The Journal of Emergency Medicine, Vol. -, No. -, pp.

1–11, 2014
Copyright Ó 2014 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2014.09.059

Education

EMERGENCY MEDICINE RESIDENTS’ KNOWLEDGE OF

MECHANICAL VENTILATION

Susan R. Wilcox, MD,*† Todd A. Seigel, MD,‡§ Tania D. Strout, PHD, RN,k Jeffrey I. Schneider, MD,{
Patricia M. Mitchell, RN,{ Evie G. Marcolini, MD,** Michael N. Cocchi, MD,††‡‡ Howard A. Smithline, MD,§§
Lucienne Lutfy-Clayton, MD,§§ Marie Mullen, MD,kk Jonathan S. Ilgen, MD,{{ and Jeremy B. Richards, MD***
*Department of Emergency Medicine, †Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston,
Massachusetts, ‡Department of Emergency Medicine, Rhode Island Hospital, Providence, Rhode Island, §University of California San
Francisco, San Francisco, California, kDepartment of Emergency Medicine, Maine Medical Center, Portland, Maine, {Department of
Emergency Medicine, Boston Medical Center, Boston, Massachusetts, **Department of Emergency Medicine, Yale–New Haven Hospital,
New Haven, Connecticut, ††Department of Emergency Medicine, ‡‡Department of Anesthesia Critical Care, Division of Critical Care, Beth
Israel Deaconess Medical Center, Boston, Massachusetts, §§Department of Emergency Medicine, Baystate Medical Center, Springfield,
Massachusetts, kkDepartment of Emergency Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, {{Division
of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington, and ***Division of Pulmonary, Critical Care and
Sleep Medicine, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
Reprint Address: Susan R. Wilcox, MD, Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street,
Boston, MA 02114

, Abstract—Background: Although Emergency physi-
cians frequently intubate patients, management of mechani-
cal ventilation has not been emphasized in emergency
medicine (EM) residency curricula. Objectives: The objective
of this study was to quantify EM residents’ education, expe-
rience, and knowledge regarding mechanical ventilation.
Methods: We developed a survey of residents’ educational ex-
periences with ventilators and an assessment tool with nine
clinical questions. Correlation and regression analyses were
performed to evaluate the relationship between residents’
scores on the assessment instrument and their training, edu-
cation, and comfort with ventilation. Results: Of 312 EM res-
idents, 218 responded (69.9%). The overall correct response
rate for the assessment tool was 73.3%, standard deviation
(SD) ± 22.3. Seventy-seven percent (n = 167) of respondents
reported # 3 h of mechanical ventilation education in their
residency curricula over the past year. Residents reported
frequently caring for ventilated patients in the ED, as 64%
(n = 139) recalled caring for $ 4 ventilated patients per
Institutional Review Board approval was obtained at each
participating institution.
month. Fifty-three percent (n = 116) of residents endorsed
feeling comfortable caring for mechanically ventilated ED
patients. In multiregression analysis, the only significant pre-
dictor of total test score was residents’ comfort with caring
for mechanically ventilated patients (F = 10.963, p = 0.001).
Conclusions: EM residents report caring for mechanically
ventilated patients frequently, but receive little education
on mechanical ventilation. Furthermore, as residents’ perfor-
mance on the assessment tool is only correlated with their
self-reported comfort with caring for ventilated patients,
these results demonstrate an opportunity for increased
educational focus on mechanical ventilation management in
EM residency training. Ó 2014 Elsevier Inc.
, Keywords—mechanical ventilation; critical care; educa-
tion; residents
INTRODUCTION
Although emergency physicians frequently intubate crit-
ically ill patients in the emergency department (ED),
management of mechanical ventilation traditionally has

RECEIVED: 14 April 2014; FINAL SUBMISSION RECEIVED: 15 August 2014;

