Karlee De Monnin
Medical Student
Washington University School of Medicine, United States
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Emily Terian
Medical Student
Washington University School of Medicine, United States
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Lauren Yaegar, MA, MLIS
Medical Librarian
Washington University School of Medicine, Bernard Becker Medical Library, United States
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Ryan Pappal, n/a
Medical Student
Washington University School of Medicine, United States
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Nicholas Mohr, MD, MS, FCCM
Professor
University of Iowa Hospital and Clinics
Iowa City, IA
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Brian Roberts, MD, MSc
Associate Professor of Emergency Medicine
Cooper University Hospital, United States
Disclosure information not submitted.
Marin Kollef, MD
Professor
Washington Univ. School of Medicine, United States
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Christopher Palmer, MD, FCCM
Washington University in Saint Louis School of Medicine
Saint Louis, MO
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Enyo Ablordeppey, MD, MPH, FACEP
Washington University School of Medicine
Saint Louis, MO, United States
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Brian Fuller, MD, MSCI,FCCM
Associate Professor of Anesthesiology and Emergency Medicine
Washington University/Barnes-Jewish Hospital
Saint Louis, MO
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Title: Low tidal volume ventilation for emergency department patients: systematic review and meta-analysis
Introduction: Mechanical ventilator settings during the earliest period of respiratory failure are critical determinants of outcome. Data suggest that low tidal volume ventilation (LTVV) initiated in the emergency department (ED) has positive impact on patient-centered clinical outcomes. This systematic review and meta-analysis quantifies the impact that ED-based LTVV has on clinical outcomes as well as ventilator settings in the ED and intensive care unit (ICU).
Methods: We systematically reviewed MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, reference lists, conferences, and ClinicalTrials.gov. Randomized and nonrandomized studies of adult mechanically ventilated ED patients were eligible. Two reviewers independently screened abstracts of identified studies. LTVV was defined as tidal volume ≤ 8 mL/kg predicted body weight (PBW). A meta-analytic random effects model calculated pooled effect sizes and corresponding 95% CIs, comparing LTVV and non-LTVV groups. The primary outcome was mortality. Secondary outcomes included ventilation duration, lengths of stay, and the incidence of acute respiratory distress syndrome (ARDS) development after admission. We also assessed the impact of ED LTVV interventions on ED and ICU tidal volumes.
Results: The search identified 1,023 eligible studies. Eleven studies (n=12, 912) provided clinical outcome data and were meta-analyzed; ten additional studies (n=1,863) provided descriptive ED tidal volume data. ED LTVV was associated with lower mortality (26.5%) versus non-LTVV (31.1%) (odds ratio 0.80 [0.72 – 0.88]). ED LTVV was associated with shorter ICU (mean difference, -1.0; 95% CI, -1.7 to -0.3) and hospital (mean difference, -1.2; 95% CI, -2.3 to -0.1) lengths of stay, more ventilator-free days (mean difference, 1.4; 95% CI, 0.4 – 2.4), and lower incidence (4.5% versus 8.3%) of ARDS (odds ratio 0.57 [0.44 – 0.75]). ED LTVV interventions were associated with significant reductions in ED (-1.5 mL/kg PBW [-1.9 to -1.0]; p < 0.001) and ICU (-1.0 mL/kg PBW [-1.8 to -0.2]; p= 0.01) tidal volume.
Conclusions: The use of LTVV in the ED is associated with improved clinical outcomes, and an increase in lung protection in the ED and ICU. Interventions aimed at implementing and sustaining LTVV in the ED should be explored.