SCCM Resource Library-The Sustainability of Lung-Protective Ventilation in the Emergency Department: A 5-Year, Single-Center Experience

Video Transcription

pharmacy physician at Wash U in St. Louis. It's a pleasure to talk to you guys today. We're going to talk about the sustainability of lung protective ventilation in the ED,  really our ED, and it's the title and the abstracts at a five-year single center experience is probably closer to 10, and we've made some modifications to what I'm going to present  to you today based on just accruing data since we submitted this. So some background, mechanical ventilation in the ED, so really we did a cohort study  that we published in 2013 to sort of tell the story about how the ventilator was used in the ED and found some pretty interesting findings.  One, the tidal volume range, the median tidal volume was around nine mLs per kg indexed to predicted body weight with an interquartile range of up to 10, so 25% of the patient's  getting above 10 mLs per kg predicted body weight, obviously not good, with a very low incidence of lung protective ventilation, and then almost a universal setting of five  a peep and 100% FiO2. We sort of dovetailed that and around the same time did a systematic review looking  at lower tidal volume at the initiation of mechanical ventilation, and I think one of the most significant findings is that even though we screened over 1,500 studies for  this particular systematic review, not a single ventilator study had been done in the ED, so that was sort of a light bulb moment to improve care and a little research niches.  So on the heels of that, as well as two or three other cohort studies that we published, we decided to conduct the LOVE-ED trial, so lung protective ventilation in the ED trial,  which was part of my career development K grant, as well as it was funded by an institutional  award at Barnes-Jewish Hospital here in St. Louis, and essentially we wanted to use really  sort of nudges and defaults to make lung protective ventilation the default approach to the emergency  department and with not really sort of rocket science interventions, just limit tidal volume  six to eight after you get an accurate height, set peep more appropriately instead of the universal five and 100% FiO2, really initiated at 30 or 40% and then titrated up only in  the setting of increased peep, head to bed elevation, et cetera. So in that particular trial, the LOVE-ED trial, which is published in Annals of Emergency  Medicine, we reduced tidal volume by about two mLs per kg predicted body weight, and then we limited hyperoxia, really cut in half the amount of FiO2, head to bed elevation  really went way high as well as lung protective ventilation. Improved clinical outcomes associated with that with respect to ventilator-free days,  ICU-free days, hospital-free days, and mortality as well. Again, single center, quasi-experimental study, so some limitations there, but that was the LOVE-ED trial.  So since that time, we as a research team and clinical team have conducted multiple sort of single and multi-center studies.  Some of them focused on the ventilator, some of them focused on other aspects of care such as ED-based sedation.  So we wanted to really assess ED-based lung protective ventilation since we published the LOVE-ED trial, that intervention, to see if it's sustainable.  And our hypothesis was that ED-based lung protective ventilation is sustainable over time. And you guys all know that it takes a long time for effective therapies to reach patients.  And if it's not sustainable, then what sort of benefit are we deriving from it? So this was a sneak, a peek into that. So our methods.  So you'll see here there's a lot more studies and a lot higher end on this screen than there are in the published abstract.  That's because we've been able to collate some of the data, and we wanted to look at sort of a before-after period here.  So you've got up here the studies before the LOVE-ED intervention period, studies below the, after the LOVE-ED intervention period.  So that includes the after group here, the after group here, the ED awareness study, which looked at awareness with paralysis in mechanically ventilated ED patients.  The COVID-SED study, which looked at sedation in COVID patients. That's under peer review now. The ED-SED study, which is a 15-site sedation study in the ED.  And then the ED-SED pilot trial, which is under peer review right now, which is again looking at implementing best sedation practices in the ED.  Findings, you can see this is the pre-intervention group. This is the intervention group, sort of in the sort of tan color here.  You can see PEEP has increased away from that sort of almost everyone got five of PEEP. You're seeing less patients getting five of PEEP, more getting seven, eight, 10, 12, 15.  So that's better. These are median values here, PEEP of five with interquartile range of five to eight. That could be better, but this is pretty good.  But it definitely could be better. FIO2, so we see a decrease in the universal settings of FIO2 of almost 100% in the before arm.  And then you see many more patients getting 40%, 30%, 50% as well. These are median values here. We've really cut the amount of delivered oxygen down to these patients.  Tidal volume over time. So this again, this is the Luv-ED intervention period right here in 2017. You can see we've decreased tidal volume from about 500 down to 450.  Here's our interquartile range with the drop of 1.6 mLs per kg when indexed to predicted body weight.  Encouraging is that you see less variability, and the high end of that interquartile range is a lot less as well. So you can see this is our graph of ED tidal volumes over time.  Let's see. Again, we're looking at low tidal volume ventilation. The percentage of patients getting low tidal volume ventilation in the ED has gone way up below 50% to above 90%.  Getting low tidal volume ventilation is less than 8 mLs per kg predicted body weight. And then here's some clinical outcome data. We've got mortality.  So this is just pre-intervention and intervention group. Again, that spans about 10 years of time. Mortality's decreased.  These are not adjusted analyses, so take it for what it's worth. And then when you stratify strictly based on provision of low tidal volume versus non-low  tidal volume ventilation, you see an effect there as well regardless. So this sort of dovetails with a recent systematic review and meta-analysis that we did that  show about a 5% difference in mortality when ED-based low tidal volume ventilation is employed. So it's probably a good thing to do. Secondary outcomes.  By the intervention period, you see more ventilator-free days, ICU-free days, and hospital-free days.  And then again, if you just want to splice up the data a little differently and look at regardless of intervention time period, look at the provision of non-low tidal volume  ventilation versus low, you can see better clinical outcomes there as well. Limitations. Obviously, there are many.  Observational, these are quasi-experimental studies, but I don't think you're ever going to find an RCT at this point that randomizes people to non-low tidal volume versus low  tidal volume. It's probably an ethical issue there. And if you wanted to do a study looking at lower tidal volume versus usual care, it's not going to be feasible, the effect size.  You're going to need probably 100,000 patients for that. This is also secondary analyses as well. And then, you know, temporal trends.  This is secular trends and the data could account for our results. Conclusions. Non-protective ventilation in the ED appears to be sustainable, at least at our site.  And then widespread implementation of non-protective ventilation in the ED is a feasible and low-cost way to improve.

