of LPV prior to ARDS development. A recent meta-analysis, including 20 articles with a total of 2,822 participants, demonstrated large beneficial effects for LPV in prevention of acute lung injury and mortality.2 While the included articles were heterogeneous, effectiveness in diverse patient populations ranging from general intensive care unit patients to post–cardiac surgery patients supports generalizability. Subsequently, yet another high-profile trial in postoperative patients strongly favored the benefit.3 It is unlikely that patients with severe sepsis who are admitted from the ED would respond differently to LPV. Accordingly, we would support implementation of LPV for most critically ill ED patients based on the following rationale: 1) LPV benefits all evaluated subgroups of patients with established ARDS (e.g., pneumonia, sepsis, trauma, aspiration); 2) the data to support the alternate ventilator choice, higher tidal volumes to prevent atelectasis and improve ventilation, is based on relatively minimal empirical evidence; 3) there is minimal harm reported with the use of LPV; and 4) with limited research funding it is not possible to conduct large clini-
Dr. Ginde was supported by NIH grant K23AG040708. Dr. Moss was supported by NIH grants K24HL089223 and R01NR011051.
96
ISSN 1069-6563 PII ISSN 1069-6563583
cal trials for every intervention in all potential populations and settings. We believe that the existing literature sufficiently supports the adoption of LPV for most critically ill patients, including mechanically ventilated ED patients with severe sepsis. The focus of research should therefore shift to effective implementation of LPV. Even in established ARDS, adherence to LPV remains poor,4 and clearly this is even worse in patients at risk for ARDS.1 With longer ED lengths of stay for critically ill patients,5 it is no longer acceptable for emergency physicians to defer ventilator management to the intensive care unit. We suggest enhancing educational opportunities for ventilator management and principles of LPV in emergency medicine residency training, continuing medical education, and hospital quality improvement initiatives. In addition, enhanced local collaboration and communication between emergency physicians, nurses, respiratory therapists, and critical care staff will likely improve adherence to LPV and transitions across care settings. Similar to many successful quality improvement initiatives for severe sepsis, implementation of clinical protocols and checklists for optimal ventilator management will likely decrease variability and improve outcomes in these high-risk patients. doi: 10.1111/acem.12276
Adit A. Ginde, MD, MPH ([email protected]) Department of Emergency Medicine Marc Moss, MD Division of Pulmonary Sciences and Critical Care Medicine University of Colorado School of Medicine Aurora, CO Supervising Editor: Jeffrey Kline, MD.
References 1. Fuller BM, Mohr NM, Dettmer M, et al. Mechanical ventilation and acute lung injury in emergency department patients with severe sepsis and septic
© 2013 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12276
ACADEMIC EMERGENCY MEDICINE • January 2014, Vol. 21, No. 1 • www.aemj.org
shock: an observational study. Acad Emerg Med. 2013; 20:659–69. 2. Neto AS, Cardoso SO, Manetta JA, et al. Association between use of lung-protective ventilation with lower tidal volume and clinical outcomes among patients without acute respiratory distress syndrome: a metaanalysis. JAMA. 2012; 308:1651–9. 3. Futier E, Constantin J, Paugam-Burtz C, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med. 2013; 369:428–37.
97
4. Needham DM, Colantuoni E, Mendez-Tellez PA, et al. Lung protective mechanical ventilation and two year survival in patients with acute lung injury: prospective cohort study. BMJ. 2012; 344:e2124. 5. Herring AA, Ginde AA, Fahimi J, et al. Increasing critical care admissions from U.S. emergency departments, 2001-2009. Crit Care Med. 2013; 41:1197–204.
