Research Lab

Mechanical Ventilation

Mechanical ventilation and acute lung injury in emergency department patients with severe sepsis and septic shock: an observational study Acad Emerg Med. 2013; 20(7): 659-669.  Dr. Fuller was first author of this 2013 manuscript that examined in detail the mechanical ventilation parameters and ARDS in the ED.  His findings suggest that a need for improvement in lung-protective ventilation practices, and that treatment variables provided early during mechanical ventilation likely influence the development of ARDS.  This paper received significant attention from the critical care and EM community:http://onlinelibrary.wiley.com/doi/10.1111/acem.12156/abstract

Lower tidal volume at initiation of mechanical ventilation may reduce progression to acute respiratory distress syndrome - a systematic review Crit Care. 2013 Jan 18; 17 (1): R1 1.  In this investigation, Dr. Fuller and colleagues review over 1,700 papers to assess the link between initial tidal volume settings and progression to ARDS.  This paper also received significant attention and was accompanied by an editorial highlighting his work http://ccforum.biomedcentral.com/articles/10.1186/cc12516

Dr. Fuller has also been actively involved in the debate regarding best ventilator practices in patients without ARDS, and has co-authored several publications in this domain.  Low tidal volume ventilation should be the routine ventilation strategy of choice for all emergency department patients.  Ann Emerg Med.  2012 Aug; 60 (2): 215-6.  Protective ventilation for patients without acute respiratory distress syndrome.  Jama.  2013 Feb 20; 309 (7): 654-5.

This work hinges on the concept that patients intubated in the ED already have "pre-injured" lungs, and that lung injury does not exist on a "yes/no" diagnosis.  To demonstrate this, Dr. Fuller conducted a pilot trial examining pulmonary neutrophilic inflammation in patients without ARDS, and found significan inflammation in the lungs of patients exposed to higher tidal volumes.


Mechanical ventilation and acute respiratory distress syndrome in the emergency department: a multi-center, observational, prospective, cross-sectional study Chest 2015  Aug 1 ; 148 (2): 365-74.  To examine if ED-based mechanical ventilation practices extended beyond his home institution, Dr. Fuller conducted a multi-center prospective study.  This also showed that ED mechanical ventilation practices could be improved and may be in the casual pathway for the development of complications.

Sepsis-associated pulmonary complications in emergency department patients monitored with serial lactate: an observational cohort study.  J Crit Care 2015 Dec; 30(6): 1163-1168.  This cohort study demonstrated that mechanical ventilation in the ED was independently associated with the development of ARDS, and patients that developed ARDS received higher tidal volumes compared to patients that did not develop ARDS.



The LOV-ED Trial

Given the findings of the above research, Dr. Fuller's research group implemented a lung-protective ventilator protocol in the ED of Barnes-Jewish Hospital/Washington University in St. Louis in 2014, and studied the impact that this protocol had on clinical outcomes.  Details regarding the protocol and the study results can be found at:

Lung-protective ventilation initiated in the emergency department (LOV-ED): a study protocol for a quasi-experimental, before-after trial aimed at reducing pulmonary complication. BMJ Open 2016;6:e010991

Lung-protective ventilation initiated in the emergency department (LOV-ED): a quasi-experimental, before-after trial. Annals of Emerg Med 2017. [in press]. The main findings from the LOV-ED trial were that an ED-based lung-protective mechanical ventilator protocol: 1) can be implemented effectively in the ED; 2) significantly changed how mechanical ventilation was delivered in both the ED and ICU; and 3) reduced the incidence of pulmonary complications, ventilator duration, and mortality. This pragmatic investigation into an affordable and simple intervention suggests that the ED should be targeted for lung-protective ventilation to improve patient outcome.

 

A quasi-experimental, before-after trial examining the impact of an emergency department mechanical ventilator protocol on clinical outcomes and lung-protective ventilation in acute respiratory distress syndrome. Crit Care Med 2017. [in press] In a pre-planned sub-study on the patients with ARDS from the LOV-ED study, the ED-based protocol was associated with increased adherence to lung-protective ventilation in ARDS and a reduction in mortality.

 



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