Ventilation in ED may cause acute lung injury

The incidence of acute lung injury in patients started on mechanical ventilation in the emergency department could be reduced if ED staff paid a little more attention to ventilator settings and patient monitoring, said investigators at the annual congress of the Society of Critical Care Medicine.

A retrospective study of 251 mechanically ventilated patients with severe sepsis found that tidal volumes delivered to patients were highly variable, and the high tidal volumes and other preventable causes of acute lung injury (ALI) were common in the treatment of intubated patients in the ED, reported Dr. Brian M. Fuller of the departments of emergency medicine and anesthesiology – critical care at Washington University in St. Louis, Missouri, and his colleagues.

"Inspiratory plateau pressure is monitored infrequently in the ED. Ventilator settings seem to be static, with relatively little titration, and this appears to extend to care beyond the ED as well," they wrote in a poster presentation.

"These are things you can absolutely easily intervene on with some education," Dr. Rahul Nanchal of the department of medicine at the Medical College of Wisconsin, Waukesha, said in an interview. Dr. Nanchal comoderated a poster session at which the study was presented, but was not involved in the research.

Dr. Fuller and his colleagues noted that although mechanical ventilation is commonly used in the emergency department, how it is used has not been well studied.

"Acute lung injury typically occurs early after intensive care unit admission and remains difficult to treat after onset, suggesting that prevention may be the best current therapy," they wrote.

To see just what was going on, they retrospectively reviewed records on a cohort of 251 mechanically ventilated patients with severe sepsis who presented to an urban academic emergency department with more than 95,000 annual visits.

They defined lung-protective ventilation as tidal volume (V_t) less than 8 mL/kg of ideal body weight (IBW), which had previously been established in studies of low V_t in ALI as the upper limit of V_t allowed.

They found that the median tidal volume was 8.8 mL/kg per IBW (range 7.8-10.0). Inspiratory plateau pressures were recorded for only 76 (30.3%) of patients.

In 236 patients (94%), the first tidal volume delivered was the highest, and non–lung-protective ventilation was used for a median of 230 minutes (range 0 to 354.0).

Patients were exposed to a fraction of inspired oxygen of 100%, for a median of 251 (range 148-373) minutes. In addition, 60 patients (24.8%) were exposed to the same V_t for more than 24 hours.

"High tidal volume is common in intubated ED patients, as well as other potentially injurious settings, such as prolonged exposure to high levels of oxygen," the investigators wrote.

They noted that acute lung injury occurs in about 8.8%, and progression to acute injury occurs in more than one-fourth of patients (27.5%) early after admission, at a mean of 2.1 days.

"Future trials aimed at ALI prevention should consider targeting ED mechanical ventilation in patients at high risk for ALI," they wrote.

Dr. Nanchal said that pulmonary specialists can intervene by recommending that respiratory therapists lower tidal volumes delivered to acceptable rates, monitor plateau pressures more frequently, and inform physicians if the plateau pressures are too high.

chestphysician@elsevier.com

The incidence of acute lung injury in patients started on mechanical ventilation in the emergency department could be reduced if ED staff paid a little more attention to ventilator settings and patient monitoring, said investigators at the annual congress of the Society of Critical Care Medicine.

A retrospective study of 251 mechanically ventilated patients with severe sepsis found that tidal volumes delivered to patients were highly variable, and the high tidal volumes and other preventable causes of acute lung injury (ALI) were common in the treatment of intubated patients in the ED, reported Dr. Brian M. Fuller of the departments of emergency medicine and anesthesiology – critical care at Washington University in St. Louis, Missouri, and his colleagues.

"Inspiratory plateau pressure is monitored infrequently in the ED. Ventilator settings seem to be static, with relatively little titration, and this appears to extend to care beyond the ED as well," they wrote in a poster presentation.

"These are things you can absolutely easily intervene on with some education," Dr. Rahul Nanchal of the department of medicine at the Medical College of Wisconsin, Waukesha, said in an interview. Dr. Nanchal comoderated a poster session at which the study was presented, but was not involved in the research.

Dr. Fuller and his colleagues noted that although mechanical ventilation is commonly used in the emergency department, how it is used has not been well studied.

"Acute lung injury typically occurs early after intensive care unit admission and remains difficult to treat after onset, suggesting that prevention may be the best current therapy," they wrote.

To see just what was going on, they retrospectively reviewed records on a cohort of 251 mechanically ventilated patients with severe sepsis who presented to an urban academic emergency department with more than 95,000 annual visits.