ACCEPTED: 30 September 2014

1
2 S. R. Wilcox et al.
not been emphasized in emergency medicine (EM) prac-
tice and residency training curricula (1–4). Nonetheless,
management of positive-pressure ventilation can
influence outcomes of critically ill patients for several
conditions commonly encountered in EM practice (5–
10). For example, patients with asthma, once intubated,
are at high risk of complications and deterioration (7).
Low-tidal-volume ventilation improves mortality in pa-
tients with acute respiratory distress syndrome (ARDS)
(11). Careful management of oxygenation and ventilation
by emergency care providers has been shown to improve
outcomes in intubated patients with traumatic brain
injury (12,13). Furthermore, due to hospital crowding,
emergency physicians may be primarily responsible for
prolonged management of mechanically ventilated
patients (14–16). Even for patients who are in the ED
only briefly, evidence suggests that ventilator-induced
lung injury can occur in as little as 20 min (17).
We designed this study to quantify EM residents’
experience and knowledge regarding mechanical ventila-
tion. We surveyed EM residents to assess how frequently
they receive education on mechanical ventilation, fre-
quency with which they care for mechanically ventilated
patients in the ED, and their subjective comfort with man-
aging patients on mechanical ventilation. In addition, we
created an assessment tool to characterize residents’
application of knowledge regarding mechanical ventila-
tion involving common emergency scenarios. We hypoth-
esized that the residents with the most experience in
managing mechanical ventilators in the ED would
perform superiorly on the knowledge assessment tool.
MATERIALS AND METHODS
Survey Instrument Development
To quantify EM residents’ training experiences, we
developed a 5-point Likert scale survey tool to assess res-
idents’ level of training, hours of education on mechani-
cal ventilation, and exposure to the topic at local and
national conferences (Appendix). The survey also
queried residents regarding the frequency with which
they care for mechanically ventilated patients and their
comfort with managing ventilators. Survey responses
were dichotomized as affirmative or negative: the re-
sponses ‘‘often’’ and ‘‘frequently’’ were defined as affir-
mative responses, whereas ‘‘never,’’ ‘‘rarely,’’ or ‘‘don’t
know’’ were defined as negative. Any responses left blank
were scored as ‘‘don’t know.’’
Assessment Instrument Development
A literature review did not identify preexisting assessment
tools for assessing EM residents’ knowledge regarding
clinical issues involving mechanical ventilation. We iden-
tified one validated test with a focus on management of
mechanical ventilation in the intensive care unit (ICU) de-
signed for Internal Medicine residents, and this test served
as a foundation for development of our assessment tool. A
project team with backgrounds in EM and critical care,
and experience in educational survey development, gener-
ated an assessment instrument with questions specific to
EM (18–20). We created a series of questions involving
key principles consistent with outlined objectives for
resident education in mechanical ventilation, and
similar in style and content to the validated test for
internal medicine residents (18,21). These principles
included respiratory physiology, modes of mechanical
ventilation, and complications of mechanical ventilation
(18,21).
The content was modified to be relevant to manage-
ment of mechanically ventilated patients in the ED. Spe-
cific clinical scenarios emphasized emergency
management of ventilated patients with asthma, ARDS,
and traumatic brain injury, as evidence supports the
importance of conscientious ventilator management in
these clinical scenarios (5,7,10–12,22–28).
Our assessment tool was formatted using multiple-
choice questions, an accepted means of assessing clinical
competence, following guidelines recommended by the
National Board of Medical Examiners (29–32). To
enhance validity, candidate questions were reviewed
and edited by subject experts in an iterative fashion to
optimize content, length, and relevance to the
assessment tool’s goals. Eleven faculty members from
multiple institutions, with backgrounds ranging from
community EM, academic EM, pulmonology/critical
care, trauma surgery, anesthesiology, and critical care
medicine, critically reviewed the survey and assessment
tool. The faculty provided further comment, review, and
editing of the questions.
To assess validity regarding the response process, the
survey and assessment tool were then piloted with faculty
and senior EM residents to assess question clarity, to
determine survey length, and identify potentially redun-
dant questions (33,34). After piloting, the project was
reviewed for final approval by EM faculty with critical
care fellowship training who were not originally
involved in the first two iterations of the survey
development.
Study Protocol
The finalized versions of the survey and assessment tool
were administered anonymously using Research Elec-
tronic Data Capture (REDCap, Nashville, TN) tools
hosted at Massachusetts General Hospital (35). REDCap
is a secure, Web-based application designed to support
EM Residents’ Knowledge of Mechanical Ventilation
