Evolution Over Time of Ventilatory Management and Outcome of Patients With Neurologic Disease*

Abstract

OBJECTIVES: To describe the changes in ventilator management over time in patients with neurologic disease at ICU admission and to estimate factors associated with 28-day hospital mortality. DESIGN: Secondary analysis of three prospective, observational, multicenter studies. SETTING: Cohort studies conducted in 2004, 2010, and 2016. PATIENTS: Adult patients who received mechanical ventilation for more than 12 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among the 20,929 patients enrolled, we included 4,152 (20%) mechanically ventilated patients due to different neurologic diseases. Hemorrhagic stroke and brain trauma were the most common pathologies associated with the need for mechanical ventilation. Although volume-cycled ventilation remained the preferred ventilation mode, there was a significant (p < 0.001) increment in the use of pressure support ventilation. The proportion of patients receiving a protective lung ventilation strategy was increased over time: 47% in 2004, 63% in 2010, and 65% in 2016 (p < 0.001), as well as the duration of protective ventilation strategies: 406 days per 1,000 mechanical ventilation days in 2004, 523 days per 1,000 mechanical ventilation days in 2010, and 585 days per 1,000 mechanical ventilation days in 2016 (p < 0.001). There were no differences in the length of stay in the ICU, mortality in the ICU, and mortality in hospital from 2004 to 2016. Independent risk factors for 28-day mortality were age greater than 75 years, Simplified Acute Physiology Score II greater than 50, the occurrence of organ dysfunction within first 48 hours after brain injury, and specific neurologic diseases such as hemorrhagic stroke, ischemic stroke, and brain trauma. CONCLUSIONS: More lung-protective ventilatory strategies have been implemented over years in neurologic patients with no effect on pulmonary complications or on survival. We found several prognostic factors on mortality such as advanced age, the severity of the disease, organ dysfunctions, and the etiology of neurologic disease.

Effects of Positive End-Expiratory Pressure on Lung Recruitment, Respiratory Mechanics, and Intracranial Pressure in Mechanically Ventilated Brain-Injured Patients

“…Indeed, a recent expert consensus (Robba et al, 2020) suggested that in brain-injured patients the levels of PEEP should be the same as for the general critically ill population. Similarly, a survey of the European Society of Intensive Care (Stocchetti et al, 2014) and a recent large multicenter study (Tejerina et al, 2021) suggest that moderate-high levels of PEEP are currently part of the clinical practice of neurocritical care physicians.…”

Ventilatory settings in the initial 72 h and their association with outcome in out-of-hospital cardiac arrest patients: a preplanned secondary analysis of the targeted hypothermia versus targeted normothermia after out-of-hospital cardiac arrest (TTM2) trial

“…Evidence have progressively demonstrated that low V T is associate with favorable outcome after cardiac arrest [37], and very low PEEP or zero PEEP (ZEEP) can aggravate the risk of atelectasis and lung damage [40,41]. As consequence of this, over time, physicians are increasingly applying lower tidal volume and higher PEEP even in cardiac arrest patients [5,42], and as well as in brain injured patients at risk of intracranial hypertension [43]. In a secondary analysis from a multicenter study in ICU patients receiving mechanical ventilation [44], Sutherasan et al showed that in 1998 the mean tidal volume used in cardiac arrest patients was 8.9 mL/Kg, and mean PEEP was 3.5 cmH 2 0 [5].…”

Validation of the flow index to detect low inspiratory effort during pressure support ventilation

“…However, this result should be interpreted with caution because a lot of data on brainstem impairment were not collected. Given the increased use of PSV in brain-injured patients [ 16 , 26 , 27 ], further studies are warranted in this population.…”

“…However, this result should be interpreted with caution because a lot of data on brainstem impairment were not collected. Given the increased use of PSV in brain-injured Table 3 Diagnostic performance of flow index to detect low inspiratory effort using the cutoff value derived from the previous study a a The cutoff value of flow index derived from the previous study was 2.6 [14] Between parentheses is the 95% confidence interval (95% CI) patients [16,26,27], further studies are warranted in this population.…”