Ventilator Management July 2020

Volume 22, Number 7

of Adult Patients in the

Author

Ryan Pedigo, MD
Director, Medical Student Education, Harbor-UCLA Medical Center;

Emergency Department
Assistant Professor of Emergency Medicine, David Geffen School
of Medicine at UCLA, Los Angeles, CA

Peer Reviewers

William A. Knight, IV, MD, FACEP, FNCS

Abstract
There are a variety of ventilator options available to the emer-
gency clinician, and decisions on choosing optimal settings
will depend on the clinical circumstances. Understanding the
latest literature in ventilator management can improve patient
Associate Professor of Emergency Medicine and Neurosurgery,
Medical Director, EM Advanced Practice Provider Program;
Associate Medical Director, Neuroscience ICU, University of
Cincinnati, Cincinnati, OH
Charles Stewart, MD, EMDM, MPH
Emergency Physician; Tulsa, OK; Visiting Professor, European
Master Disaster Medicine Program

outcomes by ensuring optimal oxygenation and ventilation

Prior to beginning this activity, see “CME Information”
and reducing the potential for ventilator-induced lung injury. on the back page.
This article reviews the most appropriate ventilator settings
for a variety of conditions in intubated adult patients present-
ing to the emergency department, and gives recommenda-
tions on monitoring the ventilated patient and making venti-
lator adjustments. An update on managing COVID-19-associ-
ated acute respiratory distress syndrome is also included.

Editor-In-Chief
Andy Jagoda, MD, FACEP
Professor and Chair Emeritus,
Department of Emergency Medicine;
Director, Center for Emergency
Medicine Education and Research,
Icahn School of Medicine at Mount
Sinai, New York, NY
Associate Editor-In-Chief
Kaushal Shah, MD, FACEP
Associate Professor, Vice Chair
for Education, Department of
Emergency Medicine, Weill Cornell
School of Medicine, New York, NY
Editorial Board
Saadia Akhtar, MD, FACEP
Associate Professor, Department of
Emergency Medicine, Associate Dean
for Graduate Medical Education,
Program Director, Emergency
Medicine Residency, Mount Sinai
Beth Israel, New York, NY
William J. Brady, MD
Professor of Emergency Medicine
and Medicine; Medical Director,
Emergency Management, UVA
Medical Center; Operational Medical
Director, Albemarle County Fire
Rescue, Charlottesville, VA
Calvin A. Brown III, MD
Director of Physician Compliance,
Credentialing and Urgent Care
Services, Department of Emergency
Medicine, Brigham and Women's
Hospital, Boston, MA
Peter DeBlieux, MD Medicine, NYU/Langone and
Professor of Clinical Medicine,
Louisiana State University School of
Medicine; Chief Experience Officer,
University Medical Center, New
Orleans, LA
Deborah Diercks, MD, MS, FACEP,
FACC
Professor and Chair, Department of
Emergency Medicine, University of
Texas Southwestern Medical Center,
Dallas, TX
Daniel J. Egan, MD
Associate Professor, Vice Chair of
Education, Department of Emergency Associate Professor, Department
Medicine, Columbia University
Vagelos College of Physicians and
Surgeons, New York, NY
Marie-Carmelle Elie, MD
Associate Professor, Department
of Emergency Medicine & Critical
Care Medicine, University of Florida
College of Medicine, Gainesville, FL
Nicholas Genes, MD, PhD
Associate Professor, Department of
Emergency Medicine, Icahn School
of Medicine at Mount Sinai, New
York, NY
Michael A. Gibbs, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Carolinas
Medical Center, University of North Ali S. Raja, MD, MBA, MPH
Carolina School of Medicine, Chapel Executive Vice Chair, Emergency
Hill, NC
Steven A. Godwin, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Assistant
Dean, Simulation Education,
University of Florida COM-
Jacksonville, Jacksonville, FL
Joseph Habboushe, MD MBA
Assistant Professor of Emergency
Bellevue Medical Centers, New York, Alfred Sacchetti, MD, FACEP
NY; CEO, MD Aware LLC
Eric Legome, MD
Chair, Emergency Medicine, Mount
Sinai West & Mount Sinai St. Luke's;
Vice Chair, Academic Affairs for
Emergency Medicine, Mount Sinai
Health System, Icahn School of
Medicine at Mount Sinai, New York, NY
Keith A. Marill, MD, MS
of Emergency Medicine, Harvard
Medical School, Massachusetts
General Hospital, Boston, MA
Angela M. Mills, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Columbia
University Vagelos College of
Physicians & Surgeons, New York,
NY
Charles V. Pollack Jr., MA, MD,
FACEP, FAAEM, FAHA, FESC
Professor & Senior Advisor for
Interdisciplinary Research and
Clinical Trials, Department of
Emergency Medicine, Sidney Kimmel
Medical College of Thomas Jefferson Associate Professor of Emergency
University, Philadelphia, PA
Medicine, Massachusetts General
Hospital; Associate Professor of
Emergency Medicine and Radiology, Scott D. Weingart, MD, FCCM
Harvard Medical School, Boston, MA Professor of Emergency Medicine;
Robert L. Rogers, MD, FACEP,
FAAEM, FACP
Assistant Professor of Emergency
Medicine, The University of
Maryland School of Medicine,
Baltimore, MD
Assistant Clinical Professor,
Department of Emergency Medicine,
Thomas Jefferson University,
Philadelphia, PA
Robert Schiller, MD International Editors
Chair, Department of Family Medicine,
Peter Cameron, MD
Beth Israel Medical Center; Senior
Academic Director, The Alfred
Faculty, Family Medicine and
Emergency and Trauma Centre,
Community Health, Icahn School of
Monash University, Melbourne,
Medicine at Mount Sinai, New York, NY
Australia
Scott Silvers, MD, FACEP
Associate Professor of Emergency Andrea Duca, MD
Attending Emergency Physician,
Medicine, Chair of Facilities and
Planning, Mayo Clinic, Jacksonville, FL Ospedale Papa Giovanni XXIII,
Bergamo, Italy
Corey M. Slovis, MD, FACP, FACEP
Suzanne Y.G. Peeters, MD
Professor and Chair, Department
Attending Emergency Physician,
of Emergency Medicine, Vanderbilt
Flevo Teaching Hospital, Almere,
University Medical Center, Nashville, TN
The Netherlands
Ron M. Walls, MD
Edgardo Menendez, MD, FIFEM
Professor and COO, Department of
Professor in Medicine and Emergency
Emergency Medicine, Brigham and
Medicine; Director of EM, Churruca
Women's Hospital, Harvard Medical
Hospital of Buenos Aires University,
School, Boston, MA
Buenos Aires, Argentina
Critical Care Editors Dhanadol Rojanasarntikul, MD
Attending Physician, Emergency
William A. Knight IV, MD, FACEP, Medicine, King Chulalongkorn
FNCS Memorial Hospital; Faculty of
Medicine, Chulalongkorn University,
Medicine and Neurosurgery, Medical Thailand
Director, EM Advanced Practice
Provider Program; Associate Medical Stephen H. Thomas, MD, MPH
Director, Neuroscience ICU, University Professor & Chair, Emergency
of Cincinnati, Cincinnati, OH
Medicine, Hamad Medical Corp.,
Weill Cornell Medical College, Qatar;
Emergency Physician-in-Chief,
Hamad General Hospital,
Chief, EM Critical Care, Stony Brook
Medicine, Stony Brook, NY Doha, Qatar
Edin Zelihic, MD
Research Editors Head, Department of Emergency
Aimee Mishler, PharmD, BCPS Medicine, Leopoldina Hospital,
Emergency Medicine Pharmacist, Schweinfurt, Germany
Program Director, PGY2 EM
Pharmacy Residency, Valleywise
Health, Phoenix, AZ
Joseph D. Toscano, MD
Chief, Department of Emergency
Medicine, San Ramon Regional
Medical Center, San Ramon, CA
Case Presentations
Your very first patient is wheeled into the resuscita-
tion bay as you are walking through the doors to start
your shift. A 30-year-old woman (5’3” tall, 120 kg) is in
respiratory failure from an acute asthma exacerbation and
requires a crash airway despite your best efforts to avoid
endotracheal intubation. After intubation, the respiratory
therapist asks for initial ventilator settings. You recall
that these patients are at risk for breath-stacking and you
start to devise your ventilator strategy...
Halfway into your shift, a 21-year-old man with type
1 diabetes mellitus presents, obtunded, with Kussmaul
breathing. You start your standard resuscitation, but the
patient requires endotracheal intubation, as he is unre-
sponsive to all stimuli. You consider whether you should
use the bag-valve mask during the apneic period during
rapid sequence intubation...
At the end of your shift, a 50-year-old man who was
seen 2 days ago at an outside hospital for pneumonia now
presents in severe hypoxemic respiratory failure. The
patient is intubated, but is difficult to oxygenate. A chest
x-ray demonstrates good endotracheal tube placement, but
bilateral diffuse infiltrates. You suspect acute respiratory
distress syndrome and start thinking about the strate-
gies you will use if your initial approach is ineffective in
oxygenating the patient...
Introduction
When it becomes necessary to place a patient on a
ventilator in the emergency department (ED), there
are many options regarding ventilator settings, and
understanding the strategies for each clinical sce-
nario can improve patient outcomes.1,2 A pre/post
study on a multifaceted ED-based mechanical ven-
tilator protocol found that initiating best ventilator
management practice in the ED decreased mortality,
duration of ventilation, and hospital length of stay.3
Fundamental to successful airway management
is the optimization of oxygenation and perfusion
prior to intubation and placement on a ventilator, if
possible; failure to do this has been associated with
an increased risk of peri-intubation cardiac arrest.4,5
Most cases of intubation-related cardiac arrest occur
within 10 minutes of intubation.6
Because patients require mechanical ventilation
for a wide variety of conditions, the considerations
and initial approach to ventilator management could
be substantially different in different scenarios. This
issue of Emergency Medicine Practice reviews general
approaches to ventilator management, with a focus
on specific conditions where a different approach to
mechanical ventilation would be advantageous.
Copyright © 2020 EB Medicine. All rights reserved. 2
Critical Appraisal of the Literature
A literature search was performed using the
PubMed Medical Subject Headings (MeSH) with
key words respiratory distress syndrome (432 articles);
ventilator-induced lung injury (72 articles); respiration,
artificial (2528 articles); and ventilators, mechanical
(66 articles) restricted to adults and trials in the past
10 years. Literature on randomized trials specific to
the ED is relatively uncommon, as most are longi-
tudinal studies performed in the intensive care unit
(ICU). Many of the studies included patients who
were enrolled in the ED, with the majority of the
interventions carried out in the ICU. Nonetheless,
there are supportive quasi-experimental (pre/post)
and observational data with outcomes that mirror
the randomized ICU-conducted trials. Therefore, it
is reasonable to assume that the benefits found in the
ICU ventilator trials are applicable to the ED popula-
tion. Specific trials analyzing most individual compo-
nents of ventilator management are lacking, except
for trials regarding acute respiratory distress syn-
drome (ARDS), where literature is robust. All major
trials on ventilator management were reviewed, as
well as expert opinion articles regarding ED ventila-
tor management.
Prehospital Care
If mechanical ventilation is within the scope of prac-
tice of the prehospital provider, the guidelines in this
article apply. Most recent data show that hyperoxia
in acutely ill medical patients is harmful, and expert
recommendations advise following the same oxygen-
ation guidelines in the prehospital setting as in the
ED/inpatient setting by generally avoiding hyper-
oxia. (See the “Oxygen Delivery” section, on page 5.)
If using bag-valve mask (BVM) ventilation for
hypoxia during transport, utilize a positive end-
expiratory pressure (PEEP) valve to provide PEEP
where it is necessary, as adjusting PEEP on a ventila-
tor. A PEEP valve may be integrated with the BVM
or it may be an optional add-on, and it typically
allows for the application of 0 to 20 cm H2O of PEEP.
PEEP provides pressure to the airways at the end of
expiration, which can increase alveolar patency and
improve oxygenation, especially in areas of shunt-
ing. Shunting refers to areas where alveoli are being
perfused but not being ventilated (eg, shunting due
to alveolar fluid accumulation in pulmonary edema,
alveolar hemorrhage, pneumonia, etc). PEEP can
keep these alveoli patent and participating in gas
exchange. Following the same recommendations for
PEEP as discussed in ventilated patients in the fol-
lowing sections is appropriate.
Reprints: www.ebmedicine.net/empissues
Approach to Initial Ventilator Settings
Modes of Ventilation
A 2015 systematic review and meta-analysis
compared pressure-controlled ventilation versus
volume-controlled ventilation in acute respiratory
failure in adults, and it did not find a difference in
terms of hemodynamics, work of breathing, or clini-
cal outcomes.7 In adult ED patients, for simplicity, a
volume assist-control mode of ventilation is general-
ly best, as patients will be guaranteed a set tidal vol-
ume regardless of lung compliance and regardless
of respiratory effort. The disadvantage of this is that
it may deliver these breaths by generating pressures
higher than desired. (See the “Ventilator Pressures”
section, pages 12-13, for more information on moni-
toring pressures.) However, if individual or local
expertise favors a pressure-controlled initial setting,
that is reasonable as well.
Volume Assist-Control Mode
A volume assist-control mode of ventilation allows
the ventilator to take over the work of breathing but
does also allow for over-breathing. The “control”
is that the patient gets the preset respiratory rate at
the preset tidal volume, regardless of patient effort,
as ventilator-initiated breaths. The “assist” is that
if the patient attempts to trigger a breath, they can
do so and will get the set tidal volume each time,
which are patient-initiated breaths. In a volume
assist-control mode, each breath delivered is given at
the prespecified tidal volume, regardless of whether
this is a control breath or assist breath. Therefore,
the set respiratory rate is a minimum and the patient
can breathe faster if they want to, but each time the
patient initiates an extra breath, the full preset tidal
volume will be triggered. As a more advanced set-
ting, the clinician can also change the flow charac-
teristic of the breath delivered, such as a “square”
waveform, where the flow is constant throughout
the breath, or a “ramp” waveform, where the flow
decelerates as the volume delivered increases.
Pressure-Regulated Volume Control
Some EDs may have pressure-regulated volume con-
trol (PRVC) which is another form of assist-control
ventilation. In PRVC, the machine uses the prior
breath to decide on the initial inspiratory pressure
needed to achieve the chosen tidal volume. The
ventilator will then adjust this pressure on a breath-
by-breath basis which, theoretically, allows for the
lowest overall pressure to be applied for a set tidal
volume, varying dynamically with change in patient
effort and/or lung mechanics. The user-specified
settings are otherwise the same as for a volume
assist-control mode of ventilation. For these modes,
the following settings are variable:8
July 2020 • www.ebmedicine.net
• Tidal volume
• Inspiratory peak flow rate (or inspiratory time)
• Respiratory rate
• PEEP
• Fraction of inspired oxygen (FiO2)
• Inspiratory to expiratory time (I:E ratio)
Tidal Volume
The tidal volume is the volume per breath delivered,
which is set in a volume-cycled mode. In volume
assist-control mode, this is the volume that will be
delivered if the machine delivers a control breath at
the specified respiratory rate, or the volume that will
be delivered if the patient triggers an assist breath.
In patients with ARDS, 6 mL/kg of predicted body
weight (PBW), not actual body weight, is a reason-
able starting point (range, 4-8 mL/kg of PBW). A
randomized clinical trial of 961 patients without
ARDS demonstrated that a lower tidal volume
strategy of approximately 6 mL/kg was not superior
to an intermediate tidal volume strategy of approxi-
mately 8 mL/kg, so it is reasonable to choose a tidal
volume within that range (6-8 mL/kg of PBW) for
non-ARDS patients.9 See Tables 1 and 2, page 4 for
charts of PBWs and their associated tidal volumes.
Inspiratory Peak Flow Rate (Inspiratory Time)
The peak flow rate specifies how fast the specified
tidal volume is delivered, in liters/minute. The in-
spiratory time is another setting to achieve the same
goal and specifies the duration (in seconds) that the
breath is given. One of these 2 values can be ad-
justed on a ventilator. An initial flow rate of 40 to 60
L/min or an inspiratory time of 0.5 to 0.8 seconds is
reasonable. Substantially faster flow rates or shorter
inspiratory times may lead to patient discomfort on
the ventilator, since the tidal volume will be deliv-
ered more rapidly. Flow rates that are too slow may
also cause dyspnea from increased work of breath-
ing. Comfort on the ventilator is often patient- and
sedation-dependent, and modifying this variable
can sometimes be helpful to allow for improved
patient-ventilator synchrony. Faster flow rates or
shorter inspiratory times will also lead to increases
in peak airway pressure from the rapidity of the
breath delivery.
Respiratory Rate
The respiratory rate is how many control breaths per
minute the machine will deliver automatically in the
absence of any patient-initiated assist breaths. This
is a minimum, as the patient can over-breathe the
ventilator if they are able to trigger assist breaths.
Considerations for this setting will include whether
the patient is at risk for breath-stacking (where an
additional breath is delivered before full exhalation,
in which case a lower respiratory rate would be
more favorable) or whether they need a high minute
3 Copyright © 2020 EB Medicine. All rights reserved.
ventilation to compensate for a metabolic acidosis
(where a higher respiratory rate would be more
favorable). Since the tidal volume is set based on
PBW, the respiratory rate is the main variable that is
modified when attempting to increase total minute
ventilation, where minute ventilation = respiratory
rate × tidal volume.
When a ventilator is on a volume assist-control
mode at a rate of 12 breaths/min, if the patient is
not triggering any breaths, the ventilator will auto-
matically deliver a breath every 5 seconds (control
breaths). If the patient attempts to breathe in, the
ventilator will then deliver an assisted breath. The
next control breath will be delivered 5 seconds later
if no additional breaths are triggered by the patient
during this time interval.
Positive End-Expiratory Pressure
The PEEP is how much pressure will remain in the
system at the end of a breath. A common initial