data capture for research studies, providing an interface
for validated data entry.
The survey and assessment tool were distributed by e-
mail to all of the EM residents enrolled in eight EM res-
idency training programs in the northeastern United
States, for a total of 312 EM residents. These eight insti-
tutions include both 3-year and 4-year training programs.
The survey was sent to all EM residents in each training
program by a local investigator at each site. Residents at
these institutions received an e-mail invitation to partici-
pate once a week for 3 weeks, beginning in early January
2013. The study protocol was approved by the institu-
tional review boards of all participating institutions. Con-
sent for participation in the survey was obtained from
each resident at the time of participation, as the survey
introduction stated that partaking of the survey indicated
consent.
Data Analysis
Study data were exported into a Microsoft Excel (Micro-
soft Corporation, Redmond, WA) spreadsheet program
and were then transferred into SPSS (v. 11.0, SPSS,
Inc., Chicago, IL) for analysis. For all variables, missing
data were excluded on a case-by-case basis.
For the purposes of this study, we assumed the correct
response rate for the assessment tool (test score) to be a
surrogate for knowledge of mechanical ventilation. We
examined the continuous outcome variable test score
for normality in two ways. First, the outcome was exam-
ined visually using histograms and normal quantile-
quantile plots. After visual examination, Pearson’s
second skewness coefficient was computed, revealing
mild skew to the left, Sk2 = 0.61. Survey data regarding
study participants and their training programs, mechani-
cal ventilation educational experiences, and ventilator
management experience were summarized using descrip-
tive statistics. One-way analysis of variance was used to
assess for differences in total test score across partici-
pating institutions.
As our hypothesis was that the residents with the most
exposure to managing mechanical ventilators in the ED
would perform better on the knowledge assessment
tool, we examined the relationship between these vari-
ables in several ways. Ordinary least-squares regression
analyses were performed, with total test score serving
as the outcome variable. The frequency with which resi-
dents managed mechanically ventilated patients was the
predictor variable. To examine the relationship between
these variables after controlling for other variables signif-
icantly correlated to test score in simple correlation anal-
ysis (Spearman’s r), hierarchical multiple regression
models using the additional predictors of postgraduate
year (PGY) of training, number of EM residency mechan-
3
ical ventilation lecture hours completed, number of hours
of education outside EM residency curricula, and subjec-
tive comfort with managing mechanically ventilated ED
patients were employed. Exploratory regression analyses
were then conducted to determine which variables, alone
and in combination, were the strongest predictors of total
test score.
In addition to assessing normality as described above,
additional linear regression assumptions were evaluated
using residual analyses and assessment of influence diag-
nostics. Multicollinearity was evaluated using variance
inflation factors, which were all well below the recom-
mended cut points. Multivariate logistic regression ana-
lyses were performed to evaluate the extent to which
PGY of training, hours of residency curriculum-based
formal ventilator management education, hours of extra-
curricular ventilator-related training, and the frequency
with which participants reporting caring for ventilated
patients in the ED influenced residents’ self-reported
comfort with managing mechanically ventilated patients.
Coefficient estimates, adjusted odds ratios (aORs), and
95% confidence intervals are reported for each variable.
We accepted an alpha of < 0.05 as statistically significant.
RESULTS
Characteristics of the Study Subjects and Their Training
Programs
Study surveys were distributed to a total of 312 EM
residents, with 219 residents responding (response
rate = 70.2%). One resident completed only the first sur-
vey question and was subsequently dropped from the
study, leaving data from 218 residents’ complete surveys
for analysis (69.9%). Nine residents (4%) did not fully
complete the knowledge assessment tool. Of the residents
who completed the surveys, there was relatively equal dis-
tribution by PGY class (26.6% PGY-1, 28.0% PGY-2,
27.5% PGY-3, and 17.9% PGY-4.) The eight institutions
included in this study represented both 3-year (37.7%)
and 4-year EM programs (63.3%), and the response rate
from the institutions ranged from 43.6% to 81.4%.
Educational Experiences and Experience Managing
Ventilated Patients
Overall, study participants reported few residency-based
educational opportunities regarding mechanical ventila-
tion. Seventy-seven percent of residents (n = 167) re-
ported receiving 3 or fewer hours of ventilation-related
education in their residency curricula over the past year,
and 34% (n = 73) reported receiving between 0 and 1 h
of education. Similarly, 73% (n = 159) of residents
described receiving 3 or fewer hours of mechanical
4 S. R. Wilcox et al.

