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Lung-Protective Ventilation and Associated Outcomes and Costs Among Patients Receiving Invasive Mechanical Ventilation in the ED

  • Shannon M. Fernando
    Correspondence
    CORRESPONDENCE TO: Shannon M. Fernando, MD, MSc
    Affiliations
    Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada

    Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
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  • Eddy Fan
    Affiliations
    Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada

    Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
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  • Bram Rochwerg
    Affiliations
    Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada

    Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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  • Karen E.A. Burns
    Affiliations
    Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada

    Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada

    Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada
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  • Laurent J. Brochard
    Affiliations
    Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada

    Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada
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  • Deborah J. Cook
    Affiliations
    Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada

    Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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  • Allan J. Walkey
    Affiliations
    Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, MA

    Center for Implementation and Improvement Sciences, Boston University School of Medicine, Boston, MA
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  • Niall D. Ferguson
    Affiliations
    Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
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  • Catherine L. Hough
    Affiliations
    Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR
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  • Daniel Brodie
    Affiliations
    Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY

    Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY
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  • Andrew J.E. Seely
    Affiliations
    Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada

    Department of Surgery, University of Ottawa, Ottawa, ON, Canada

    School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada

    Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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  • Venkatesh Thiruganasambandamoorthy
    Affiliations
    Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada

    School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada

    Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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  • Jeffrey J. Perry
    Affiliations
    Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada

    School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada

    Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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  • Alexandre Tran
    Affiliations
    Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada

    Department of Surgery, University of Ottawa, Ottawa, ON, Canada

    School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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  • Peter Tanuseputro
    Affiliations
    School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada

    Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada

    Bruyére Research Institute, Ottawa, ON, Canada

    Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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  • Kwadwo Kyeremanteng
    Affiliations
    Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada

    Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada

    Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada

    Institut du Savoir Montfort, Ottawa, ON, Canada
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Published:September 19, 2020DOI:https://doi.org/10.1016/j.chest.2020.09.100

      Background

      Invasive mechanical ventilation is often initiated in the ED, and mechanically ventilated patients may be kept in the ED for hours before ICU transfer. Although lung-protective ventilation is beneficial, particularly in ARDS, it remains uncertain how often lung-protective tidal volumes are used in the ED, and whether lung-protective ventilation in this setting impacts patient outcomes.

      Research Question

      What is the association between the use of lung-protective ventilation in the ED and outcomes among invasively ventilated patients?

      Study Design and Methods

      A retrospective analysis (2011-2017) of a prospective registry from eight EDs enrolling consecutive adult patients (≥ 18 years) who received invasive mechanical ventilation in the ED was performed. Lung-protective ventilation was defined by use of tidal volumes ≤ 8 mL/kg predicted body weight. The primary outcome was hospital mortality. Secondary outcomes included development of ARDS, hospital length of stay, and total hospital costs.

      Results

      The study included 4,174 patients, of whom 2,437 (58.4%) received lung-protective ventilation in the ED. Use of lung-protective ventilation was associated with decreased odds of hospital death (adjusted OR [aOR], 0.91; 95% CI, 0.84-0.96) and development of ARDS (aOR, 0.87; 95% CI, 0.81-0.92). Patients who received lung-protective ventilation in the ED had shorter median duration of mechanical ventilation (4 vs 5 days; P < 0.01), shorter median hospital length of stay (11 vs 14 days; P < .001), and reduced total hospital costs (Can$44,348 vs Can$52,484 [US$34,153 vs US$40,418]; P = .03) compared with patients who received higher tidal volumes.

      Interpretation

      Use of lung-protective ventilation in the ED was associated with important patient- and system-centered outcomes, including lower hospital mortality, decreased incidence of ARDS, lower hospital length of stay, and decreased total costs. Protocol development promoting the regular use of lung-protective ventilation in the ED may be of value.

      Key Words

      Abbreviations:

      ABG (arterial blood gas), aOR (adjusted OR), PBW (predicted body weight), PEEP (positive end-expiratory pressure)
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      Linked Article

      • Response
        CHESTVol. 159Issue 3
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          We thank Moroz and Zaccagnini for their comments on our study.1 As requested, we have included data showing the annual prevalence of lung-protective ventilation in the ED from our multicenter cohort (Table 1). Minimal variability has been seen in year-to-year use of lung-protective ventilation, in keeping with previous work demonstrating the overall low prevalence of ED lung-protective ventilation.2 Unfortunately, we do not have data examining whether predicted body weight calculations were performed.
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      • Moving From the “Why” of Lung-Protective Ventilation to the “How” of Lung-Protective Ventilation
        CHESTVol. 159Issue 3
        • Preview
          We congratulate Fernando et al1 for rigorously investigating lung-protective ventilation (LPV) within the ED. The article published in CHEST (February 2021) shows that implementing LPV in the ED may lead to improved patient- and system-level outcomes. This study provides robust evidence that LPV may be beneficial for many patients, including in non-ICU settings. Additionally, the results suggest that LPV is still not fully implemented in routine care despite current recommendations.2 Finally, the potential cost savings of LPV for respiratory therapy services suggest that LPV in ED may allow for better distribution of these services in health care.
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