Table 1. Predicted Body Weight for Females of Various Heights and Associated Tidal Volumes
Height (in) PBW (kg) 4 mL/kg TV 5 mL/kg TV 6 mL/kg TV 7 mL/kg TV 8 mL/kg TV
5’ 0” (60) 45.5 182 228 273 319 364
5’ 1” (61) 47.8 191 239 287 335 382
5’ 2” (62) 50.1 200 251 301 351 401
5’ 3” (63) 52.4 210 262 314 367 419
5’ 4” (64) 54.7 219 274 328 383 438
5’ 5” (65) 57 228 285 342 399 456
5’ 6” (66) 59.3 237 297 356 415 474
5’ 7” (67) 61.6 246 308 370 431 497
5’ 8” (68) 63.9 256 320 383 447 511
5’ 9” (69) 66.2 265 331 397 463 530
5’ 10” (70) 68.5 274 343 411 480 548
5’ 11” (71) 70.8 283 354 425 496 566
6’ 0” (72) 73.1 292 366 439 512 585
6’ 1” (73) 75.4 302 377 452 528 603
6’ 2” (74) 77.7 311 389 466 544 622

Abbreviations: PBW, predicted body weight; TV, tidal volume

Source: National Institutes of Health and the National Heart, Lung, and Blood Institute. http://www.ardsnet.org/files/pbwtables_2005-02-02.pdf

Table 2. Predicted Body Weight for Males of Various Heights and Associated Tidal Volumes
Height (in) PBW (kg) 4 mL/kg TV 5 mL/kg TV 6 mL/kg TV 7 mL/kg TV 8 mL/kg TV
5’ 0” (60) 50 200 250 300 350 400
5’ 1” (61) 52.3 209 262 314 366 418
5’ 2” (62) 54.6 218 273 328 382 437
5’ 3” (63) 56.9 228 285 341 398 455
5’ 4” (64) 59.2 237 296 355 414 474
5’ 5” (65) 61.5 246 308 369 431 492
5’ 6” (66) 63.8 255 319 383 447 510
5’ 7” (67) 66.1 264 331 397 463 529
5’ 8” (68) 68.4 274 342 410 479 547
5’ 9” (69) 70.7 283 354 424 495 566
5’ 10” (70) 73 292 365 438 511 584
5’ 11” (71) 75.3 301 377 452 527 602
6’ 0” (72) 77.6 310 388 466 543 621
6’ 1” (73) 79.9 320 400 479 559 639
6’ 2” (74) 82.2 329 411 493 575 658

Abbreviations: PBW, predicted body weight; TV, tidal volume

Source: National Institutes of Health and the National Heart, Lung, and Blood Institute. http://www.ardsnet.org/files/pbwtables_2005-02-02.pdf

Copyright © 2020 EB Medicine. All rights reserved. 4 Reprints: www.ebmedicine.net/empissues