ventilation education from nonresidency sources,
including journal clubs, local or national conference
attendance, and reading articles (Table 1). Responses
regarding educational experiences were consistent
among residents from the individual institutions, particu-
larly when grouped by PGY of training.
Conversely, residents reported frequently caring for
mechanically ventilated patients in the ED. Sixty-four
percent (n = 139) of residents reported that they care
for 4 or more ventilated patients per month in the ED,
and 22% (n = 48) reported caring for 10 or more venti-
lated patients per month. Fifty-three percent (n = 116)
of participants described feeling comfortable caring
for mechanically ventilated ED patients ‘‘often’’ or
‘‘frequently’’; whereas 45% of respondents described
‘‘never’’ or ‘‘ rarely’’ feeling comfortable managing these
patients. Only 16% (n = 35) described management of the
ventilator as the responsibility of an emergency physician
(resident or attending) at their institution. Seventy-eight
percent (n = 170) identified the respiratory therapist as be-
ing primarily in charge of ventilator management
(Table 1).
Ventilator Management Knowledge

The overall correct response rate for the nine-question

Table 1. Residents’ Self-reported Education and assessment tool was 73.3%, SD 6 22.3%. Of the 218 res-
Experience Regarding Mechanical Ventilation idents who completed the assessment tool, 134 (61.5%)
Respondents achieved a score of at least 70%. Statistically significant
(%) differences in total test scores were not noted between in-
stitutions (F = 1.035, p = 0.408). Increasing PGY level
How many hours of lecture on mechanical
ventilation have you received through your was associated with increased scores on the knowledge
EM residency in the last year? tool (Figure 1). Correlation analysis revealed statistically
0–1 73 (33.5) significant relationships between total test score and the
2–3 94 (43.1)
4–5 18 (8.3) frequency of managing ventilated ED patients, PGY of
More than 5 12 (5.5) training, self-reported residency-related hours of venti-
Don’t know 21 (9.2) lator management education, extracurricular ventilator
How many hours of instruction have you
received on mechanical ventilation from education, and level of comfort with managing ventilated
other EM sources (EM articles, discussion patients. The relationships between total test score and
in EM journal clubs, EM lectures/ residency design or who bears primary responsibility
conferences, etc.) in the last year?
0–1 68 (31.2) for ventilator management were not significant (Table 2).
2–3 91 (41.8)
4–5 24 (11.0) Multivariate Results
More than 5 18 (8.3)
Don’t know 17 (4.6)
How often do you care for mechanically We evaluated the relationship between total test score and
ventilated patients in the Emergency exposure to mechanical ventilation management with
Department?
Never 18 (8.3) multivariate linear regression modeling. After adjusting
Rarely (1–3 patients/month) 58 (26.6) for the effects of PGY of training, residency-related hours
Often (4–9 patients/month) 91 (41.7) of education, extracurricular hours of education, and
Frequently (>10 patients/month) 48 (22.0)
Don’t know 3 (1.4) comfort with managing mechanically ventilated patients,
How often do you feel comfortable managing we determined that self-reported exposure to manage-
mechanical ventilation and troubleshooting ment of patients on mechanical ventilation was not a sig-
issues with ventilated patients in the ED?
Never 15 (6.9) nificant predictor of total test score (t = 0.569, p = 0.570).
Rarely 82 (37.6) Exploratory regression analyses revealed that the stron-
Often 94 (43.1) gest and only significant predictor of total test score
Frequently 22 (10.1)
Don’t know 5 (2.3) was residents’ self-reported confidence in caring for me-
Who primarily manages and makes changes chanically ventilated patients (F = 10.963, p = 0.001). On
to the mechanical ventilator for intubated average, test scores increased by approximately 10 points
patients in your ED?
Respiratory therapist 170 (78.0) (95% confidence interval 4.0–15.6 points, p = 0.001)
Nurse 0 (0) when residents reported feeling comfortable managing
EM resident 27 (12.4) ventilated patients ‘‘often’’ or ‘‘frequently.’’ The addition
EM attending 8 (3.7)
Other doctor (ICU physician, pulmonologist, 0 (0) of any other predictor variables, alone or in combination,
etc.) did not produce a more parsimonious model.
Don’t know 13 (6.0) Three variables were statistically significantly associ-
EM = emergency medicine; ED = emergency department; ated with resident comfort managing mechanically venti-
ICU = intensive care unit. lated patients. The respondents’ year in residency was
EM Residents’ Knowledge of Mechanical Ventilation 5

and their length of stay in the ED is increasing (15,36).

