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Protective lung mechanical ventilation in the ED: how and how much we need

      Mechanical ventilation (MV) is the a common criterion standard therapy for severe forms of acute respiratory failure in emergency departments (EDs) [
      • Mosier JM
      • Hypes C
      • Joshi R
      • Whitmore S
      • Parthasarathy S
      • Cairns CB
      Ventilator strategies and rescue therapies for management of acute respiratory failure in the emergency department.
      ]. Current practices are toward avoiding additional complications such as barotrauma, infections, and ventilator-associated lung injury. However, information about the application of the lung-protective MV in ED is scarce [
      • Wright BJ
      Lung-protective ventilation strategies and adjunctive treatments for the emergency medicine patient with acute respiratory failure.
      ]. In line with this, we read with very interest the article by Wilcox et al [
      • Wilcox SR
      • Richards JB
      • Fisher DF
      • Sankoff J
      • Seigel TA
      Initial mechanical ventilator settings and lung protective ventilation in the ED.
      ] and congratulate the authors for the results presented. With this observational study, the authors investigated patients with acute condition who were submitted to MV in the ED. They focused their attention on MV settings and on the application of lung-protective ventilation. Nearly 40% of the ED patients were ventilated with non–lung-protective ventilation; at the same time, low positive end-expiratory pressure and high fraction of inspired oxygen were applied in most cases. Surprisingly, the outcomes were not significantly different between patients submitted to lung-protective and non–lung-protective ventilation.We appreciated the effort of Wilcox et al to investigate and describe the practice of invasive MV in the ED, with this interesting study. However, we consider that there are some issues that need to be taken into account for proper clinical extrapolations:
      • 1.
        In our opinion, it is difficult to summarize homogeneous information on patients enrolled in this study as the indications for patient's invasive MV–supported breathing were heterogeneous.
      • 2.
        In any case, it is not surprising that outcomes between patients submitted to lung-protective and non–lung-protective ventilation, respectively, are not significantly different: in fact, as the authors acknowledged as well, in both groups, tidal volume and plateau pressure were lower than 10 mL/kg and 20 cm H2O, respectively [
        • Mosier JM
        • Hypes C
        • Joshi R
        • Whitmore S
        • Parthasarathy S
        • Cairns CB
        Ventilator strategies and rescue therapies for management of acute respiratory failure in the emergency department.
        ].
      • 3.
        Moreover, the short MV time should be taken into account, to evaluate negative or positive effects of nonprotective ventilation: the patients were ventilated for 5 hours in the ED, before they were admitted to the intensive care unit, whereas the overall length of ventilation was on average 4 days [
        • Sutherasan Y
        • Vargas M
        • Pelosi P
        Protective mechanical ventilation in the non-injured lung: review and meta-analysis.
        ]. In addition, the setting of ventilator in ICU is not reported. As a consequence, it could be argued that the length of MV in ED was too short to significantly influence the outcome. This is a controversial topic in ED.
      • 4.
        In most cases, the indication for the endotracheal intubation was other than respiratory disease, with only a low percentage of the patients (14.6% in the case of lung-protective ventilation and the 9% in the case of non–lung-protective ventilation, respectively) needing vasopressors because of hemodynamic instability. As a matter of the fact, both these remarks suggest that most patients participating in the study had low-risk factors to develop acute respiratory distress syndrome [
        • Jia X
        • Malhotra A
        • Saeed M
        • Mark RG
        • Talmor D
        Risk factors for ARDS in patients receiving mechanical ventilation for >48 h.
        ].
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      References

        • Mosier JM
        • Hypes C
        • Joshi R
        • Whitmore S
        • Parthasarathy S
        • Cairns CB
        Ventilator strategies and rescue therapies for management of acute respiratory failure in the emergency department.
        Ann Emerg Med. 2015 Nov; 66 ([Epub 2015 May 23, Review, PubMed PMID: 26014437]): 529-541https://doi.org/10.1016/j.annemergmed.2015.04.030
        • Wright BJ
        Lung-protective ventilation strategies and adjunctive treatments for the emergency medicine patient with acute respiratory failure.
        Emerg Med Clin North Am. 2014 Nov; 32 ([Epub 2014 Sep 18, Review]): 871-887https://doi.org/10.1016/j.emc.2014.07.012
        • Wilcox SR
        • Richards JB
        • Fisher DF
        • Sankoff J
        • Seigel TA
        Initial mechanical ventilator settings and lung protective ventilation in the ED.
        Am J Emerg Med. 2016; ([pii: S0735–6757(16)30051–1])https://doi.org/10.1016/j.ajem2016.04027
        • Sutherasan Y
        • Vargas M
        • Pelosi P
        Protective mechanical ventilation in the non-injured lung: review and meta-analysis.
        Crit Care. 2014; 18: 211
        • Jia X
        • Malhotra A
        • Saeed M
        • Mark RG
        • Talmor D
        Risk factors for ARDS in patients receiving mechanical ventilation for >48 h.
        Chest. 2008; 133: 853-861