Mechanical ventilation in emergency departments: Non invasive or invasive mechanical ventilation. Where is the answer?

Background The Emergency Department length of stay for patients requiring mechanical ventilation paper in this issue is very illustrative of many variables that still confound the way we treat patients that may not require endotracheal intubation (ETI) but may benefit from non-invasive mechanical ventilation (NIV) [1]. Rose L et al. bring to light several important aspects the chief of which is the way we view this modality [1]. Patients that refused endotracheal intubation, but accepted NIV were not clearly identified as to whether this was done as a terminal mode as an end-of-life decision or if this was a bridge to prevent endotracheal intubation and allow pharmacotherapy to improve patient status such as heart failure. Caregiver trends and service battles are clearly illustrated in this study as a large confounder was or which service will care for the patient on the floor, step down or intensive care unit (ICU). With the great pressure to provide proper utilization of staff and technology rich environments, much of the push back to keep patients of NIV in the in the ED may be from the ICU itself. ED staff input is also a key variable leading the delays we found in interesting that only 55.2% of patients received arterial blood gas following commencement of mechanical ventilation which would be unusual for accepted ICU practice [1]. This lack of follow-up illustrates how patients receiving ventilator support are placed in a holding pattern in the ED and do not get active care input.