Ventilator management decisions can directly affect
patient outcomes, especially in scenarios commonly
encountered in the ED, such as asthma, ARDS, and
traumatic brain injury (14–16). Furthermore, ventilated
patients are among the most critically ill in the ED and
are at high risk for deterioration (37). Although mechan-
ical ventilation has been considered integral to EM prac-
tice by a collaboration of key EM organizations,
including the American Board of Emergency Medicine,
the hours required for training or methods of determining
proficiency are not specified (38).
The knowledge assessment tool used in this study was
designed to reflect educational objectives for manage-
Figure 1. The mean percent correct on the knowledge
assessment tool stratified by postgraduate year (PGY) level,
ment of mechanically ventilated patients, and tested
with error bars indicating standard deviations. *p < 0.05. knowledge in clinical scenarios commonly encountered
by residents in the ED (18,21). The instrument was
rigorously designed, pretested, and pilot tested to
most strongly associated with conveying confidence in optimize psychometric and performance characteristics.
caring for ventilated patients, with an aOR of 10.049 The assessment tool was developed to be consistent
(p < 0.001) for PGY-4s as compared to PGY-1s. Next, with a previously validated test focused on ventilator
hours of residency education were associated with com- management in the ICU tailored to senior internal
fort, as residents reporting 4–5 h of curriculum-based ed- medicine residents (18). Although not all aspects were
ucation were more likely to report confidence than those applicable to EM residents, many of the principles from
reporting 1 or fewer hours (aOR 8.9, p = 0.018). Finally, the validated test provided a framework for our survey
caring for mechanically ventilated patients ‘‘frequently’’ development. The mean test score in that study was
or ‘‘often,’’ compared to ‘‘rarely’’ or ‘‘never’’ was associ- 74%, with an SD of 6 14, very similar to our score of
ated with comfort (aOR 3.426, p = 0.003) (Table 3). 73.3% 6 22. As such, the knowledge assessment tool
developed for and used in this study seems to be an
DISCUSSION acceptable means of assessing EM residents’ knowledge
regarding common clinical scenarios involving mechani-
Emergency physicians frequently care for critically ill, cally ventilated patients in the ED.
mechanically ventilated patients in the ED and may be In our study, EM residents report that the curricular
called upon to care for these patients elsewhere. With time dedicated to mechanical ventilation varies among
overcrowding and aging of the population, the incidence EM residency training programs, but is overall relatively
of mechanically ventilated patients in the ED is growing, minimal. The majority of residents, 77%, responded that
they had received 3 or fewer hours of education on me-
chanical ventilation in their residency curricula in the
Table 2. Correlations between Training Program last year, and one-third of respondents reported they
Characteristics and Total Score on Assessment had received 0–1 h. Residents similarly reported few
Tool
educational opportunities on mechanical ventilation
Correlation outside of residency, in venues such as journal clubs
Characteristics of Training Program with Total Test and EM conferences, with only 16% endorsing receiving
and Experience Score (r) p Value
> 3 h in such settings over the last year. Although the res-
Residency design 0.028 0.684 idents reported few hours of education, 64% of residents
Residency training site 0.005 0.946 responded that they often or frequently care for intubated
Postgraduate year of training 0.177 0.009
Hours of EM curricular education 0.153 0.024 patients in the ED.
Hours of extracurricular education 0.153 0.024 Although each PGY of training was associated with a
Frequency of managing ventilated 0.135 0.046 modest improvement in scores on the knowledge assess-
patients
Level of comfort with managing 0.223 <0.001 ment tool, the impact of the years in residency on the
mechanically ventilated patients score on the assessment tool was less than may be ex-
EM management of mechanical 0.037 0.589 pected, accounting for only 3% in the variation in scores.
ventilator
The prior study of internal medicine residents demon-
EM = emergency medicine. strated a stronger correlation between PGY and test score,
6 S. R. Wilcox et al.
Table 3. Relationships between Candidate Predictor
Variables and Resident’s Level of Comfort with
Managing Mechanically Ventilated Patients
Correlation
with Resident
Variable Comfort (r) p Value
Postgraduate year of training 0.409 <0.001
Hours of EM curricular education 0.222 0.001
Hours of extracurricular education 0.149 0.024
Frequency of managing ventilated 0.441 <0.001
patients
EM management of mechanical 0.024 0.728
ventilator
EM = emergency medicine.
with a Spearman correlation coefficient of 0.57
(p = 0.0001). The reason for this discrepancy between
the prior study and our results is unclear, but may be
due to the structure of many EM training programs as
compared to internal medicine programs. Rotations in
ICUs frequently occur only within the first 2 years of
EM training, with minimal teaching on mechanical vents
occurring in the EM curriculum, whereas internal medi-
cine residents generally rotate in ICUs during all 3 years
of residency.
An additional finding from this study is that the major-
ity of EM residents (78%) identified respiratory therapists
as being primarily responsible for managing ventilators
in the ED, whereas only 16% stated that the management
of the ventilator was the responsibility of an emergency
physician. However, emergency physicians’ assuming re-
sponsibility for the ventilator was not associated with an
improvement in test score on the assessment tool in uni-
variate analysis.
Residents’ self-reported confidence with managing
mechanically ventilated patients was the only parameter
that significantly predicted performance on the knowl-
