Lung-Protective Ventilation Initiated in the Emergency Department (LOV-ED): A Quasi-Experimental, Before-After Trial

Ann Emerg Med. 2017 Sep;70(3):406-418.e4. doi: 10.1016/j.annemergmed.2017.01.013. Epub 2017 Mar 2.

Abstract

Study objective: We evaluated the efficacy of an emergency department (ED)-based lung-protective mechanical ventilation protocol for the prevention of pulmonary complications.

Methods: This 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.

Results: A 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).

Conclusion: Implementing 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.

Publication types

  • Observational Study

MeSH terms

  • Clinical Protocols
  • Controlled Before-After Studies*
  • Emergency Service, Hospital*
  • Female
  • Guideline Adherence*
  • Humans
  • Intensive Care Units*
  • Male
  • Middle Aged
  • Outcome and Process Assessment, Health Care
  • Patient Positioning
  • Prospective Studies
  • Respiration, Artificial* / instrumentation
  • Respiration, Artificial* / methods
  • Respiratory Distress Syndrome / physiopathology
  • Respiratory Distress Syndrome / therapy*
  • Respiratory Rate
  • Tidal Volume