Video Summary

The speaker discusses the sustainability of lung protective ventilation in the emergency department (ED) and the results of a single-center study. The study aimed to make lung protective ventilation the default approach in the ED using simple interventions such as limiting tidal volume and adjusting peep and FiO2 levels. The study found improvements in clinical outcomes, including ventilator-free days, ICU-free days, hospital-free days, and mortality. The speaker also mentions other studies conducted by their research and clinical team on topics such as sedation in the ED. The conclusion is that non-protective ventilation in the ED is sustainable and can improve patient outcomes.

Asset Subtitle

Pulmonary, Quality and Patient Safety, 2022

Asset Caption

INTRODUCTION: Lung-protective ventilation (LPV) improves outcome in mechanically ventilated patients, especially when implemented early in the course of respiratory failure. Despite this, adherence to LPV is low. In 2013, we published a cohort study that demonstrated emergency department (ED) adherence to LPV was 27.1%. Median (IQR) tidal volume was 8.8 (7.8–10.0) mL/kg predicted body weight (PBW), and almost all patients received 100% fraction of inspired oxygen (FiO2) and positive end-expiratory pressure (PEEP) of 5 cm H2O. This prompted a clinical trial (LOV-ED Trial, 2017) which implemented LPV in the ED, and was associated with: 1) increase in LPV in both the ED and intensive care units (ICU); and 2) improved clinical outcomes. The objective of the current analysis was to assess ED-based LPV over the 5 years since our interventional trial, in order to assess intervention sustainability. METHODS: ED-based LPV was protocolized through strong collaboration with Respiratory Therapy, as part of our clinical trial. This included default tidal volume settings of 6-8 mL/kg PBW, initiating FiO2 at 0.30 – 0.40 (instead of 1.0) to limit hyperoxia, and PEEP setting with a PEEP-FiO2 table. In this current analysis, ventilator data from three prospective studies conducted at our center since 2017 were combined. LPV was defined as tidal volume ≤ 8 mL/kg PBW. Descriptive statistics were used to analyze data. Chi-square was used to compare ED LPV before and after implementation. RESULTS: 619 patients were included in the final analysis. Median tidal volume was 6.7 mL/kg PBW (6.2–7.3), FiO2 was 0.40 (0.40–0.80), and PEEP was 5 cm H2O (5–7.5). LPV was provided to 558 (90.1%) patients across the three studies after protocol implementation. This was significantly different (p < 0.01) compared to data from three cohort studies (n= 1,662) conducted before ED LPV implementation, which demonstrated ED LPV adherence in 760 (45.7%) patients. CONCLUSIONS: These data demonstrate that ED LPV is a sustainable intervention via protocolized implementation of ED ventilator settings and collaboration with Respiratory Therapy. Given the known patient-centered benefits of LPV, implementing through Respiratory Therapy during the earliest period of respiratory failure is likely a high fidelity intervention to improve quality and outcomes.

Meta Tag

Content Type Presentation

Knowledge Area Pulmonary

Knowledge Area Quality and Patient Safety

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Respiratory Failure

Tag Evidence Based Medicine

Year 2022

Keywords

sustainability

lung protective ventilation

emergency department

clinical outcomes

sedation in the ED

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