edge assessment tool. Residents who reported feeling
comfortable managing ventilated patients ‘‘often’’ or
‘‘frequently’’ had an improvement in their test scores of
approximately 10 points, as compared to residents who
demonstrated apprehension in caring for these patients.
Postgraduate year, hours of residency education on
mechanical ventilation, and frequency of caring for me-
chanically ventilated patients were positively associated
with residents’ self-reported comfort. As may be ex-
pected, PGY-4 residents were 10 times more likely to
report comfort when managing mechanically ventilated
patients as compared to their PGY-1 counterparts. Resi-
dents participating in 4 to 5 h of EM curriculum-based ed-
ucation regarding ventilator management were nearly
nine times more likely to report comfort than those
receiving 1 or fewer hours of education. In addition,
when compared to those who reported caring for venti-
lated patients ‘‘rarely’’ or ‘‘never,’’ those who did so
‘‘often’’ or ‘‘frequently’’ were more than three times as
likely to report comfort with ventilated patients in the ED.
Notably, although hours of education were associated
with higher scores on univariate analysis, this correlation
did not persist in multivariate analysis. Hours of educa-
tion were, however, associated with increased comfort,
the only factor independently associated with improved
score. This apparent dichotomy is likely explained by
acknowledging that residents’ comfort in caring for these
critically ill patients is complex and based upon
numerous factors, including their years of training and
the frequency of caring for ventilated patients. Ulti-
mately, self-perceived comfort in caring for mechanically
ventilated patients may be the result of a confluence of ex-
periences, ability, knowledge, and confidence (39–41).
Dispositional characteristics, experiences outside of the
ED, or other factors not assessed in our study may lead
to increased confidence.
Our study identifies an opportunity for improving EM
residents’ knowledge of mechanical ventilation.
Although all residents will eventually gain more experi-
ence and accrue more years in training, the hours of edu-
cation is the only readily modifiable factor for EM
residency programs. Although EM residents have moder-
ate baseline knowledge about mechanical ventilation,
they are not actively applying that knowledge in the ED
and are often ceding opportunities to manage the venti-
lator to respiratory therapists. These results identify an
opportunity to improve EM residents’ familiarity with
ventilators by increasing hours of education and encour-
aging more active involvement with ventilator manage-
ment decisions in the ED.
Limitations
Although our response rate was high, at 69.9%, it is
possible that our results have been influenced by nonre-
sponder bias. Residents’ interest in the topic of mechan-
ical ventilation may have influenced participation in this
study, with interested residents being more likely to com-
plete the knowledge assessment tool and less interested
residents being less likely to participate and complete
the tool. In addition, although responses correlated
among residents from the same program, residents’ per-
ceptions may not accurately reflect the actual frequency
with which they receive teaching on mechanical ventila-
tion in their residency curricula or other forums (e.g.,
journal clubs, conferences). Similarly, residents’ self-
reported perceptions of the frequency with which they
care for mechanically ventilated patients may not pre-
cisely reflect the actual frequency with which they care
for such patients.
EM Residents’ Knowledge of Mechanical Ventilation
When asked who manages the ventilator in the ED,
few residents reported that emergency physicians were
responsible for ventilator management at their institu-
tions. Some respondents may have interpreted the survey
question to be asking who manually makes the changes
on the ventilator, rather than who makes decisions
regarding ventilator settings and management. However,
residents’ responses to this question correlated among in-
stitutions, with the majority of respondents claiming EM
responsibility coming from a single institution. There-
fore, it is less likely that this response reflects misunder-
standing of the question, and more likely that this reflects
the culture and practice of deferring ventilator manage-
ment decisions to respiratory therapists.
Although we endeavored to create a rigorously devel-
oped assessment tool supported by established guidelines
and a validated instrument, the external validity of this
tool has not been tested in a larger population. The sce-
narios were selected to be consistent with recommenda-
tions, test understanding of physiology, and reflect
circumstances of evidence-based ventilation interven-
tions, but responses to these questions may not entirely
reflect residents’ knowledge of other aspects of mechan-
ical ventilation. Finally, our multicenter study included
EM residency programs in the northeastern United States,
and the generalizability of our results to other regions or
countries is not known.
CONCLUSIONS
EM residents report caring for mechanically ventilated
patients frequently in the ED, but receive little education
on mechanical ventilation. Furthermore, few residents
identify ventilator management as the responsibility of
EM physicians. Additionally, residents’ performance on
our knowledge assessment tool was only correlated
with their self-reported comfort with caring for mechan-
ically ventilated patients. These results indicate opportu-
nities for increased educational focus on mechanical
ventilation management in EM residency training.
Acknowledgments—This study was supported by institutional
funds without external grant support. The authors would like
to thank John T. Nagurney, MD for his assistance with the
design of the project.
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EM Residents’ Knowledge of Mechanical Ventilation 9