PEEP setting would be 5 cm H2O. In hypoxemia that
is mediated by shunt physiology (such as in pulmo-
nary edema, pneumonia, etc), increasing the PEEP
will typically improve oxygenation. In patients with
obstructive physiology, some advocate for the use of
zero PEEP (“ZEEP”) because this is the least amount
of resistance to exhale against. There are no studies
to inform the optimal PEEP strategy in patients with
obstructive physiology. High PEEP values have the
potential to decrease preload and cause hypotension.
Fraction of Inspired Oxygen
The FiO2 determines what percentage of the breath
delivered is oxygen. The “Oxygen Delivery” section
(following) discusses oxygenation targets. An initial
setting of 100% is reasonable, with plans to imme-
diately down-titrate the oxygen, depending on the
patient’s oxygen needs.
Inspiratory to Expiratory Time (I:E Ratio)
The I:E ratio is the ratio of time allotted for inspira-
tion to the time allotted for expiration. Nonintubated
patients who are breathing normally have an I:E
ratio of approximately 1:2, meaning for every second
devoted to inhalation, 2 seconds are devoted to
exhalation. This becomes important in patients with
obstructive physiology, discussed in more detail in
the section, “Obstructive Physiology,” pages 6-8.
The I:E ratio will depend on the other param-
eters set. As a simple example for illustration, at a re-
spiratory rate of 15 breaths/min and an inspiratory
time of 1 sec/breath, 15 seconds of every minute (15
breaths/min at 1 sec/breath) are devoted to inhala-
tion. Therefore, the other 45 seconds of each minute
are dedicated to exhalation. This will result in an I:E
ratio of 15 sec:45 sec, or 1:3. Increasing the respira-
tory rate (either by patient-initiated assist breaths or
by the clinician adjusting the set minimum rate) will
increase the I:E ratio, as more time will be allocated
to inspiration each minute. Decreasing the inspira-
tory time or increasing the inspiratory flow rate
will deliver each breath over a shorter period and
can also make the I:E ratio more favorable, albeit at
the expense of higher peak pressures and patient
discomfort.
Other Modes of Ventilation
Synchronous Intermittent Mandatory Ventilation
With Pressure Support
Another mode that may be encountered includes
synchronous intermittent mandatory ventilation
with pressure support (SIMV with PS), in which a
set number of control tidal volumes are delivered
per minute. The difference in this mode is apparent
when the patient initiates an additional breath. In
this scenario, the ventilator will support their breath
with pressure, and the tidal volume will be variable
depending on lung compliance, the pressure sup-
July 2020 • www.ebmedicine.net
port chosen, and patient effort. In the ED, this can
be problematic because in patients who are fatigued,
have poor compliance, or are highly sedated/para-
lyzed, those breaths may not have enough tidal
volume to support appropriate minute ventilation if
the minimum respiratory rate is not set high enough.
If a patient is completely paralyzed, SIMV with PS
will look identical to a volume assist-control mode
because they behave the same in the absence of
patient-initiated assist breaths.
Airway Pressure Release Ventilation
Airway pressure release ventilation (APRV) is a
form of inverse I:E ratio ventilation where the ven-
tilator is set to deliver a high pressure nearly all the
time. As the name implies, the ventilator briefly re-
leases the pressure to allow for exhalation, but then
quickly reapplies the pressure before alveoli have a
chance to collapse. This can be thought of as a mode
that has constant positive airway pressure (CPAP)
to keep alveoli recruited, with very brief releases
of pressure to allow for ventilation. By keeping the
depressurized time brief, this mode keeps alveoli
recruited, preventing the atelectrauma involved with
alveoli frequently opening and collapsing. This is
sometimes utilized as a rescue mode of ventilation
for patients with ARDS and refractory hypoxemia.
Importantly, patients can and should also spontane-
ously breathe with this mode of ventilation with the
pressure support provided, which can reduce seda-
tion needs. Since patients will be generating addi-
tional tidal volumes with the support provided, this
mode of ventilation is most effective after the para-
lytic used in rapid sequence intubation has worn
off. As with all forms of inverse I:E ratio ventilation,
this modality favors oxygenation over ventilation.
For more information on settings for APRV, see the
“Nontraditional Ventilator Settings in ARDS” sec-
tion, page 9.
Oxygen Delivery
Traditionally, critically ill patients have been given
supplemental oxygen reflexively, regardless of their
oxygen saturation. Newer evidence has shown that
in many patient subgroups, hyperoxia is associated
with worse outcomes. Therefore, more judicious use
of oxygen is likely to lead to better patient outcomes.
A classic example is that oxygen was previously a
cornerstone of therapy for patients with acute myo-
cardial infarction. A 2015 prospective randomized
controlled trial of 441 patients with a STEMI and a
room air oxygen saturation > 94% demonstrated that
patients randomized to administration of oxygen
(8 L/min) had an increased infarct size compared
to the patients who did not receive supplemental
oxygen.10 An ED-based observational study found
that hyperoxia in the ED in mechanically ventilated
patients was associated with increased mortality,
5 Copyright © 2020 EB Medicine. All rights reserved.
emphasizing the importance of starting best prac-
tices in the ED setting.11
A 2018 systematic review and meta-analysis of
16,307 acutely ill adults that included those with
sepsis, critical illness, stroke, trauma, myocardial
infarction, cardiac arrest, and emergency surgery,
demonstrated an increase in mortality with a liberal
oxygenation strategy (where average oxygen satura-
tion [SpO2] was approximately 96%) compared to a
more conservative oxygenation strategy.12 Another
review similarly found that, especially in post car-
diac arrest patients and patients on extracorporeal
life support, an increase in mortality was seen with
hyperoxia.13 In that review, other patient subgroups
(such as traumatic brain injury, stroke, and hemor-
rhage) did not show a difference, but the authors
admitted these cohorts had smaller sample sizes
and there may be a small true difference that was
not detected. For traumatic brain injury specifically,
a retrospective multicenter cohort study of 24,148
traumatic brain injury patients showed no associa-
tion between hyperoxia and in-hospital mortality,
but it did show that hypoxemia was associated with
increased mortality.14
Based on these data, The BMJ published a
Rapid Recommendations clinical practice guideline
for adult patients receiving oxygen therapy.15 The
authors make a strong recommendation that all
medical patients should have a goal SpO2 of ≤ 96%
unless they have a specific need for hyperoxia (such
as a pneumothorax or carbon monoxide poisoning).
They recommend not starting oxygen therapy for
stroke or myocardial infarction patients unless their
saturation is ≤ 93% (strong recommendation) or ≤ 90%
to 92% (weak recommendation).
The 2016 Oxygen-ICU trial randomized pa-
tients at a single center to different oxygen satura-
tion levels (94%-98% in the conservative group
or 97%-100% in the conventional/liberal control
group), but it was stopped early due to difficulty
with enrollment. This study found that, in critically
ill mechanically ventilated patients, targeting the
conservative oxygen strategy of 94% to 98% de-
creased mortality compared to the liberal strategy.
This suggested that a conservative oxygen strategy
was superior.16
A multicenter randomized trial in 2020, the
LOCO2 trial, assigned patients with ARDS to receive
either conservative oxygen therapy (PaO2 55-70 mm
Hg; SpO2 88%-92%) or liberal oxygen therapy (PaO2
90-105 mm Hg; SpO2 ≥ 96%) with the same mechani-
cal ventilation strategy. The trial was stopped early
due to futility, with a trend toward harm in the
conservative oxygen strategy group. Although the
results did not reach statistical significance, there
was a strong trend toward harm and a statistically
significant increase in mesenteric ischemia events in
the conservative oxygen strategy group.17
Copyright © 2020 EB Medicine. All rights reserved. 6
For oxygen therapy in the mechanically venti-
lated patient, we recommend to start at 100% FiO2
and then rapidly titrate down based on the patient’s
SpO2 until the oxygen saturation is 93% to 96%. It is
similarly important to avoid hypoxemia, so clini-
cians should be vigilant about ensuring the oxygen
saturation is neither too high nor too low. It ap-
peared from the previous trials that persistently high
pulse oximetry values (97%-100%) or persistently
lower pulse oximetry values (88%-92%) were both
more harmful than an intermediate value. Utilize
100% FiO2 for carbon monoxide poisoning, and uti-
lize arterial blood gas (ABG) values when the SpO2
monitor is unreliable, such as in methemoglobin-
emia or carbon monoxide poisoning.
Approach to Specific Types of Patients
Requiring Mechanical Ventilation
Obstructive Physiology (Asthma and
Chronic Obstructive Pulmonary Disease)
In obstructive physiology such as that encountered
in patients with asthma and COPD, there is difficul-
ty in getting the air out of the lungs due to increased
lung compliance. Therefore, ventilator strategy is
aimed at allowing the patient a long expiratory
time to ensure each delivered tidal volume is fully
exhaled before the next one is delivered. An example
of initial ventilator settings that may be appropriate
are noted in Table 3. The I:E ratio would ideally be
at least 1:3 or lower (eg, 1:4 or 1:5), since this allows
for more time for the patient to exhale. The exact
amount that each patient needs will vary, depend-
ing on the severity of the obstructive physiology.
Although the I:E ratio can be set on some ventilators,
this setting cannot defy the laws of physics. The I:E
ratio is dependent on the respiratory rate and the
inspiratory time, and if the ventilator uses peak flow
rate instead of inspiratory time, there will also be a
Table 3. Examples of Initial Ventilator
Settings for Obstructive Physiology
(Asthma/COPD), Volume Assist-Control
Mode
Mode Setting Comments
Tidal volume 6-8 mL/kg PBW • Tolerate permissive
Respiratory rate 8-10/min, monitor for hypercapnia
• Monitor for breath-
breath-stacking
stacking
FiO2 As required for SpO2
• Ensure patient is not
88%-94%
over-breathing the
PEEP 0-5 cm H2O ventilator
Abbreviations: COPD, chronic obstructive pulmonary disease; FiO2,
fraction of inspired oxygen; PEEP, positive end-expiratory pressure;
PBW, predicted body weight; SpO2, oxygen saturation.
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small dependence on the tidal volume. Acute Respiratory Distress Syndrome
When patients do not exhale fully prior to the ARDS is an example of restrictive lung disease,
next breath being delivered, there will be pressure in where a decrease in compliance of the respiratory
the system added to the clinician-applied PEEP (nor- system leads to difficulty getting air into the alveoli.
mally the only pressure that should be present at the In addition, aeration can vary in different parts of
end of exhalation). This excess pressure is termed the lung. In dependent parts of the lung, where
auto-PEEP and should be avoided. Auto-PEEP can atelectasis and edema predominate, compliance is
cause hypotension, barotrauma, and worsen the low and aeration is poor. In contrast, the indepen-
patient’s ability to ventilate, due to the increased dent lung areas have better compliance and are
pressure.18 The term breath-stacking is the process better aerated but can be prone to overdistension.
that leads to auto-PEEP, where an additional breath With mechanical ventilation, the goal is to provide
is stacked on top of the prior breath, which has not oxygenation and ventilation while minimizing lung
had time to exhale fully. injury. See Table 4 for an example of initial ventila-
There are no data to guide the ideal amount of tor settings that may be appropriate in patients with
clinician-applied PEEP in patients with obstructive ARDS. Permissive hypercapnia can help minimize
pathology. There are some advocates for a zero PEEP ventilator-induced lung injury.
strategy to, theoretically, provide a better pressure The landmark ARDSnet trial found a substantial
gradient for exhalation. There are also advocates for mortality benefit in using a 6 mL/kg tidal volume,
a conventional amount of PEEP of 5 cm H2O be- based on PBW, in comparison to a 12 mL/kg tidal
cause (particularly in COPD) there may be collapse volume.21 In this trial, the PEEP and FiO2 were pre-
of small airways during late exhalation that may be determined, and plateau pressures were maintained
stented open by a small amount of PEEP. at < 30 cm H2O. (See Table 5, Lower-PEEP Strategy/
Remember that the respiratory rate set is a FiO2 rows.)
minimum; in volume assist-control ventilation, the
patient can trigger many more breaths than the
minimum. If you set the rate at 10 breaths/min and Table 4. Examples of Initial Ventilator
the patient is breathing at 30 breaths/min due to Settings for ARDS Patients, Volume Assist-
over-breathing on the ventilator, the I:E ratio will Control Mode
be much worse, and your patient will likely breath- Mode Setting Comments
stack. Aggressive sedation is of utmost importance Tidal volume • Range: 4-8 mL/kg • Tolerate
for these patients. Due to a respiratory acidosis, their PBW, start at permissive
respiratory center chemoreceptors as well as the dis- 6 mL/kg PBW hypercapnia
comfort of being intubated will promote hyperven- • If plateau pressure • If SpO2 goal is
tilation. The respiratory rate can be increased safely > 30 cm H2O, not achieved at
in a stepwise fashion as the patient’s bronchospasm decrease by maximum PEEP/
1 mL/kg PBW FiO2, options
improves, if breath-stacking is always monitored.
Respiratory rate • As required for desired include prone
(See the section, “Assessing for Breath-Stacking,” on
minute ventilation positioning, APRV,
page 13). or veno-venous
Hypercapnia is to be tolerated (permissive hy- FiO2 • As required for SpO2
ECMO
percapnia) in this setting, as the risk for breath-stack- 93%-96%
ing is greater than the risk for the respiratory acido- PEEP • Initial 10-12 cm H2O is
sis. The safe limits of this permissive hypercapnia are reasonable
unclear, but in prior studies on ARDS, in a different • See Table 5 for PEEP
patient population, a mean maximum PaCO2 of 66 adjustment based on
FiO2
mm Hg and pH of 7.23 was well tolerated.19 Further
supporting safety in this patient population, in trials
Abbreviations: APRV, airway pressure release ventilation; ARDS, acute
of noninvasive positive pressure ventilation, success
respiratory distress syndrome; ECMO, extracorporeal membrane
in avoiding intubation in patients with COPD was oxygenation; FiO2, fraction of inspired oxygen; PEEP, positive end-
common among those who had a pH of 7.28 and expiratory pressure; PBW, predicted body weight; SpO2, oxygen
mean CO2 levels of 80 mm Hg.20 saturation.
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Table 5. ARDSNet Trial FiO2/PEEP (cm H2O) Protocol, Lower Versus Higher Strategy
FiO2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
Lower-PEEP strategy 5 8 10 10 10-14 14 16-18 20-24
Higher-PEEP strategy 12-14 14-16 18 18-20 18-20 22 22 22-24

Abbreviations: ARDSNet, ARDS Network; FiO2, fraction of inspired oxygen; PEEP, positive end-expiratory pressure.

July 2020 • www.ebmedicine.net 7 Copyright © 2020 EB Medicine. All rights reserved.