Lung-protective Ventilation in Emergency Department Patients With Severe Sepsis To the Editor: Lung-protective ventilation (LPV) is a cornerstone of management for patients with established acute respiratory distress syndrome (ARDS) to limit ventilatorinduced lung injury and improve clinical outcomes. While the use of LPV for prevention of ARDS remains controversial, a growing body of evidence supports its use. Fuller and colleagues1 recently described the limited implementation of LPV for ARDS prevention in emergency department (ED) patients with severe sepsis. While the authors were appropriately cautious in their interpretation of the literature, emergency medicine and critical care physicians must continue to make clinical decisions on ventilator management—what should be recommended? The physiology and biologic plausibility of LPV in patients at risk for ARDS make sense. Numerous studies in multiple animal models have demonstrated that mechanical ventilation with higher tidal volumes damages the previously uninjured lung and causes pulmonary and systemic inflammation. More recently, clinical studies have provided evidence for the use of LPV prior to ARDS development. A recent meta-analysis, including 20 articles with a total of 2,822 participants, demonstrated large beneficial effects for LPV in prevention of acute lung injury and mortality.2 While the included articles were heterogeneous, effectiveness in diverse patient populations ranging from general intensive care unit patients to post–cardiac surgery patients supports generalizability. Subsequently, yet another high-profile trial in postoperative patients strongly favored the benefit.3 It is unlikely that patients with severe sepsis who are admitted from the ED would respond differently to LPV. Accordingly, we would support implementation of LPV for most critically ill ED patients based on the following rationale: 1) LPV benefits all evaluated subgroups of patients with established ARDS (e.g., pneumonia, sepsis, trauma, aspiration); 2) the data to support the alternate ventilator choice, higher tidal volumes to prevent atelectasis and improve ventilation, is based on relatively minimal empirical evidence; 3) there is minimal harm reported with the use of LPV; and 4) with limited research funding it is not possible to conduct large clini-
Dr. Ginde was supported by NIH grant K23AG040708. Dr. Moss was supported by NIH grants K24HL089223 and R01NR011051.
96
ISSN 1069-6563 PII ISSN 1069-6563583
cal trials for every intervention in all potential populations and settings. We believe that the existing literature sufficiently supports the adoption of LPV for most critically ill patients, including mechanically ventilated ED patients with severe sepsis. The focus of research should therefore shift to effective implementation of LPV. Even in established ARDS, adherence to LPV remains poor,4 and clearly this is even worse in patients at risk for ARDS.1 With longer ED lengths of stay for critically ill patients,5 it is no longer acceptable for emergency physicians to defer ventilator management to the intensive care unit. We suggest enhancing educational opportunities for ventilator management and principles of LPV in emergency medicine residency training, continuing medical education, and hospital quality improvement initiatives. In addition, enhanced local collaboration and communication between emergency physicians, nurses, respiratory therapists, and critical care staff will likely improve adherence to LPV and transitions across care settings. Similar to many successful quality improvement initiatives for severe sepsis, implementation of clinical protocols and checklists for optimal ventilator management will likely decrease variability and improve outcomes in these high-risk patients. doi: 10.1111/acem.12276
Adit A. Ginde, MD, MPH ([email protected]) Department of Emergency Medicine Marc Moss, MD Division of Pulmonary Sciences and Critical Care Medicine University of Colorado School of Medicine Aurora, CO Supervising Editor: Jeffrey Kline, MD.
References 1. Fuller BM, Mohr NM, Dettmer M, et al. Mechanical ventilation and acute lung injury in emergency department patients with severe sepsis and septic
© 2013 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12276
ACADEMIC EMERGENCY MEDICINE • January 2014, Vol. 21, No. 1 • www.aemj.org
shock: an observational study. Acad Emerg Med. 2013; 20:659–69. 2. Neto AS, Cardoso SO, Manetta JA, et al. Association between use of lung-protective ventilation with lower tidal volume and clinical outcomes among patients without acute respiratory distress syndrome: a metaanalysis. JAMA. 2012; 308:1651–9. 3. Futier E, Constantin J, Paugam-Burtz C, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med. 2013; 369:428–37.
97
4. Needham DM, Colantuoni E, Mendez-Tellez PA, et al. Lung protective mechanical ventilation and two year survival in patients with acute lung injury: prospective cohort study. BMJ. 2012; 344:e2124. 5. Herring AA, Ginde AA, Fahimi J, et al. Increasing critical care admissions from U.S. emergency departments, 2001-2009. Crit Care Med. 2013; 41:1197–204.