APPENDIX Who primarily manages and makes changes to the

mechanical ventilator for intubated patients in your
Survey and Knowledge Assessment Instrument
ED?
A. Respiratory therapist
What is the design of your Emergency Medicine resi-
B. Nurse
dency?
C. EM resident
A. 1 - 3 years
D. EM Attending
B. 1 - 4 years
E. Physician not affiliated with the ED (ICU, Pulmo-
C. 2 - 4 years
nologist, etc.)
What year are you in EM residency? F. Don’t know
A. 1
What is the difference between assist-control and
B. 2
pressure support?
C. 3
A. With assist control, the patient cannot trigger the
D. 4
ventilator; with pressure support, the patient triggers
How many hours of lecture have you received on each breath.
mechanical ventilation through your EM residency B. With assist control, the patient always receives the
in the last year? same PEEP; with pressure support, the patient can adjust
A. 0 – 1 the PEEP via their effort.
B. 2 – 3 C. With assist control, the patient receives a set vol-
C. 4 – 5 ume or pressure with each breath; with pressure support,
D. more than 5 the patient can adjust the volume they receive via their
E. Don’t know effort.
(Please provide your best estimate) D. With assist control, the patient triggers each breath;
How many hours of instruction have you received with pressure support, the patient cannot trigger the venti-
on mechanical ventilation from other EM sources lator.
(reading EM articles, discussion in EM journal clubs, E. Don’t know.
national EM lectures/conferences, etc.) in the last A patient with pneumonia is intubated for hypox-
year? emic respiratory failure and sepsis. Her vent is set at
A. 0 – 1 volume control (VC) with a tidal volume of 500 ccs,
B. 2 – 3 PEEP of 12 cm H2O, rate of 20, and a FiO2 of
C. 4 – 5 100%. Her first ABG returns as a pH of 7.34, a
D. more than 5 PaCO2 of 42, PaO2 of 240. The following change
E. Don’t know should be made to her ventilator settings:
(Please provide your best estimate) A. The PEEP should be increased to 15.
How often do you care for mechanically ventilated B. The respiratory rate should be decreased to 18.
patients in the Emergency Department? C. The tidal volume should be increased to 600.
A. Never D. The FiO2 should be decreased to 80%.
B. Rarely (1-3 patients/month) E. Don’t know.
C. Often (4-9 patients/month) A patient with massive posterior epistaxis is intu-
D. Frequently (>10 patients/month) bated in the Emergency Department to protect his
E. Don’t know airway. His vent is set at VC 550 ccs, PEEP of 5
(Please provide your best estimate) cm H2O, rate of 24, and a FiO2 of 40%. His ABG re-
How often do you feel comfortable managing me- turns with a pH of 7.52, PaCO2 of 25, PaO2 of 120.
chanical ventilation and troubleshooting issues with The following change should be made to his vent
ventilated patients in the ED? settings:
A. Never A. The respiratory rate should be decreased to 20.
B. Rarely B. The tidal volume should be increased to 600.
C. Often C. The FiO2 should be increased to 100%.
D. Frequently D. The PEEP should be increased to 8.
E. Don’t know E. Don’t know.
10
A patient with a prior tracheostomy and a new
diagnosis of ARDS is transferred to the Emergency
Department from his rehabilitation center. He is
started on his prior vent settings from his last hospital-
ization at the rehab prior to transfer. What should be
the guiding principles in changing his vent settings
once he is in the hospital?
A. Keep the FiO2 high to maximize his oxygenation.
B. Decrease the PEEP to minimize barotrauma to the
alveoli.
C. Keep the plateau pressure less than 30 to minimize
barotrauma to the alveoli.
D. Keep the tidal volume high to prevent respiratory
acidosis.
E. Don’t know.
The patient above has ventilator settings of VC 525
ccs, PEEP of 5 cm H2O, rate of 22, and a FiO2 of
100%. His ABG returns with pH of 7.35, PaCO2 41,
PaO2 of 95. His PIP is 36 cm H2O, and his Pplat is
33 cm H2O. His Auto-PEEP is 0. The following change
should be made to his vent settings:
A. Decrease his respiratory rate to decrease his PIP.
B. Decrease his TV to decrease his Pplat.
C. Turn down the PEEP because his oxygenation is
adequate.
D. Increase his TV to assist in compensating for his
metabolic acidosis.
E. Don’t know.
A patient with a traumatic brain injury is intubated
in the ED for a GCS of < 8. His first ABG is pH 7.54,
PaCO2 26, PaO2 100. The most important value to
intervene upon is:
A. Increasing the CO2 to maximize oxygen delivery to
the injured brain.
B. Increasing the CO2 to prevent brain herniation.
C. Increasing the PaO2 to maximize oxygen delivery
to the injured brain.
D. Decreasing the PaO2 to minimize free-radical dam-
age to the injured brain.
E. Don’t know.
S. R. Wilcox et al.
A patient with severe asthma is intubated for respi-
ratory failure in the ED. Her ventilator is set with of
VC 450 ccs, PEEP of 5 cm H2O, rate of 22, and an
FiO2 of 100%. Her PIP is 38 cm H2O, and her Pplat
is 26 cm H2O. Her Auto-PEEP is 12. Her oxygen satu-
ration is 100%. These values tell you the following
about her respiratory system:
A. Her respiratory system has high resistance.
B. Her respiratory system as poor compliance.
C. Her respiratory system has a large shunt.
D. Her respiratory system has a large amount of dead
space
E. Don’t know.
Regarding this patient with severe respiratory fail-
ure, her ventilator is set with VC 450 ccs, PEEP of 5
cm H2O, rate of 22, and an FiO2 of 100%. Her PIP
is 38 cm H2O and Pplat is 26 cm H2O. Her Auto-
PEEP is 12. Her oxygen saturation is 100%. What
change should be made immediately to the vent set-
tings?
A. The tidal volume should be increased because asth-
matics are often dehydrated
B. The PEEP should be increased because of the risk
of V/Q mismatch in asthma
C. The rate should be decreased to allow for exhalation
D. The FiO2 should be decreased due to risk of oxygen
toxicity.
E. Don’t know.
An elderly patient with end-stage COPD is intu-
bated in the Emergency Department for respira-
tory failure. While awaiting his bed in the ICU,
the high-pressure alarm on his ventilator goes off.
What is the first thing the doctor caring for him
should do?
A. Bilateral needle decompressions of the chest
B. Disconnect the patient from the vent and hand-bag
via the endotracheal tube
C. Order a STAT chest x-ray
D. Give the patient a bolus of sedation
E. Don’t know.
EM Residents’ Knowledge of Mechanical Ventilation 11