 A subsequent randomized controlled trial
showed that, at 6 mL/kg tidal volume, clinical
outcomes were similar whether a lower-PEEP or
higher-PEEP strategy was used.22 (See Table 5,
Higher-PEEP Strategy/FiO2 rows, page 7.) The mean
PEEP was 8 cm H2O in the lower-PEEP group and 13
cm H2O in the higher-PEEP group.22 A meta-analysis
of individual patient data found that, in moderate
to severe ARDS, there was an association between
a higher survival rate and a higher-PEEP strategy.23
Based on the data, it is reasonable to use the lower-
PEEP strategy in milder forms of ARDS and reserve
the higher-PEEP strategy for severe ARDS.
Tidal volume should be approximately 6 mL/kg
of PBW, with FiO2 and PEEP increased as necessary
to provide appropriate oxygenation. If plateau pres-
sures are > 30 cm H2O, decreasing the tidal volume by
1 mL/kg of PBW to a minimum of 4 mL/kg of PBW
should be considered. With the decrease in tidal vol-
ume, an increase in respiratory rate will be necessary
to keep the same minute ventilation, since
minute ventilation = respiratory rate × tidal volume.
Higher tidal volumes and higher plateau pres-
sures—not higher PEEP—appear to be associated
with worsened lung injury and worsened outcomes.24
In more severe ARDS cases, higher PEEP strategies
likely keep lung areas open that would have other-
wise been collapsed. Hypercapnia is to be tolerated
(permissive hypercapnia) if the patient is hemody-
namically stable and the pH is, ideally, still above
7.20. The rationale for this is to prevent ventilator-
induced lung injury that could potentially occur by
attempting to maintain eucapnia. In some patients
who may not tolerate permissive hypercapnia, such
as in pregnancy, some toxicologic ingestions (eg,
tricyclic antidepressants, salicylates), or in patients
with increased intracranial pressure, the appropriate
level of partial pressure of carbon dioxide (PaCO2)
should be considered on a case-by-case basis.
Use of Paralytic Agents in ARDS
At this time, routine paralysis after intubation of adult
ED patients with moderate to severe ARDS treated
with a high PEEP strategy is not indicated. Routine
use of paralytics in moderate to severe ARDS gained
popularity with the 2010 publication of the ACURA-
SYS trial, which demonstrated a mortality benefit
with a 48-hour infusion of cisatracurium.25 This was
re-evaluated in 2019 with the larger randomized
controlled ROSE trial, which compared a 48-hour
continuous infusion of paralytics and deep sedation
versus usual care without routine neuromuscular
blockade and lighter sedation.26 There was no dif-
ference in 90-day mortality between groups, and the
trial was stopped early due to futility. Although there
was a difference in sedation level between groups, the
lighter-sedation group reflects typical current prac-
tice more closely. The best available evidence now
Copyright © 2020 EB Medicine. All rights reserved. 8
suggests that routine paralysis should not be utilized.
However, if required for patient-ventilator synchrony
after appropriate analgosedation has been provided,
paralysis should still be considered.
Recruitment Maneuvers in ARDS
Recruitment maneuvers are not indicated routinely.
A recruitment maneuver is the strategy of briefly using
high pressures to “open” the alveoli, and initially it
was shown to increase oxygenation. However, a sub-
sequent multicenter randomized controlled trial at
120 ICUs demonstrated that, in patients with moder-
ate to severe ARDS, routine use of lung recruitment
maneuvers was associated with increased mortal-
ity.27 There are still complex arguments about which
subgroups may benefit from recruitment maneuvers,
but in ED populations, other strategies should be
utilized, given evidence of the lack of benefit. A sub-
sequent review article hypothesized that recruitment
maneuvers may benefit patients who respond to the
maneuver,24 but further data are needed before it can
be recommended in the ED setting.
Prone Positioning in ARDS
Prone positioning allows for improved aeration
of the dorsal lung, which has a greater lung mass.
In studies, there has been uniformly higher PaO2
after prone positioning of patients with refractory
ARDS.28 In the subgroups with the most severe
ARDS, prone positioning offered an absolute sur-
vival advantage of 10% to 17%. The PROSEVA study
was a multicenter randomized trial that showed a
large mortality benefit from prone positioning in
severe ARDS, 32.8% versus 16%.29 This study does
have some limited applicability in that it required
a 12-hour stabilization period prior to proning. A
systematic review showed that there is a mortality
reduction in patients with moderate to severe ARDS
when prone positioning is used for at least 12 hours a
day, but this was associated with an increased risk of
endotracheal tube obstruction and pressure sores.30
At this time, we do not know whether initiation
of prone positioning in the ED improves outcomes,
but it is likely to improve oxygenation and may
therefore improve some patient outcomes if oxy-
genation cannot be improved by other means. The
ED patient is likely to experience a higher rate of
complications related to prone positioning than
patients described in the ICU literature, given the
relative infrequency that this procedure is per-
formed. Either prone positioning or nontraditional
ventilator settings, such as APRV, can be considered
when patients with severe ARDS experience refrac-
tory hypoxemia on standard high-PEEP ventilation
modes, provided there is adequate staff present who
are familiar with these interventions.
The optimal PEEP strategy with prone position-
ing is unknown. However, it is reasonable to use the
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same PEEP strategy outlined previously for ARDS,
regardless of whether the patient is prone or supine,
until more data are available.
Nontraditional Ventilator Settings in ARDS
In a single-center randomized trial, patients with
ARDS randomized to APRV compared to standard
lung-protective ventilation showed more ventilator-
free days and a shorter ICU length of stay, as well as
a strong trend toward decreased mortality.31 Larger,
multicenter studies are needed to determine the con-
ditions under which APRV may be best suited for
management of refractory hypoxemia in ARDS, but
at this time, APRV can be considered when standard
lung-protective ventilation strategies are insufficient.
If a high-PEEP volume assist-control strategy is in-
sufficient in providing appropriate oxygenation, and
prone positioning in the ED is not feasible, APRV is
potentially a valuable rescue mode.
Initial APRV settings include Phigh, which is the
pressure the ventilator will keep for most of the
breath (typically starting 30-35 cm H2O); Plow is the
pressure for the brief airway pressure release that
allows for ventilation (0 cm H2O). Thigh is how long
the high pressure is applied for each cycle (typi-
cally 4-5 seconds), and Tlow is how long the brief low
pressure is held to allow for ventilation (typically
0.5-0.8 seconds). Patients can breathe spontaneously
at either pressure, as this is a pressure-supported
mode. Subsequent adjustments should be made with
assistance of expert consultation, as the Tlow should
be adjusted to let the patient exhale 1 normal tidal
volume or target an end-expiratory flow rate of 75%
of the peak expiratory flow rate. This may necessi-
tate a longer time period in patients with obstructive
physiology such as underlying COPD. The expirato-
ry flow should not be permitted to go to zero (mean-
ing all the air has been exhaled) because that would
collapse and derecruit alveoli, which this mode of
ventilation is attempting to avoid. Even though the
Plow is set to zero, the pressure in the system does not
actually reach zero because a full exhalation does
not occur prior to Phigh resuming.
High-frequency oscillatory ventilation (HFOV)
is another proposed rescue therapy for ARDS, but
based on available evidence, it should not be used
outside of special circumstances, with expert con-
sultation.32-35
ARDS and Coronavirus Disease Infection
The management of patients who have been endo-
tracheally intubated for respiratory failure due to
coronavirus disease (COVID-19) from SARS-CoV-2
is rapidly evolving, and clinicians are encouraged
to review the latest evidence. At the time of this
publication, prevailing evidence is limited to case
series and expert opinion. Intradepartmental col-
laboration within institutions will be helpful in order
July 2020 • www.ebmedicine.net
to set uniform practice for management of mechani-
cally ventilated COVID-19 patients. These practices
should be revisited frequently as new data emerge.
The ARDS caused by COVID-19 may be differ-
ent enough from the ARDS seen in prior non-COVID
trials to warrant different management. Because of
this, it has been suggested that COVID-19 ARDS be
called coronavirus disease-associated acute respiratory
distress syndrome, or CARDS.36
In general, ARDS patients have low lung com-
pliance; however, in CARDS, it appears that at least
a subgroup of patients have relatively normal lung
compliance. This has led some to suggest classifying
the patients as either having “type L” CARDS (char-
acterized by low lung elastance [high compliance])
or “type H” CARDS (characterized by high lung
elastance [low compliance]).37 The type L CARDS
patients would be expected to be poorly responsive
to PEEP, due to the already high compliance of the
lung, whereas the type H CARDS patients would be
expected to have higher response to the traditional
higher-PEEP strategies employed in ARDS.
It has been suggested that, for patients with type
L CARDS, the normal lung compliance would allow
for safe administration of higher tidal volumes, such
as 8 mL/kg PBW, similar to how this tidal volume
was found to be safe in patients without ARDS. This
is because the normal compliance of the lung al-
lows these pressures to be delivered at very modest
plateau pressures. Lower-PEEP strategies in patients
with type L CARDS would therefore be indicated.
Patients with type H CARDS would be treated identi-
cally to the ARDS guidelines noted previously. Early
expert consultation is advised in this changing envi-
ronment as more data from trials become available.
Distinguishing between types may be challeng-
ing, but the following characteristics have been pro-
posed and are potentially measurable in the ED:38
• CT findings: Type L CARDS would typically
have only ground-glass opacities, whereas type
H CARDS would typically have substantially
increased lung weight, due to edema.
• Compliance:
l
Static compliance (Cstat) lower than ap-
proximately 50-60 mL/cm H2O is expected
in type H CARDS.
l
See “Ventilator Pressures,”page 13, for
information on measuring plateau pressure
(Pplat).
l
Cstat can be measured using the following
equation: (Cstat, in mL/cm H2O) = tidal
volume in mL/(Pplat in cm H2O – PEEP in
cm H2O)
• Recruitability: Increases in PEEP will lead to
improved oxygenation in type H CARDS but
not in type L CARDS, since in type L CARDS,
most lung tissue is already aerated and partici-
pating in gas exchange.
9 Copyright © 2020 EB Medicine. All rights reserved.
 Clinical Pathway for Ventilator Management in the Emergency Department

Patient presents in Perform:

need of intubation • Pre-intubation optimization
• Endotracheal intubation

ARDS: Obstructive physiology Metabolic acidosis: Undetermined:

• TV 6 mL/kg PBW (asthma/COPD): • TV 8 mL/kg PBW • TV 6-8 mL/kg PBW
• Titrate PEEP/FiO2 • TV 6 mL/kg PBW • RR 30/min • RR 12-16/min
using table • RR 8-10/min (Class II) • Titrate FiO2 to target
• RR as needed for • Treat underlying cause SpO2 93%-96%
desired minute (Class II) (Class I)
ventilation
• Perform ABG
(Class I)
• Check actual PaCO2
compared to expected
Breath-stacking? PaCO2 using Winters’
formula
YES (Class II)
NO

Plateau > 30 cm Refractory

H2O hypoxemia • RR
➞ ➞

RR slowly
➞

• TV by 1
➞

• FiO2
➞ ➞

if needed • Inspiration Observed Observed

mL/kg PBW • PEEP
(Class II) time PaCO2 PaCO2
• RR if (Class I) > expected < expected
➞

• Ensure
needed to patient is not
keep MV over-breathing
the ventilator
APRV (Class II) and/or
• Obtain expert RR RR
➞

➞
prone positioning (Class I)
consultation (Class II) (Class II)
and expert consultation
(Class II)

V-V ECMO (Class I)

Abbreviations: ABG, arterial blood gas; APRV, airway pressure release ventilation; ARDS, acute respiratory distress syndrome; FiO2, fraction of inspired
oxygen; MV, minute ventilation; PaCO2, partial pressure of carbon dioxide; PEEP, positive end-expiratory pressure; PBW, predicted body weight; RR,
respiratory rate; SpO2, oxygen saturation; TV, tidal volume; V-V ECMO, veno-venous extracorporeal membrane oxygenation.

Class of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.
Class I Class II Class III Indeterminate
• Always acceptable, safe • Safe, acceptable • May be acceptable • Continuing area of research
• Definitely useful • Probably useful • Possibly useful • No recommendations until further
• Proven in both efficacy and effectiveness • Considered optional or alternative treat- research
Level of Evidence: ments
Level of Evidence: • Generally higher levels of evidence Level of Evidence:
• One or more large prospective studies • Nonrandomized or retrospective studies: Level of Evidence: • Evidence not available
are present (with rare exceptions) historic, cohort, or case control studies • Generally lower or intermediate levels of • Higher studies in progress
• High-quality meta-analyses • Less robust randomized controlled trials evidence • Results inconsistent, contradictory
• Study results consistently positive and • Results consistently positive • Case series, animal studies, • Results not compelling
compelling consensus panels
• Occasionally positive results

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2020 EB Medicine. www.ebmedicine.net. No part of this publication may be reproduced in any format without written consent of EB Medicine.

Copyright © 2020 EB Medicine. All rights reserved. 10 Reprints: www.ebmedicine.net/empissues

