Ventilator Management of Adult Patients in the Emergency Department

Points and Pearls Excerpt

• Initiating best-practice ventilation management in the ED has been shown to decrease duration of ventilation, hospital stay, and mortality.
• Failure to optimize oxygenation and perfusion prior to intubation and mechanical ventilation has been associated with an increased risk of peri-intubation cardiac arrest.
• Hyperoxia in acutely ill patients is harmful. Large reviews have demonstrated an increase in mortality with a liberal oxygenation strategy compared to a more conservative approach.
• Start the newly mechanically ventilated patient at 100% FiO₂, but then rapidly titrate down the oxygen until the oxygen saturation is 93%-96%.

Most Important References

• Weingart SD. Managing initial mechanical ventilation in the emergency department. Ann Emerg Med. 2016;68(5):614-617. (Expert opinion) 
• Siemieniuk RAC, Chu DK, Kim LH, et al. Oxygen therapy for acutely ill medical patients: a clinical practice guideline. BJM. 2018;363:K4169. (Clinical practice guideline) 
• Guerin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159-2168. (Randomized controlled trial; 466 patients) 
• Casey JD, Janz DR, Russell DW, et al. Bag-mask ventilation during tracheal intubation of critically ill adults. N Engl J Med. 2019;380(9):811-821. (Randomized controlled trial; 401 patients) 
• Combes A, Hajage D, Capellier G, et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. N Engl J Med. 2018;378(21):1965-1975. (Randomized controlled trial; 249 patients)