ARTICLE SUMMARY
1. Why is this topic important?
Emergency physicians frequently care for mechani-
cally ventilated patients, and management of mechanical
ventilation can influence outcomes for critically ill pa-
tients. However, education on mechanical ventilation
traditionally has not been emphasized in emergency med-
icine (EM) training.
2. What does this study attempt to show?
We designed this study to quantify EM residents’ expe-
rience with mechanical ventilation and tested their knowl-
edge of physiology and evidence-based ventilator
practices in scenarios common in EM practice.
3. What are the key findings?
EM residents report frequently caring for mechanically
ventilated patients, but receive few hours of education on
ventilation. Although over 60% of residents achieved a
score of > 70%, the average score was only 73%. The fac-
tors associated with an improved score were the residents’
hours of education, postgraduate year, and reported com-
fort in caring for ventilated patients in the univariate
model, and only comfort correlated with score in a multi-
variate model.
4. How is patient care impacted?
With emergency department overcrowding, projections
show that emergency physicians will continue to
frequently care for mechanically ventilated patients.
Given the evidence demonstrating the importance of
good ventilator management, mechanical ventilation is
an increasingly important topic in EM. This study demon-
strates that there are opportunities to increase hours of ed-
ucation regarding mechanical ventilation in EM training,
and that doing so can increase residents’ confidence and
knowledge of mechanical ventilation.