 Prone positioning likely has value in CARDS,
including in awake, nonventilated patients. In one
study, 24 patients in a before/after single-center
trial found that 6 of 15 patients put in a prone
position had an increase in PaO2 > 20% from base-
line.39 Another study in 15 awake patients found
that respiratory rates were lower and oxygenation
higher during proning, compared to baseline.40
These small studies without control groups suggest
that many patients with mild to moderate CARDS
respond to prone positioning while awake, but it is
unclear whether mortality or intubation is reduced.
An exploratory single-center observational study
of intubated patients showed that lung recruitabil-
ity improved with alternating proning-supination
cycles.41 If CARDS functions similarly to ARDS, it is
reasonable to assume that proning is beneficial, but
further studies are required.
Severe Metabolic Acidosis
For patients with a severe metabolic acidosis who re-
quire intubation, maintaining a high minute ventila-
tion to allow for respiratory compensation is critical.
If a patient requires rapid sequence intubation and is
thought to not be at high risk for aspiration, bagging
during the apneic period will maintain some respira-
tory compensation and should be considered.42 For
patients at risk for aspiration, the data are less clear,
and clinician judgment should be exercised on a
case-by-case basis.
Arterial CO2 levels are inversely proportional to
the minute ventilation. This means that, in general,
doubling the minute ventilation will decrease PaCO2
by half. This can be accommodated mostly by in-
creasing the respiratory rate, but to some extent can
also occur by increasing the tidal volume. For each
change in PaCO2 by 10 mm Hg, the pH will change
by 0.08 in the opposite direction. Therefore, respira-
tory compensation can alleviate severe acidemia by
“breathing off” more CO2, which is a volatile acid.
The predicted PaCO2 in a metabolic acidosis can
be calculated by using Winters’ formula, which is:
Expected PaCO2 = 1.5 x HCO3- + 8 ± 2
If the ABG sample demonstrates a higher than ex-
pected PaCO2, increase the minute ventilation, if this
is tolerated by the patient.
In the absence of ARDS, tidal volume increases
appear safe to at least 8 mL/kg PBW, based on a
2018 randomized trial that assessed whether low
tidal volumes were helpful in critically ill patients
without ARDS, compared to intermediate tidal
volumes. This trial randomized 961 patients to a
low tidal volume strategy of approximately 6 mL/
kg versus an intermediate tidal volume strategy of
8 mL/kg and found no difference in outcomes.9 An
example of initial ventilator settings that may be ap-
propriate are in Table 6.
Patients with extremely high minute ventila-
July 2020 • www.ebmedicine.net
tions (usually > 20 L/min) can have auto-PEEP even
in the absence of existing lung pathology. This is
because as the respiratory rate increases, the I:E ratio
must necessarily get worse (eg, a shorter expiratory
time per breath) and, when combined with larger
tidal volumes, incomplete exhalation may occur. In
patients with pre-existing asthma or COPD, this may
occur more rapidly and should be anticipated and
monitored closely.
Monitoring and Making Changes to the
Ventilator Settings
Arterial Blood Gas
A normal arterial pH is 7.35 to 7.45. Acidemia is
present when the pH is below the lower limit of nor-
mal, or < 7.35. Alkalemia is present when the pH is
above the upper limit of normal, or > 7.45. Once pH
has been determined, the bicarbonate level (HCO3-)
and carbon dioxide level (PaCO2) should be evalu-
ated to investigate what the primary disturbance is
that caused the acidemia or alkalemia. Determina-
tion of whether appropriate compensation has oc-
curred can then be made.
If a patient is acidemic, it could be primarily
due to a respiratory acidosis (increased PaCO2), a
metabolic acidosis (decreased HCO3-), or both. If the
PaCO2 is > 40 mm Hg, there is a respiratory acidosis,
which indicates insufficient minute ventilation on
the ventilator. In some scenarios, this hypercapnia
is to be accepted if increasing the minute ventilation
could worsen a patient’s outcome. This would be
the case in obstructive physiology, where increas-
ing the respiratory rate may increase the risk of
breath-stacking. If the HCO3- is < 24 mEq/L, there
is a metabolic acidosis. If a patient has a metabolic
acidosis, the appropriate respiratory compensation
is to decrease PaCO2 and breathe off some CO2. The
appropriate decrease in PaCO2 for a metabolic acido-
Table 6. Example of Initial Ventilator Settings
for Patients With a Severe Metabolic
Acidosis, Volume Assist-Control Mode
Mode Setting Comments
Tidal volume 8 mL/kg PBW • Calculate expected
Respiratory rate 30 breaths/minute PaCO2 using
Winters’ formula:
FiO2 As required for SpO2
Expected PaCO2 =
93%-96%
1.5 × HCO3- + 8 ± 2
PEEP 5 cm H2O • Adjust minute
ventilation based on
target PaCO2
Abbreviations: FiO2, fraction of inspired oxygen; HCO3-, bicarbonate;
PaCO2, partial pressure of carbon dioxide; PEEP, positive end-
expiratory pressure; PBW, predicted body weight; SpO2, oxygen
saturation.
www.ebmedicine.net
11 Copyright © 2020 EB Medicine. All rights reserved.
sis can be calculated using Winters’ formula.
If a patient is alkalotic, it could be due primar-
ily to a respiratory alkalosis (decreased PaCO2), a
metabolic alkalosis (increased HCO3-), or both. If the
PaCO2 is < 40 mm Hg, there is a respiratory alkalosis,
which indicates an excess of minute ventilation on the
ventilator. This can occur due to inadequate sedation
with too many triggered breaths, salicylate toxicity
with increased respiratory stimulation, or too high of
a set minute ventilation on the ventilator. If the HCO3-
is > 24 mEq/L, there is a metabolic alkalosis.
Pulse Oximetry
Pulse oximetry is an accurate measure of oxygen
saturation with values above 80%, in the absence of
conditions where pulse oximetry is not representa-
tive of the patient’s oxygen saturation, such as in
methemoglobinemia and carbon monoxide poison-
ing. If a patient is in a hypoperfusion state, the pulse
oximeter may also have difficulty giving an output.
The pulse oximetry reading can be used to make
ventilator adjustments for a typical target saturation
of 93% to 96% for most patient populations. Except
in cases where hyperoxia is beneficial, such as with
carbon monoxide poisoning, if a patient has an SpO2
of 100%, their FiO2 should be titrated down.
cific for ROSC, but not sensitive (97% specific, 33%
sensitive).43 This indicates that, if present, an abrupt
increase in EtCO2 predicts ROSC (specific) but that
ROSC may also be achieved without this abrupt rise
(not sensitive). A 2018 systematic review found that
an EtCO2 of < 10 mm Hg after 20 minutes of CPR
was associated with a 0.5% likelihood of ROSC.44
Ventilator Pressures
The 2 pressures that are commonly measured in
ventilated patients include the peak pressure and the
plateau pressure. The peak pressure represents the
alveolar pressure and the airway resistance pres-
sure. The peak pressure is the highest pressure in
the system, so if the peak pressure is normal (< 30
cm H2O), the plateau pressure will be normal. If the
peak pressure is high, a plateau pressure must be
measured, as it is unclear whether only the peak
pressure is elevated, or both the peak and plateau
pressures are elevated.
Figure 1. Normal Output of Waveform
Capnography

Waveform Capnography
Waveform capnography gives graphical informa-
tion regarding exhaled carbon dioxide. In contrast,
quantitative capnometry gives a number only, and
semiquantitative capnometry gives color change only.
Since waveform capnography measures exhaled CO2,
the end-tidal CO2 (EtCO2) at the end of an exhalation
can never be higher than the patient’s PaCO2. This is
because a patient cannot exhale a greater amount of
CO2 than what exists in their blood. Therefore, a high
EtCO2 signals that the PaCO2 is at least that high, but Image courtesy of Alex Yartsev, www.derangedphysiology.com
could potentially be much higher. CO2 is a highly Available at: https://derangedphysiology.com/main/cicm-primary-exam/
diffusible gas in nonpathologic states, so the typical required-reading/respiratory-system/Chapter%205592/normal-capno-
arterial-alveolar CO2 gradient is small, usually < 5 graph-waveform
mm Hg. However, in pathologic states where ventila-
tion and perfusion are not matched (V/Q mismatch), Figure 2. Waveform Capnography
this gradient can be higher, so it should always be Demonstrating Bronchospasm
verified by an ABG sample.
In addition to the reported EtCO2 value, the
capnography waveform provides additional infor-
mation. A “shark fin” appearance of the waveform
indicates slow emptying of alveolar CO2 during
exhalation, which could raise suspicion for a state
of high airway resistance, such as bronchospasm or
endotracheal tube obstruction. See Figures 1 and 2
for examples of a normal waveform and a waveform
of a patient with bronchospasm, respectively.
EtCO2 can also be used during CPR to correlate
Image courtesy of Alex Yartsev, www.derangedphysiology.com
with return of spontaneous circulation (ROSC) in
Available at: https://derangedphysiology.com/main/required-reading/
patients with cardiac arrest. A cross-sectional study
respiratory-medicine-and-ventilation/Chapter%20113/end-tidal-cap-
demonstrated that an abrupt rise in EtCO2 was spe- nometry-waveform

Copyright © 2020 EB Medicine. All rights reserved. 12 Reprints: www.ebmedicine.net/empissues

 The peak airway pressures are typically dis- volumes. In patients who are breath-stacking, when
played automatically on a ventilator for each breath, a second tidal volume is being delivered prior to
but display of plateau pressure generally requires a complete exhalation, the overall intrathoracic
the clinician to initiate an inspiratory hold on the volume is higher, and therefore both the peak and
ventilator. An inspiratory hold is a brief pause at the plateau pressure would be higher.
end of inspiration that allows the tidal volume de-
livered to come to equilibrium, and it demonstrates Assessing for Breath-Stacking
the pressure the alveoli experience. Elevated plateau The ventilator will display the flow-versus-time
pressures, not elevated peak pressures, are what waveform in real time, and it can be assessed to deter-
determine the risk for barotrauma. (See Figure 3.) mine whether the patient is breath-stacking. In Figure
Plateau pressure is measured most accurately 4, a typical flow-versus-time graph is demonstrated.
when the patient is heavily sedated or paralyzed, The first positive deflection is the first tidal volume
to ensure that the patient’s chest wall and respira- being delivered. The negative deflection is exhala-
tory muscles do not influence the measurement. tion, which goes to zero prior to the next breath being
It can also be technically challenging to measure delivered. This indicates that there is no more flow in
a plateau pressure in very tachypneic patients, as the system and full exhalation has completed prior
the ventilator cycles so frequently. Even though to the delivery of the next tidal volume. In the next
plateau pressures are the pressures that are relevant tidal volume delivered, during exhalation there is still
to barotrauma, if the peak pressures exceed the negative flow when the next tidal volume is deliv-
ventilator’s maximum pressure limit, the full tidal ered. This indicates that exhalation was not complete
volume may not be delivered, as a safety mecha- and the patient is breath-stacking.
nism. In these situations, monitoring the ventilator Another modality to assess for breath-stacking is
is of critical importance. In certain scenarios when performing an expiratory hold, which measures the
high peak pressures occur (such as in severe bron-
chospasm), the ventilator may hit the alarm limits,
and the alarm limits or ventilator settings will need Table 7. Scenarios and Their Associated Peak
to be adjusted. Pressure and Plateau Pressure Changes
Table 7 describes various scenarios and their
associated peak and plateau pressures. Any sce- Scenario Peak Pressure Plateau Pressure
nario that causes increased resistance before the Patient bites down on High Normal
alveoli, such as a kinked endotracheal tube, mucus endotracheal tube
plugging, or bronchospasm will increase the peak Secretion blocks High Normal
pressure but will have a normal plateau pressure. endotracheal tube
This is because after the delivered breath makes it Bronchospasm High Normal
past the site of resistance, the pressure will become Tension pneumothorax High High
normal. Therefore, these patients are not at risk for Mainstem intubation High High
barotrauma. In settings where the alveoli experience Increased tidal volume High High
the higher pressures, the plateau pressure will also
Breath-stacking (intrinsic High High
be elevated. This would be the case in a mainstem PEEP)
bronchus intubation, where 1 lung is receiving all
the preset tidal volume, or setting an increased tidal Abbreviation: PEEP, positive end-expiratory pressure.
volume where the alveoli are exposed to higher Courtesy of Ryan Pedigo, MD.
www.ebmedicine.net

Figure 3. Peak Versus Plateau Pressure

Figure 4. Graph of Flow Versus Time

Plateau pressure is measured by an inspiratory hold and must, by The first breath demonstrates no breath-stacking; the second breath
definition, be lower than the peak pressure. indicates breath-stacking.
Image courtesy of Ryan Pedigo, MD. Image courtesy of Ryan Pedigo, MD.
www.ebmedicine.net www.ebmedicine.net

July 2020 • www.ebmedicine.net 13 Copyright © 2020 EB Medicine. All rights reserved.

