Effects of expiratory tracheal gas insufflation in patients with severe head trauma and acute lung injury

Martínez-Pérez, Melcior; Bernabè, Francesca; Peña, Rocı́o; Fernández, Rafael; Nahum, Avi; Blanch, Lluís

doi:10.1007/s00134-004-2439-6

Cited by 27 publications

(14 citation statements)

References 33 publications

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“…Our data suggest that in addition to a lower PaO 2 /FIO 2 , ventilation with large VTs and relatively high RR represents an important predictor of ALI/ARDS development in patients with severe brain injury. Further studies are required to identify optimal ventilator strategies to protect the lung and maintain a tight a CO 2 control (35).…”

Section: Discussionmentioning

confidence: 99%

High tidal volume is associated with the development of acute lung injury after severe brain injury: An international observational study*

Mascia

Zavala

Bosma

et al. 2007

Critical Care Medicine

208

158

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Section: Discussionmentioning

confidence: 99%

High tidal volume is associated with the development of acute lung injury after severe brain injury: An international observational study*

Mascia

Zavala

Bosma

et al. 2007

Critical Care Medicine

208

158

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“…Several studies have shown that TGI can be used either to decrease PaCO 2 in the setting of hypercapnia or to maintain normocapnia while tidal volume is decreased [66]. In patients with severe head trauma and ALI, Martinez-Perez et al [67] showed that the application of phasic TGI (at mid-to-end expiration) allowed ventilation with lower tidal volumes and driving pressures while maintaining PaCO 2 constant without any deleterious effects on cerebral parameters.…”

Section: Alternative Ventilatory Techniquesmentioning

confidence: 98%

Acute Lung Injury in Patients with Severe Brain Injury: A Double Hit Model

2009

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The presence of pulmonary dysfunction after brain injury is well recognized. Acute lung injury (ALI) occurs in 20% of patients with isolated brain injury and is associated with a poor outcome. The "blast injury" theory, which proposes combined "hydrostatic" and "high permeability" mechanisms for the formation of neurogenic pulmonary edema, has been challenged recently by the observation that a systemic inflammatory response may play an integral role in the development of pulmonary dysfunction associated with brain injury. As a result of the primary cerebral injury, a systemic inflammatory reaction occurs, which induces an alteration in blood-brain barrier permeability and infiltration of activated neutrophils into the lung. This preclinical injury makes the lungs more susceptible to the mechanical stress of an injurious ventilatory strategy. Tight CO2 control is a therapeutic priority in patients with acute brain injury, but the use of high tidal volume ventilation may contribute to the development of ALI. Establishment of a therapeutic regimen that allows the combination of protective ventilation with the prevention of hypercapnia is, therefore, required. Moreover, in patients with brain injury, hypoxemia represents a secondary insult associated with a poor outcome. Optimal oxygenation may be achieved by using an adequate FiO2 and by application of positive end-expiratory pressure (PEEP). PEEP may, however, affect the cerebral circulation by hemodynamic and CO2-mediated mechanisms and the effects of PEEP on cerebral hemodynamics should be monitored in these patients and used to titrate its application.

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“…Alternative, rescue ventilatory strategies for severe TBI/ARDS patients include prone positioning [5], high-frequency percussive ventilation (HFPV) [5], CMV-TGI [32], pumpless extracorporeal lung assist (pECLA) with a heparin-coated circuit [5,33], and extracorporeal membrane oxygenation (ECMO) [34]. Regarding the use of the first two strategies in TBI/ARDS, only scarce and inconclusive published data exist [5].…”

Section: Discussionmentioning

confidence: 99%

High-frequency oscillation and tracheal gas insufflation in patients with severe acute respiratory distress syndrome and traumatic brain injury: an interventional physiological study

et al. 2013

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IntroductionIn acute respiratory distress syndrome (ARDS), combined high-frequency oscillation (HFO) and tracheal gas insufflation (TGI) improves gas exchange compared with conventional mechanical ventilation (CMV). We evaluated the effect of HFO-TGI on PaO2/fractional inspired O2 (FiO2) and PaCO2, systemic hemodynamics, intracranial pressure (ICP), and cerebral perfusion pressure (CPP) in patients with traumatic brain injury (TBI) and concurrent severe ARDS.MethodsWe studied 13 TBI/ARDS patients requiring anesthesia, hyperosmolar therapy, and ventilation with moderate-to-high CMV-tidal volumes for ICP control. Patients had PaO2/FiO2 <100 mm Hg at end-expiratory pressure ≥10 cm H2O. Patients received consecutive, daily, 12-hour rescue sessions of HFO-TGI interspersed with 12-hour periods of CMV. HFO-TGI was discontinued when the post-HFO-TGI PaO2/FiO2 exceeded 100 mm Hg for >12 hours. Arterial/central-venous blood gases, hemodynamics, and ICP were recorded before, during (every 4 hours), and after HFO-TGI, and were analyzed by using repeated measures analysis of variance. Respiratory mechanics were assessed before and after HFO-TGI.ResultsEach patient received three to four HFO-TGI sessions (total sessions, n = 43). Pre-HFO-TGI PaO2/FiO2 (mean ± standard deviation (SD): 83.2 ± 15.5 mm Hg) increased on average by approximately 130% to163% during HFO-TGI (P < 0.01) and remained improved by approximately 73% after HFO-TGI (P < 0.01). Pre-HFO-TGI CMV plateau pressure (30.4 ± 4.5 cm H2O) and respiratory compliance (37.8 ± 9.2 ml/cm H2O), respectively, improved on average by approximately 7.5% and 20% after HFO-TGI (P < 0.01 for both). During HFO-TGI, systemic hemodynamics remained unchanged. Transient improvements were observed after 4 hours of HFO-TGI versus pre-HFO-TGI CMV in PaCO2 (37.7 ± 9.9 versus 41.2 ± 10.8 mm Hg; P < 0.01), ICP (17.2 ± 5.4 versus 19.7 ± 5.9 mm Hg; P < 0.05), and CPP (77.2 ± 14.6 versus 71.9 ± 14.8 mm Hg; P < 0.05).ConclusionsIn TBI/ARDS patients, HFO-TGI may improve oxygenation and respiratory mechanics, without adversely affecting PaCO2, hemodynamics, or ICP. These findings support the use of HFO-TGI as a rescue ventilatory strategy in patients with severe TBI and imminent oxygenation failure due to severe ARDS.

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Effects of expiratory tracheal gas insufflation in patients with severe head trauma and acute lung injury

Abstract: In patients with severe head trauma and ALI receiving mechanical ventilation, expiratory tracheal gas insufflation allowed the targeted arterial PCO(2) level to be maintained together with a substantial reduction in tidal volume.

Cited by 27 publications

References 33 publications

High tidal volume is associated with the development of acute lung injury after severe brain injury: An international observational study*

High tidal volume is associated with the development of acute lung injury after severe brain injury: An international observational study*

Acute Lung Injury in Patients with Severe Brain Injury: A Double Hit Model

High-frequency oscillation and tracheal gas insufflation in patients with severe acute respiratory distress syndrome and traumatic brain injury: an interventional physiological study

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