They defined lung-protective ventilation as tidal volume (V_t) less than 8 mL/kg of ideal body weight (IBW), which had previously been established in studies of low V_t in ALI as the upper limit of V_t allowed.

They found that the median tidal volume was 8.8 mL/kg per IBW (range 7.8-10.0). Inspiratory plateau pressures were recorded for only 76 (30.3%) of patients.

In 236 patients (94%), the first tidal volume delivered was the highest, and non–lung-protective ventilation was used for a median of 230 minutes (range 0 to 354.0).

Patients were exposed to a fraction of inspired oxygen of 100%, for a median of 251 (range 148-373) minutes. In addition, 60 patients (24.8%) were exposed to the same V_t for more than 24 hours.

"High tidal volume is common in intubated ED patients, as well as other potentially injurious settings, such as prolonged exposure to high levels of oxygen," the investigators wrote.

They noted that acute lung injury occurs in about 8.8%, and progression to acute injury occurs in more than one-fourth of patients (27.5%) early after admission, at a mean of 2.1 days.

"Future trials aimed at ALI prevention should consider targeting ED mechanical ventilation in patients at high risk for ALI," they wrote.

Dr. Nanchal said that pulmonary specialists can intervene by recommending that respiratory therapists lower tidal volumes delivered to acceptable rates, monitor plateau pressures more frequently, and inform physicians if the plateau pressures are too high.

chestphysician@elsevier.com

The incidence of acute lung injury in patients started on mechanical ventilation in the emergency department could be reduced if ED staff paid a little more attention to ventilator settings and patient monitoring, said investigators at the annual congress of the Society of Critical Care Medicine.

A retrospective study of 251 mechanically ventilated patients with severe sepsis found that tidal volumes delivered to patients were highly variable, and the high tidal volumes and other preventable causes of acute lung injury (ALI) were common in the treatment of intubated patients in the ED, reported Dr. Brian M. Fuller of the departments of emergency medicine and anesthesiology – critical care at Washington University in St. Louis, Missouri, and his colleagues.

"Inspiratory plateau pressure is monitored infrequently in the ED. Ventilator settings seem to be static, with relatively little titration, and this appears to extend to care beyond the ED as well," they wrote in a poster presentation.

"These are things you can absolutely easily intervene on with some education," Dr. Rahul Nanchal of the department of medicine at the Medical College of Wisconsin, Waukesha, said in an interview. Dr. Nanchal comoderated a poster session at which the study was presented, but was not involved in the research.

Dr. Fuller and his colleagues noted that although mechanical ventilation is commonly used in the emergency department, how it is used has not been well studied.

"Acute lung injury typically occurs early after intensive care unit admission and remains difficult to treat after onset, suggesting that prevention may be the best current therapy," they wrote.

To see just what was going on, they retrospectively reviewed records on a cohort of 251 mechanically ventilated patients with severe sepsis who presented to an urban academic emergency department with more than 95,000 annual visits.

They defined lung-protective ventilation as tidal volume (V_t) less than 8 mL/kg of ideal body weight (IBW), which had previously been established in studies of low V_t in ALI as the upper limit of V_t allowed.

They found that the median tidal volume was 8.8 mL/kg per IBW (range 7.8-10.0). Inspiratory plateau pressures were recorded for only 76 (30.3%) of patients.

In 236 patients (94%), the first tidal volume delivered was the highest, and non–lung-protective ventilation was used for a median of 230 minutes (range 0 to 354.0).

Patients were exposed to a fraction of inspired oxygen of 100%, for a median of 251 (range 148-373) minutes. In addition, 60 patients (24.8%) were exposed to the same V_t for more than 24 hours.

"High tidal volume is common in intubated ED patients, as well as other potentially injurious settings, such as prolonged exposure to high levels of oxygen," the investigators wrote.

They noted that acute lung injury occurs in about 8.8%, and progression to acute injury occurs in more than one-fourth of patients (27.5%) early after admission, at a mean of 2.1 days.

"Future trials aimed at ALI prevention should consider targeting ED mechanical ventilation in patients at high risk for ALI," they wrote.

Dr. Nanchal said that pulmonary specialists can intervene by recommending that respiratory therapists lower tidal volumes delivered to acceptable rates, monitor plateau pressures more frequently, and inform physicians if the plateau pressures are too high.

chestphysician@elsevier.com