pressure in the system at the end of expiration. (See
Figure 5.) During the expiratory hold, the patient
does not breathe. In the absence of any pathology,
the pressure in the system should be equal to the
clinician-provided PEEP that was set on the ventila-
Figure 5. An Expiratory Hold Demonstrating
Auto-PEEP (Pressure Above the Set PEEP)
Abbreviation: PEEP, positive end-expiratory pressure.
Image courtesy of Ryan Pedigo, MD.
www.ebmedicine.net
Risk Management Pitfalls in Mechanical Ventilation
in the Emergency Department (continued on page 15)
1. “The patient with ARDS had difficulty oxygen-
ating, so I increased the tidal volume to 12 mL/
kg as my first intervention.”
Increased tidal volumes have been shown
to increase mortality in ARDS. Using lung-
protective lower tidal volume strategies is
preferred, using the FiO2 and PEEP to maintain
appropriate oxygenation. If this fails, prone
positioning and/or APRV should be considered.
2. “The patient with ARDS had initial ventila-
tor settings with a PEEP of 5 cm H2O, but was
still hypoxemic to 85% SpO2, so I activated our
ECMO team and placed her on V-V ECMO.”
The EOLIA trial demonstrated no reduction
in mortality for an early V-V ECMO strategy
compared to optimizing ventilator strategy
first. Optimize ventilator settings and, if unsure,
seek expert consultation to find out whether
ventilator settings can be changed to allow for
appropriate oxygenation prior to initiating V-V
ECMO.
3. “I wanted 6 mL/kg tidal volume, so I set my
patient with ARDS, a 5’3” woman at 100 kg, to
600 mL tidal volume.”
Tidal volumes are based on predicted body
weight, not actual body weight. This patient’s
PBW is 52 kg, substantially lower than her actual
body weight. A 6 mL/kg tidal volume on this
patient would be 312 mL.
Copyright © 2020 EB Medicine. All rights reserved. 14
tor. Pressure in excess of this indicates that there is
additional pressure in the system.
The amount of auto-PEEP is calculated by
subtracting the clinician-provided PEEP setting (the
amount of pressure that should be in the system at
the end of expiration) from the total pressure in the
system. This result is typically an underestimation,
as the small airways that remain collapsed will not
come to equilibrium and are thus not represented in
this measurement. Similar to measurement of pla-
teau pressures, measurement of auto-PEEP is most
accurate when a patient is heavily sedated and/or
paralyzed.
Lastly, a physical examination can help assess for
breath-stacking in a patient with asthma or COPD. If
the patient is wheezing audibly during the expiratory
phase and that wheezing continues all the way until
the patient receives the next breath, they were still
exhaling at the time the next breath was delivered.
4. “This patient with severe DKA coded 5 min-
utes after I intubated him. I don’t understand
why, since I used normal ventilator settings.”
Patients with severe metabolic acidosis need
adequate respiratory compensation by using a
high minute ventilation. Patients who receive
longer-acting paralytics (such as rocuronium),
are initially unable to over-breathe the ventilator
since they are still paralyzed. Taking away
their respiratory compensation with a lower
minute ventilation after intubation can cause a
precipitous decline in pH and lead to cardiac
arrest.
5. “My patient with ARDS had refractory hy-
poxemia despite optimal ventilator settings,
and we do not have access to V-V ECMO, so I
just let her continue to be hypoxemic to 60%
because I ‘did everything.’”
Although the ED setting is often less familiar
with proning techniques, studies have shown
very favorable outcomes. In the setting of
refractory ARDS-related hypoxemia, consider
proning, while being mindful that there will be
increased rates of ETT obstruction and difficulty
with vascular access. Early transfer to an ECMO
center should be considered for refractory
hypoxemia, but the data do not support empiric
V-V ECMO for ARDS before optimizing non-
ECMO management.
Reprints: www.ebmedicine.net/empissues
Special Populations
Obese Patients
Ventilated obese patients have decreased lung com-
pliance due to thoracic wall weight and decreased
ability for diaphragmatic excursion due to abdomi-
nal fat mass. These issues are exacerbated in the
supine position, as gravity acts against ventilation.
An increased body mass index is associated with an
increased risk of developing ARDS,45 but is para-
doxically associated with a lower mortality in ARDS.
A meta-analysis of 199,421 intubated patients found
a longer ventilator duration for obese patients, but
lower overall mortality.46 Another meta-analysis
found similar results.47 A 2019 review covered speci-
ficities in management of ARDS in obese patients
and found that the reverse Trendelenburg position
decreased the effect of obesity by allowing for gravi-
tational offloading.48 This review also found that the
prone position was feasible with a trained team, but
this may not be generalizable to the ED setting.
Risk Management Pitfalls in Mechanical Ventilation
in the Emergency Department (continued from page 14)
6. “My patient with STEMI developed cardiogenic
shock and was intubated. I left the FiO2 on 100%
because I was taught that oxygen was a critical
part of myocardial infarction management.”
The AVOID trial10 showed that routine
administration of oxygen to patients with STEMI
without hypoxemia increased infarction size.
The FiO2 should be titrated down to a lower
SpO2 goal, as tolerated by the patient.
7. “My patient in septic shock was altered but
maintaining his airway, but I intubated him
when his pressure was 60/40 mm Hg to de-
crease his work of breathing.”
Peri-intubation cardiac arrest is best predicted
by pre-intubation hypoxemia and hypotension.
If a patient does not need to be emergently
intubated, resuscitating them prior to intubation
is likely to decrease risk of peri-intubation
cardiac arrest.
8. “My patient had high peak pressures, so I de-
creased the tidal volume to protect the lungs.”
Increased peak pressures may or may not be
indicative of increased plateau pressures. A
plateau pressure should be measured using an
inspiratory hold. If only the peak pressure is
elevated, consider causes of increased airway
resistance (such as a kinked endotracheal tube,
bronchospasm, or mucus plugging); decreasing
the tidal volume would not be beneficial.
July 2020 • www.ebmedicine.net
It is important to recall that, for lung-protective
ventilation, tidal volumes are determined based on
PBW and not actual body weight, and these num-
bers will be different in obese patients.
Controversies and Cutting Edge
Extracorporeal Membrane Oxygenation
For refractory hypoxemia due to ARDS, veno-
venous extracorporeal membrane oxygenation (V-V
ECMO) is an option to maintain oxygenation. How-
ever, in 2018, the ELOIA trial was published, which
was an international randomized intervention in
which patients with severe ARDS received imme-
diate V-V ECMO or continued conventional treat-
ment.49 The 60-day mortality was not different be-
tween groups, but there were more complications in
the V-V ECMO group. Therefore, V-V ECMO should
not be considered before exhausting other methods
of improving oxygenation in ARDS. If available, V-V
ECMO remains a viable option as salvage therapy
9. “My patient had severe hypoxemia during
the RSI attempt, but I did not want to bag her
because she could aspirate.”
A randomized controlled trial showed no
increased risk of aspiration in patients that
were bagged during the apneic period of RSI.
Note that the trial excluded patients with an
increased risk of aspiration from ongoing
emesis, hematemesis, or hemoptysis, limiting
generalizability in those populations. In these
patients, individual clinician judgment of risks
and benefits of bagging during the apneic period
of RSI should be considered.
10. “My patient with asthma was intubated, and
the PaCO2 was 70 mm Hg, so I increased the
respiratory rate to increase his minute ventila-
tion to ‘blow off’ some CO2.”
Patients with asthma are at high risk for breath-
stacking, and the high PaCO2 reflects poor
air movement from severe bronchospasm.
Increasing the respiratory rate indiscriminately
in this case is likely to lead to breath-stacking,
which is dangerous. Monitoring the patient for
breath-stacking is critical prior to any increases
in respiratory rate, and hypercapnia in this
situation should be tolerated as long as the pH
remains above 7.20 (permissive hypercapnia).
15 Copyright © 2020 EB Medicine. All rights reserved.
when other interventions have failed. Early trans-
fer to an ECMO center should be considered in the
event other interventions in oxygenating the patient
are unsuccessful.
Esophageal Pressure Monitoring
Pleural pressure can be estimated by using esopha-
geal pressure monitoring, which has shown initial
promise in directing PEEP usage in patients with
ARDS. The theory behind this strategy was that
pleural pressure monitoring could assist in find-
ing the optimal PEEP to recruit alveoli and prevent
atelectrauma, while at the same time preventing
overdistension. A single-center trial demonstrated
improved oxygenation in patients who had received
esophageal pressure monitoring to guide PEEP
usage compared to an empirical PEEP strategy.50 A
subsequent multicenter randomized controlled trial
comparing esophageal pressure monitor-guided
PEEP strategy to an empiric high-PEEP-FiO2 strategy
failed to show any difference in mortality or days
free from mechanical ventilation.51 The subsequent
multicenter trial, which showed no benefit, used
a PEEP strategy that was much more aggressive.
Based on the currently available data, using esopha-
geal pressure monitoring to guide PEEP is not indi-
cated if the alternative is a high-PEEP-FiO2 strategy.
Summary
Almost all adult patients should have a volume
assist-control mode of ventilation chosen for initial
ventilator management in the ED unless institutional
or existing clinician experience is with a different
mode. Except in conditions where hyperoxia is
useful, such as pneumothorax or carbon monoxide
poisoning, hyperoxia should be avoided. Except for
methemoglobinemia or carbon monoxide poison-
ing, pulse oximetry is reliable with values > 80%. If
the patient has an oxygen saturation > 96%, the FiO2
should be titrated down.
There are special considerations for initial ventila-
tor management for patients with ARDS, metabolic
acidosis, and obstructive physiology. For patients
with ARDS, lung-protective ventilation with lower
tidal volumes based on PBW, and a higher-PEEP
strategy is recommended. For a severe metabolic aci-
dosis, provide respiratory compensation by providing
a high minute ventilation, as tolerated. If the patient
has substantial obstructive physiology, such as with
asthma or COPD, a low respiratory rate can optimize
the I:E ratio and allow for complete exhalation. In this
scenario, allow permissive hypercapnia and monitor
the ventilator and patient for breath-stacking. Use
continuous waveform capnography. The PaCO2 is
always higher than the EtCO2, but it will be unclear
how much higher without an ABG.
Copyright © 2020 EB Medicine. All rights reserved. 16
Case Conclusions
The 30-year-old woman was intubated for her acute asthma
exacerbation. You noted that her PBW was 52 kg for her
height of 5'3", and based on this weight, you set the tidal
volume at 312 mL at 6 mL/kg (volume mode). You started
initially at a low respiratory rate of 10 breaths/min and
watched closely for breath-stacking. You confirmed that the
flow went to zero at the end of each breath, and with inten-
sive treatment, you slowly increased the respiratory rate.
The peak pressures remained high due to bronchospasm,
but you checked a plateau pressure, which was normal. The
patient was extubated uneventfully 2 days later.
The 21-year-old man with type 1 diabetes was intu-
bated for diabetic ketoacidosis. You confirmed that he was
at low risk for aspiration, so you continued bagging during
the apneic period of RSI. You administered etomidate as
your induction agent along with rocuronium as your para-
lytic, and noted that the patient would not over-breathe the
ventilator even if he had a severe metabolic acidosis, so you
set the initial respiratory rate to 30 breaths/min, to ensure
a high minute ventilation. With continued insulin infu-
sion, his acid-base status improved, and the respiratory rate
decreased, since the metabolic acidosis was resolving. The
patient was extubated 1 day later.
Your patient with severe ARDS was intubated and
was initially hypoxemic. You set 6 mL/kg of PBW tidal
volume, and an initial PEEP of 10 cm H2O with a FiO2 of
100%. The patient remained hypoxemic, so you increased
the PEEP to 20 cm H2O with good response, remember-
ing that a higher-PEEP strategy is likely advantageous
in severe ARDS, but you alerted the team regarding the
increased risk of pneumothorax. You and your team had
been practicing and using prone positioning and APRV
in the recent months, and would have been ready to mobi-
lize these techniques, if necessary.
References
Evidence-based medicine requires a critical ap-
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randomized, and blinded trial should carry more
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To help the reader judge the strength of each
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distress. JAMA. 2020, Apr 24. Online ahead of print. (Expert
opinion)
Take This Test Online!
38. Gattinoni L, Chiumello D, Caironi P, et al. COVID-19
pneumonia: different respiratory treatments for different Current subscribers receive CME credit absolutely
phenotypes? Intensive Care Med. 2020, Apr 14. Online ahead free by completing the following test. Each issue
of print. (Expert opinion) includes 4 AMA PRA Category 1 CreditsTM, 4 ACEP
39. Elharrar X, Trigui Y, Dols AM, et al. Use of prone positioning
Category I credits, 4 AAFP Prescribed credits, or
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acute respiratory failure. JAMA. 2020, May 15;e208255. On- 4 AOA Category 2-A or 2-B credits. Online testing
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40. Sartini C, Tresoldi M, Scarpellini P, et al. Respiratory param- the QR code below with your smartphone or visit
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www.ebmedicine.net/E0720.
unit. JAMA. 2020, May 15;e207861. Online ahead of print.
(1-day cross-sectional before/after study; 15 patients)
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43. Lui CT, Poon KM, Tsui KL. Abrupt rise of end tidal carbon
stable vital signs, and an oxygen saturation of
dioxide level was a specific but non-sensitive marker of 100% on 4 L/min of oxygen by nasal cannula.
return of spontaneous circulation in patient with out-of- What is the best next step in management of
hospital cardiac arrest. Resuscitation. 2016;104:53-58. (Cross this patient?
sectional study; 2 EDs) a. Place the patient on room air
44. Paiva EF, Paxton JH, O’Neil BJ. The use of end-tidal carbon
dioxide (EtCO2) measurement to guide management of
b. Change the oxygen to 15 L/min via
cardiac arrest: a systematic review. Resuscitation. 2018;123:1- nonrebreather mask
7. (Systematic review; 17 studies, 6198 patients; 5 studies in c. Increase the oxygen to 6 L/min
meta-analysis) d. Initiate bag-valve mask ventilation
45. Gong MN, Bajwa EK, Thompson BT, et al. Body mass index is connected to 15 L/min of oxygen
associated with the development of acute respiratory distress
syndrome. Thorax. 2010;65(1):44-50. (Cohort study; 1795 patients)
46. Zhao Y, Li Z, Yang T, et al. Is body mass index associated 2. A patient with asthma is intubated and has
with outcomes of mechanically ventilated adult patients in an end-tidal CO2 of 60 mm Hg. The patient’s
intensive critical units? A systematic review and meta-anal- expiratory flow does not return to zero at the
ysis. PLoS One. 2018;13(6):e0198669. (Systematic review and end of each breath, and they have substantial
meta-analysis; 199,421 patients)
47. Ni YN, Luo J, Yu H, et al. Can body mass index predict
auto-PEEP (positive end-expiratory pressure).
clinical outcomes for patients with acute lung injury/acute The patient is not over-breathing the ventila-
respiratory distress syndrome? A meta-analysis. Crit Care. tor. What is the best next step in management?
2017;21(1):36. (Systematic review and meta-analysis; 6268 a. Increase sedation
patients) b. Decrease sedation
48. De Jong A, Verzilli D, Jaber S. ARDS in obese patients: speci-
ficities and management. Crit Care. 2019;23(1):74. (Review)
c. Increase respiratory rate
49.* Combes A, Hajage D, Capellier G, et al. Extracorporeal mem- d. Decrease respiratory rate
brane oxygenation for severe acute respiratory distress syn-
drome. N Engl J Med. 2018;378(21):1965-1975. (Randomized
controlled trial; 249 patients) DOI: https://doi.org/10.1056/
NEJMoa1800385

