Correspondence / American Journal of Emergency Medicine 34 (2016) 1883-1910

Ventilation in the ED: Attention must be paid?,??

1901

Jeffrey Sankoff, MD

To the Editor,

We would like to thank the authors for their Letter to the editor regarding our observational study of mechanical ventilation in the emergency department (ED), and we appreciate their comments. The authors of the letter observe that our population was heteroge- neous, thereby limiting the ability to draw homogenous conclusions. We wholeheartedly agree, and we noted in the Discussion that the lung protective and non-lung protective groups were not evenly matched. As it was an observational study, we could not control for all potentially confounding factors. Our univariate analyses demon- strated that receiving Lung protective ventilation was associated with increased mortality, and we suspected that this may represent in- creased attention to the Ventilator settings for higher acuity patients with respiratory failure.

Although the indications for initiating mechanical ventilation were heterogeneous, the purpose of the study was to determine if lung pro- tective ventilation was the consistent approach during the patient’s hos- pital stay. Much has been written of managing the ventilation in the intensive care unit, but there are few data showing that a lung- protective approach is practiced during the initial phase of ventilation within the ED [1]. This study was underpowered to demonstrate defin- itively whether the short term period of ventilation had an effect on out- come post-ED. Regardless, there are data showing that a low tidal volume strategy is beneficial regardless of diagnosis [2].

Although the time in the ED is relatively short, with a median of 5 hours, it has been demonstrated in studies by Dreyfuss and others that this is more than sufficient duration to cause ventilator-induced lung in- jury [3,4]. Given the robust body of evidence for the benefit of Low tidal volume ventilation, and in light of the confounders in our study, we do not conclude that our study demonstrates a safe duration for non-lung protective ventilation.

We agree that the risk for development of Acute respiratory distress syndrome is low for this group, however, prior data support using a lung protective method of mechanical ventilation for all pa- tients, rather than just those with ARDS [4,5]. Without close attention to the management of the ventilator, the patients can be subjected to additional strain which may have an impact on overall outcome. Impor- tantly, our findings suggest a hands-off method of ventilator manage- ment by emergency physicians. The consequences of this approach for ED patients may have implications beyond just the risk of developing ARDS. All intubated and ventilated patients are at risk of complications from mechanical ventilation, and emergency physicians should be dili- gent about optimizing ventilator support early and monitoring the need for ongoing support throughout the ED stay.

Susan R. Wilcox, MD Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine Division of Emergency Medicine, Medical University of South Carolina 96 Jonathan Lucas Street, Suite 812-CSB, Charleston, SC, USA

Corresponding author.

E-mail address: [email protected]

Daniel F. Fisher, MS, RRT Respiratory Care Services, Massachusetts General Hospital 55 Fruit Street, Blake 652, Boston, MA, USA

E-mail address: [email protected]

Department of Emergency Medicine, University of Colorado School of Medicine, Denver Health Medical Center 4200 E 9th Avenue, Denver, CO, USA

E-mail address: [email protected]

Todd A. Seigel, MD

Department of Emergency Medicine and Critical Care Kaiser Permanente East Bay, Oakland and Richmond Medical Centers

275 W MacArthur Blvd, CA, USA E-mail address: [email protected]

Jeremy B. Richards, MD, MA Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine Medical University of South Carolina, 96 Jonathan Lucas Street

Suite 812-CSB, Charleston, SC, USA E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2016.06.109

References

1. Putensen C, Theuerkauf N, Zinserling J, Wrigge H, Pelosi P. Meta-analysis: ventilation strategies and outcomes of the acute respiratory distress syndrome and acute lung in- jury. Ann Intern Med 2009;151:566-76.
2. Neto AS, Cardoso SO, Manetta JA, Pereira VGM, Esposito DC, Pasqualucci Mde O, et al.

   Association between use of lung-protective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome. JAMA 2012;308:1651-9.

   Dreyfuss D, Saumon G. Ventilator-induced lung injury: lessons from experimental studies. Am J Respir Crit Care Med 1998;157:294-323.

3. Hillman NH, Moss TJM, Kallapur SG, Bachurski C, Pillow JJ, Polglase GR, et al. Brief, large tidal volume ventilation initiates lung injury and a systemic response in fetal sheep. Am J Respir Crit Care Med 2007;176:575-81.
4. Futier E, Constantin J-M, Paugam-Burtz C, Pascal J, Eurin M, Neuschwander A, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med 2013;369:428-37.

   A proactive approach to ED information

   

   technology: the case of pediatric procedural sedation?

   To the Editor,

   Emergency department (ED) information systems are increasingly impacting the work of emergency physicians. Designed to record data and enhance emergency care, these systems offer to increase efficiency and promote safety. From a research perspective, their structure is com- patible with advanced data science methodologies [1].

   However, current systems are far from fully delivering on these promises [2,3]. Given this gap, a departure from exclusive vendor- based infrastructures toward more modular “app-based” systems is tak- ing place. Its advocates assert that systems can be better developed by stakeholders; clinicians, and third parties (eg, technology startups), adapting standardized “open code” interfaces [4-6]. Emergency physi- cians have been encouraged to take an active role in developing ED information systems [1] with recent attempts demonstrating encourag- ing results [5].

   In light of this change, we have developed a pediatric procedural se- dation recording tool (PSRT). We aimed to use available “best evidence” to focus on the pertinent parameters with an emphasis on time de- mands and user satisfaction. Our aim was to build a platform for case documentation which will also serve as an accessible, research grade data set, prospectively produced by standard ED documentation.

   ? Sources of support: This letter was written at the affiliated institutions without grant

   support.

   ?? Prior presentations: This work has not been previously presented or published.

   ? The authors declare no conflict of interests or specific financial support relevant to this correspondence.