Decades ago, delivery of critical care was envisioned to extend from the prehospital environment and into the intensive care unit (ICU). The emergency department (ED) was recognized as an important link in the care of the critically ill. As an Intensivist and Emergency Physician, one of Dr. Fuller’s over-arching research missions is to study critical care in both the ED and ICU, as his lab strongly believes that the clinical care and the research of critical illness should not be restricted to the ICU.
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.
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. In this rigorous systematic review, they found that the majority of data suggests a causal 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.
Dr. Fuller’s team has long advocated for targeting the ED environment to improve outcomes for mechanically ventilated patients, as outlined in this publication: Reducing the burden of acute respiratory distress syndrome: the case for early intervention and the potential role of the emergency department. Shock. 2014 41 (5): 378-387.
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 significant 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 observational cohort study. This also showed that ED mechanical ventilation practices could be improved and may be in the causal 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 Sept; 70(3): 406-418. 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. These results attracted significant attention in the EM and CCM clinical space, won numerous awards at the SCCM annual congress, and were accompanied by an editorial and highlighted in the NEJM Journal Watch.
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 Apr; 45(4): 645-652. 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. These results were also highlighted in the NEJM Journal Watch.
Sedation For Mechanically Ventilated ED Patients
The provision of sedation is a near-ubiquitous intervention for mechanically ventilated patients and a critical determinant of outcome. Dr. Fuller’s research team has expanded their investigative efforts into this domain, in order to improve outcomes for this vulnerable population.
Analgosedation practices and the impact of sedation depth among patients requiring mechanical ventilation in the emergency department: a cohort study. CHEST 2017 Nov; 152(5): 963-971. This single center ED-SED Study was the first rigorous examination of ED sedation practices for mechanically ventilated patients. Key findings demonstrated that deep sedation (RASS -3 to -5) was common and associated with worse clinical outcomes. These results were highlighted in the NEJM Journal Watch.
Practice patterns and outcomes associated with early sedation depth in mechanically ventilated patients: a systematic review and meta-analysis. Crit Care Med. March 2018- 46(3): 471-479. In a comprehensive systematic review and meta-analysis, Dr. Fuller’s research team demonstrated that early deep sedation provided during the first 48 hours of mechanical ventilation is associated with worse mortality, delirium, ventilator duration, and lengths of stay. This was accompanied by an editorial calling for a change in the paradigm of how early sedation is provided. The above two works were spearheaded by Robert J. Stephens during his TL1 research year in Dr. Fuller’s lab.
The ED-SED Study: a multicenter, prospective cohort study of practice patterns and clinical outcomes associated with Emergency Department SEDation for mechanically ventilated patients. Crit Care Med. 2019 Nov; 47(11): 1539-1548. As a follow up to the single center ED-SED Study, this 15-site study further demonstrated that ED-based deep sedation was common and associated with worse outcomes. This work was featured in SCCM’s journal club webcast, highlighted in NEJM Journal Watch, and voted as the 2nd most impactful publication in 2019 by ACEP’s CCM section.