Copyright © 2020 EB Medicine. All rights reserved. 18 Reprints: www.ebmedicine.net/empissues

3. A patient with asthma is intubated and has
an end-tidal CO2 of 60 mm Hg. The patient’s
expiratory flow does not return to zero at the
end of each breath, and they have substantial
auto-PEEP. The patient’s set respiratory rate
is 8 breaths/min but the ventilator shows the
patient is breathing 30 breaths/min. What is
the best next step in management?
a. Increase sedation
b. Decrease sedation
c. Increase respiratory rate
d. Decrease respiratory rate
4. A patient with severe acute respiratory distress
syndrome (ARDS) has an oxygen saturation
of 70% on volume assist-control mode; tidal
volume of 6 mL/kg predicted body weight;
respiratory rate of 16 breaths/min; PEEP of 5
mm Hg; and fraction of inspired oxygen (FiO2)
of 100%. To improve the patient’s hypoxemia,
what is the best change to the ventilator?
a. Increase respiratory rate
b. Increase FiO2
c. Increase PEEP
d. Change ventilation mode to airway pressure
release ventilation
5. In a patient with ARDS, which of the follow-
ing is the most likely complication of prone
positioning?
a. Worsened oxygenation
b. Dislodgement of endotracheal tube or
vascular access
c. Increased mortality
d. Increased need for veno-venous
extracorporeal membrane oxygenation
(V-V ECMO)
6. A patient with a severe metabolic acidosis due
to renal failure is intubated. A post intubation
arterial blood gas is obtained and demonstrates
a pH of 7.14; PaCO2 (partial pressure of carbon
dioxide, arterial) of 23 mm Hg; PaO2 (partial
pressure of oxygen, arterial) of 90 mm Hg, and
HCO3- of 5 mmol/L. There is no breath-stack-
ing. What is the best next step to manage the
patient?
a. Increase PEEP
b. Increase FiO2
c. Increase respiratory rate
d. Change ventilation mode to airway pressure
release ventilation
July 2020 • www.ebmedicine.net
7. A patient with severe asthma is intubated and
has a peak pressure of 50 cm H2O. The patient
is hemodynamically stable. What is the best
next step?
a. Increase respiratory rate
b. Measure a plateau pressure
c. Decrease respiratory rate
d. Change ventilation mode to airway pressure
release ventilation
8. A patient who bites down on their endotra-
cheal tube is most likely to have which of the
following sets of pressures on the ventilator?
a. Peak pressure: increased
Plateau pressure: normal
b. Peak pressure: increased
Plateau pressure: increased
c. Peak pressure: normal
Plateau pressure: increased
d. Peak pressure: normal
Plateau pressure: normal
9. A patient who has a right mainstem bronchus
intubation is most likely to have which of the
following sets of pressures on the ventilator?
a. Peak pressure: increased
Plateau pressure: normal
b. Peak pressure: increased
Plateau pressure: increased
c. Peak pressure: normal
Plateau pressure: increased
d. Peak pressure: normal
Plateau pressure: normal
10. Despite optimal ventilator management on
both a volume assist-control mode and an at-
tempt at using airway pressure release ventila-
tion, your patient with ARDS is still hypox-
emic. The patient is placed in prone position
and the hypoxemia persists. What is the best
next step in management?
a. Increase tidal volume to 12 mL/kg of actual
body weight
b. Decrease the Phigh value on APRV
c. Decrease the Thigh value on APRV
d. V-V ECMO
19 Copyright © 2020 EB Medicine. All rights reserved.
 CME Information
Date of Original Release: July 1, 2020. Date of most recent review: June 10, 2020. Termination
date: July 1, 2023.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical
Education (ACCME) to provide continuing medical education for physicians. This activity
9
December 201 12
Number
has been planned and implemented in accordance with the accreditation requirements and
and-Triggers
Volume 21,
policies of the ACCME.
The Timing- e Patient
Author P
MD, FACE ency Medicine, Beth Israel
A. Edlow, Medicine,
Jonathan of Emerg
n, Depar tment Professor of Emergency

th
Vice-Chairma

to
;
Medical Center

Ap pr oa ch Deaconess
Harvard Medic
al School,
Boston, MA

Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA
Dizziness
ers
Peer Review , FACEP

With Acute
r
MD, RDMS ency Medicine, Directoine-

Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of
-Gehring, Emerg
Petra Duran sor, Depar tment of of Florida College of Medic
Associate Profes sity
Univer
Ultrasound,
of Emergency FL
Jacksonville,
Jacksonville,

their participation in the activity.

MD sity
ndowski, State Univer
topher Lewa ine, Wayne of Emergency
Abstract tion in the
emergency Chris sor of Emerg
Clinical Profes ine; Executive Vice
Chair, Depar
tment ency Medic

mon presenta nostic appr

oach School of
Medic
Hospital, Detroi
t, MI
iness is a com er research, the diag g and Medicine,
Henry Ford
Acute dizz Fellow,

Specialty CME: Not applicable. For more information, please call Customer Service at 1-800-
Due to new on its timin asan, MD of Emergency Medicine; Rehabilitation
department. now focusing quality (vert
igo Vasisht Sriniv tor, Depar tment of Neurology
and
has changed,
OH
symptom ory Clinical Instruc l Care, Depar tment , Cincinnati,
to dizziness the patient’s g-and-triggers categ , Division of
Critica
of Cincinnati
Medical Center
of instead of timin oach University

249-5770.
ers Each appr ine,
trigg diagnostic
Medic
headedness). nosis and g benign
versus light
ation”
al diag ngui shin , see “CME Inform
differenti cians in disti es. Brain imag- ing this activity
has its own eme rgency clini g caus Prior to beginn on the back page.
aid tenin
has important
s.
which will iness from
life-threa CME credit

ACEP Accreditation: Emergency Medicine Practice is approved by the American College of

for 2 Stroke
e imaging, dizziness.
is eligible
causes of dizz magnetic resonanc This issue
enting with re-
ing, even withruling out stroke pres can be treated with
s in go
limitation tional verti cost-effective
Benign paro
xysmal posi the bedside, offering
maneuvers
positioning options.
at
MBA
Alfred Sacche
tti, MD, FACEP
Clinical Professor, e,
Pharmacy

Joseph D.
Residency, AZ
Medical Center,
Toscano,
MD
Maricopa
Phoenix,

ncy
Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
ent MPH,
Hoxhaj, MD, Jackson Assistant ncy Medicin ent of Emerge
managem Shkelzen Department
of Emerge ity, Chief, DepartmRamon Regional

AAFP Accreditation: This Enduring Material activity, Emergency Medicine Practice, has been
Medical Officer, Jefferson Univers e, San , CA
MD Chief l, Miami, FL Thomas Medicin San Ramon
Daniel J. Egan,
of
Vice Chair ial Hospita
Philadelphia,
PA Medical Center,
Professor, ncy Memor
Associate
hief
Editor-In-C, MD, FACEP Department
of Emerge
Eric Legom
e, MD e, Mount r, MD e, al Editors
Education,
Columbia
University
Chair, Emerge
ncy Medicin Luke's;
St.
Robert Schille ent of Family Medicin Internation
Andy Jagoda Chair, Department Medicine, of Physicians
and
& Mount Sinai Chair, Departm Senior on, MD
Medical Center; Peter Camer

reviewed and is acceptable for credit by the American Academy of Family Physicians. Term
Sinai West Affairs for Alfred
Professor
and
e; Director, Vagelos College York, NY Academic Beth Israel Medicine and Director, The Centre,
ncy Medicin New Vice Chair, Mount Sinai Faculty, Family School of Academic
of Emerge Medicine Surgeons, Medicine, Health, Icahn Emergency
and Trauma
Emergency Emergency of
Community York, NY Melbourne,
Center for Resear ch, Icahn s Genes, MD,
PhD
ent of System , Icahn School York, NY at Mount Sinai, New Monash University,
and Nichola Health New e
Education Mount Sinai, Professor,
Departm Mount Sinai, Medicin
Australia
Medicine at Associate Icahn School Medicine at , MD, FACEP
School of Medicine,

of approval begins 07/01/2020. Term of approval is for one year from this date. Physicians
Emergency MD, MS Scott Silvers of Emergency MD
New York,
NY Sinai, New Keith A. Marill, Department Professor Andrea Duca, Physician,
e at Mount Professor, Associate of Facilities
and
Emergency
hief of Medicin Associate Medicine, Chair Clinic, Jacksonville,
FL Attending
Editor-In-C York, NY Medicine,
Harvard
le Papa Giovan
ni XXIII,
Associate MD, FACEP FACEP of Emergency Massachusetts
, Plannin g, Mayo Ospeda
Gibbs, MD, Medical School l, Boston, MA FACP, FACEP Bergamo,
Italy
Kaushal Shah, Vice Chair Michael A. Department Slovis, MD,
Professor, Peeters, MD

should claim only the credit commensurate with the extent of their participation in the activity.
and Chair, General Hospita Corey M. ent
Associate ent of Professor e, Carolinas MA, MD, Chair, Departm Suzanne Y.G. Physician,
for Educat
ion, Departm
Weill Cornell
ncy Medicin ity of North Pollack Jr., Professor and Medicine, Vanderbilt Emergency
Medicine,
of Emerge Charles V. e, TN Attending Almere,
Emergency NY Univers
Medical Center, of Medicine, Chapel , FAHA, FESC of Emergency l Center, Nashvill g Hospital,
New York, FACEP, FAAEM for Flevo Teachin
Medicine, & Senior Advisor University Medica
School of Carolina School Professor and The Netherl
ands
Hill, NC y Research MD of dez, MD,
FIFEM
InterdisciplinarDepartment of Ron M. Walls, COO, Department
Editorial Board
ncy
Godwin, MD,
FACEP
Trials, Kimmel Profess or and Brigham and Edgardo Menen e and Emergea

AOA Accreditation: Emergency Medicine Practice is eligible for 4 Category 2-A or 2-B credit
FACEP A. ent Clinical Sidney ne, or in Medicin
Saadia Akhtar,
MD, of Steven
and Chair,
Departm Medicine, Jefferson Emergency
Medici l Profess EM, Churruc
Department Professor e, Assistant Emergency of Thomas Harvard Medica Director of ity,
Professor, Dean Hospital, Medicine; Aires Univers
Associate Associate ncy Medicin ion, Medical College lphia, PA Women's l of Buenos
Medicine, of Emerge Educat , MA Hospita
Emerge ncy Education, ion
Dean, SimulatFlorida COM- University,
Philade School, Boston Argentina
te Medical MPH rs Buenos Aires,
for Gradua r, Emergency University
of FL Radeos, MD,Emergency Care Edito sarntikul,
MD
Program Directo cy, Mount Sinai Jacksonville, Michael S. of al ol Rojana ncy

hours per issue by the American Osteopathic Association.

Jackso nville,
Associate
Profess or Critic , Dhanad
Physician,
Emerge
Medicine ResidenYork, NY MBA l College MD, FACEP Attending
ushe, MD Weill Medica Knight IV, ngkorn
Beth Israel,
New Joseph Habbo or of Emerge
ncy Medicine, ity, New York; of William A. Medicine,
King Chulalo of
nt Profess Univers ent ncy l; Faculty
Assista and of Cornell FNCS of Emerge Memorial
Hospita University,
Brady, MD NYU/Langone , New York, Director, DepartmYork Professor Medical
William J. ncy Medicin
e
Medicine, Research Associate Neurosurgery, Chulalongkorn
of Emerge Director, l Centers Medicine,
New Medicine,
Professor Bellevue Medica Emergency , Flushing,
NY Medicine and Practice
e; Medical MD Aware
LLC Advanced Medical Thailand
and Medicin UVA NY; CEO, Hospital Queens Director, EM ; Associate s, MD, MPH

Needs Assessment: The need for this educational activity was determined by a survey
Management, Medical FACEP MPH
Provider Program University Stephen H. Thoma
Emergency Operational Henry, MD, MD, MBA, cience ICU, ncy
Gregory L. ent of Ali S. Raja, Emergency Director, Neuros & Chair, Emergel Corp.,
Medical Center; rle County Fire or, Departm ity
Executive
Vice Chair, General ati, OH Professor
Clinical Profess ati, Cincinn Hamad Medica
Director, Albematesville, VA Medicine,
Univers
Medicine,
Massachusetts or of of Cincinn Medicine,
Medical College
, Qatar;
Rescue, Charlot Emergency School; CEO, te Profess rt, MD, FCCM e;
n Medical ment, Hospital; Associa e and Radiolo
gy,
Scott D. Weinga Medicin Weill Cornell
Physician-in-C
hief,
of Michiga e Risk Assess Emergency Emergency

of medical staff, including the editorial board of this publication; review of morbidity and
MD Medicin
Calvin A.
Brown III,
Compliance, Medical Practic MI Emergency , Boston, MA Professor of Care, Stony
Brook l Hospital,
r of Physician Ann Arbor, Medical School Chief, EM Critical NY Hamad Genera
Care Harvard
Directo and Urgent
Inc., FACEP, Stony Brook, Doha, Qatar
Credentialing ncy , MD, FACEP Rogers, MD, Medicine,
ent of Emerge John M. Howell or of Emergency Robert L. MD
Services, Departm and Women's Profess , FACP ncy Edito rs Edin Zelihic, Emerge ncy
Research
Clinical gton FAAEM of Emerge ent of
Medicine,
Brigham George Washin Professor Head, Departm Hospital,

mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for
r
, MA Medicine, DC; Directo Assistant ity of r, PharmD,
BCPS
Leopoldina
Hospital, Boston Washington,
University, Affairs, Best Practic
es, Medicine,
The Univers
Medicine, Aimee MishleMedicine Pharmacist, Medicine,
German y
of
ux, MD ic Maryland
School Emergency Schweinfurt,
Peter DeBlie Clinical Medicine, of Academ l, Falls r, PGY2 EM
of Fairfax Hospita Baltimore,
MD Program Directo
Professor
of ity School Inc, Inova
State Univers nce Officer, Church, VA
Louisiana

emergency physicians.
Chief Experie New
Medicine;
ity Medical Center,
Univers
Orleans, LA

Target Audience: This enduring material is designed for emergency medicine physicians,
Emergency Department
January 2020
physician assistants, nurse practitioners, and residents.
Management of Non–ST-Segm Volume 22, Number 1
ent Authors
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-
Elevation Myocardial Infarction Julianna Jung, MD, MEd,
Associate Professor of Emergency
FACEP

making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the
Medicine, Johns Hopkins
University School of Medicine,
Baltimore, MD
Abstract Sharon Bord, MD, FACEP
Assistant Professor Johns
Hopkins University School

most critical presentations; and (3) describe the most common medicolegal pitfalls for each
Department of Emergency of Medicine,
Medicine, Baltimore, MD
Chest pain is the second most
common complaint in emer- Peer Reviewers
gency departments, with 6.4
million visits annually in the Michael Gottlieb, MD

topic covered.
United States. A quarter of
these patients will be diagnosed Assistant Professor, Department
with acute coronary syndromes Emergency Ultrasound, Rush
of Emergency Medicine, Director
of
, but
will have nondiagnostic electrocard among those, nearly half
University Medical Center,
Chicago, IL
Bradley Shy, MD
iograms. Non–ST-segment
elevation myocardial infarction Visiting Associate Professor,

Objectives: Upon completion of this activity, you should be able to: (1) initiate appropriate
Department of Emergency
(NSTEMI) is twice as com- University of Colorado School Medicine,
mon as ST-segment elevation of Medicine, Aurora, CO; Medical
myocardial infarction (STEMI), Director, Adult Emergency
Department, Denver Health
and lack of clarity surroundin Authority, Denver, CO and Hospital
g the best management of
this
ventilator management for a variety of conditions in intubated adult patients; and (2) make
condition can contribute to
adverse outcomes. In this
current national manageme review,
nt guidelines for NSTEMI Prior to beginning this activity,
summarized as they pertain are see “Physician CME Information”
to the ED, and the evidence on the back page.

changes to the ventilator based on bedside evaluation, clinical data, and arterial blood gas
supporting them is considered base
. Issues surrounding special
patient populations are addressed,
and new diagnostic and
therapeutic modalities are

results.
discussed.

Editor-In-Chief Deborah Diercks, MD, MS,

Andy Jagoda, MD, FACEP FACEP, Eric Legome, MD
FACC Robert Schiller, MD

Discussion of Investigational Information: As part of the journal, faculty may be presenting

Professor and Chair, Department
of Emergency Medicine; Director,
Center for Emergency Medicine
Education and Research,
Icahn
School of Medicine at Mount
Sinai,
Chair, Emergency Medicine,
Professor and Chair, Department
of Sinai West & Mount Sinai St.
Mount Chair, Department of Family International Editors
Emergency Medicine, University Luke's; Medicine,
of Vice Chair, Academic Affairs Beth Israel Medical Center; Peter Cameron, MD
Texas Southwestern Medical for Senior
Center, Emergency Medicine, Mount Faculty, Family Medicine and Academic Director, The Alfred
Dallas, TX Sinai Community Health, Icahn School
Health System, Icahn School of Emergency and Trauma Centre,

New York, NY
Associate Editor-In-Chief
Kaushal Shah, MD, FACEP
investigational information about pharmaceutical products that is outside Food and Drug
of Medicine at Mount Sinai, New Monash University, Melbourne,
Daniel J. Egan, MD Medicine at Mount Sinai, New York, NY
York, NY Australia
Associate Professor, Vice Keith A. Marill, MD, MS Scott Silvers, MD, FACEP
Chair of
Education, Department of
Emergency Associate Professor, Department Associate Professor of Emergency Andrea Duca, MD
Medicine, Columbia University of Emergency Medicine, Harvard Medicine, Chair of Facilities
and Attending Emergency Physician,

Administration approved labeling. Information presented as part of this activity is intended

Associate Professor, Vice Vagelos College of Physicians
Chair
for Education, Department Surgeons, New York, NY
of
Emergency Medicine, Weill
Cornell Marie-Carmelle Elie, MD
School of Medicine, New York,
NY Associate Professor, Department
Medical School, Massachusetts
and
General Hospital, Boston,
MA
Angela M. Mills, MD, FACEP
Professor and Chair, Department
Planning, Mayo Clinic, Jacksonville,
FL Ospedale Papa Giovanni XXIII,
Bergamo, Italy
Corey M. Slovis, MD, FACP,
FACEP
Professor and Chair, Department Suzanne Y.G. Peeters, MD
of Emergency Medicine, Vanderbilt Attending Emergency Physician,

Editorial Board
Saadia Akhtar, MD, FACEP
Associate Professor, Department
Emergency Medicine, Associate
of
Dean Nicholas Genes, MD, PhD
for Graduate Medical Education,
solely as continuing medical education and is not intended to promote off-label use of any
of Emergency Medicine & of Emergency Medicine, Columbia University Medical Center, Nashville, Flevo Teaching Hospital, Almere,
Critical TN
Care Medicine, University University Vagelos College The Netherlands
of Florida of Ron M. Walls, MD
College of Medicine, Gainesville, Physicians & Surgeons, New
FL York, Professor and COO, Department Edgardo Menendez, MD,
NY Emergency Medicine, Brigham of FIFEM
Women's Hospital, Harvard
and Professor in Medicine and
Emergency

Program Director, Emergency
Medicine Residency, Mount
Sinai
Beth Israel, New York, NY
William J. Brady, MD
Professor of Emergency Medicine
Associate Professor, Department
of
Emergency Medicine, Icahn
School
of Medicine at Mount Sinai,
York, NY
New
Michael A. Gibbs, MD, FACEP
Professor and Chair, Department
Charles V. Pollack Jr., MA,
MD,
FACEP, FAAEM, FAHA, FESC
Professor & Senior Advisor
for
Interdisciplinary Research
and
Clinical Trials, Department
of
Emergency Medicine, Sidney
Kimmel
pharmaceutical product.
Medical Medicine; Director of EM, Churruca
School, Boston, MA Hospital of Buenos Aires University,
Buenos Aires, Argentina
Critical Care Editors
Dhanadol Rojanasarntikul,
MD
William A. Knight IV, MD, Attending Physician, Emergency
FACEP,
FNCS Medicine, King Chulalongkorn

Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance, independence,

and Medicine; Medical Director,
Emergency Management,
UVA
Medical Center; Operational
Medical
Director, Albemarle County
Fire
Medical College of Thomas Associate Professor of Emergency
of Emergency Medicine, Carolinas Jefferson Memorial Hospital; Faculty
University, Philadelphia, PA of
Medical Center, University Medicine and Neurosurgery, Medicine, Chulalongkorn University,
of North Medical
Carolina School of Medicine, Ali S. Raja, MD, MBA, MPH Director, EM Advanced Practice Thailand
Chapel Executive Vice Chair, Emergency Provider Program; Associate
Hill, NC Medical Stephen H. Thomas,
Director, Neuroscience ICU,

Rescue, Charlottesville, VA
Steven A. Godwin, MD, FACEP
Calvin A. Brown III, MD
Director of Physician Compliance,
Credentialing and Urgent Care
Medicine, Massachusetts
General
Hospital; Associate Professor
Professor and Chair, Department of
Emergency Medicine and
of Emergency Medicine, Assistant Radiology, Scott D. Weingart, MD, FCCM
Harvard Medical School, Boston,
Dean, Simulation Education,
Robert L. Rogers, MD, FACEP,
University
of Cincinnati, Cincinnati, OH
MA Professor of Emergency Medicine;
Chief, EM Critical Care, Stony
transparency, and scientific rigor in all CME-sponsored educational activities. All faculty
MD, MPH
Professor & Chair, Emergency
Medicine, Hamad Medical
Corp.,
Weill Cornell
Medical College, Qatar;
Emergency Physician-in-Chief
,

participating in the planning or implementation of a sponsored activity are expected to disclose

Services, Department of Emergency
Medicine, Brigham and Women's
Hospital, Boston, MA
Peter DeBlieux, MD
University of Florida COM- Brook Hamad General Hospital,
Jacksonville, Jacksonville, FAAEM, FACP Medicine, Stony Brook, NY Doha, Qatar
FL Assistant Professor of Emergency
Joseph Habboushe, MD
MBA Medicine, The University
of
Research Editors Edin Zelihic, MD
Assistant Professor of Emergency Maryland School of Medicine, Head, Department of Emergency
Medicine, NYU/Langone and Aimee Mishler, PharmD,

to the audience any relevant financial relationships and to assist in resolving any conflict
Professor of Clinical Medicine, Baltimore, MD BCPS Medicine, Leopoldina Hospital,
Bellevue Medical Centers, Emergency Medicine Pharmacist,
Louisiana State University New York, Alfred Schweinfurt, Germany
School of NY; CEO, MD Aware LLC Sacchetti, MD, FACEP Program Director, PGY2 EM
Medicine; Chief Experience Pharmacy Residency, Maricopa
Officer, Assistant Clinical Professor,
University Medical Center, Medical Center, Phoenix, AZ
New Department of Emergency
Orleans, LA Medicine,

of interest that may arise from the relationship. In compliance with all ACCME Essentials,
Thomas Jefferson University, Joseph D. Toscano, MD
Philadelphia, PA Chief, Department of Emergency
Medicine, San Ramon Regional
Medical Center, San Ramon,
CA

Standards, and Guidelines, all faculty for this CME activity were asked to complete a full
disclosure statement. The information received is as follows: Dr. Pedigo, Dr. Knight, Dr.
Stewart, Dr. Mishler, Dr. Toscano, Dr. Jagoda, and their related parties report no relevant
financial interest or other relationship with the manufacturer(s) of any commercial
In upcoming issues of product(s) discussed in this educational presentation.
Commercial Support: This issue of Emergency Medicine Practice did not receive any
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Earning Credit: Two Convenient Methods: (1) Go online to www.ebmedicine.net/CME and
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