VENTILatOry strategies in patients with severe traumatic brain injury: the VENTILO Survey of the European Society of Intensive Care Medicine (ESICM)

Abstract

Background: Severe traumatic brain injury (TBI) patients often develop acute respiratory failure. Optimal ventilator strategies in this setting are not well established. We performed an international survey to investigate the practice in the ventilatory management of TBI patients with and without respiratory failure.Methods: An electronic questionnaire, including 38 items and 3 different clinical scenarios [arterial partial pressure of oxygen (PaO 2 )/inspired fraction of oxygen (FiO 2 ) > 300 (scenario 1), 150-300 (scenario 2), < 150 (scenario 3)], was available on the European Society of Intensive Care Medicine (ESICM) website between November 2018 and March 2019. The survey was endorsed by ESICM. Results: There were 687 respondents [472 (69%) from Europe], mainly intensivists [328 (48%)] and anesthesiologists [206 (30%)]. A standard protocol for mechanical ventilation in TBI patients was utilized by 277 (40%) respondents and a specific weaning protocol by 198 (30%). The most common tidal volume (TV) applied was 6-8 ml/kg of predicted body weight (PBW) in scenarios 1-2 (72% PaO 2 /FIO 2 > 300 and 61% PaO 2 /FiO 2 150-300) and 4-6 ml/kg/ PBW in scenario 3 (53% PaO 2 /FiO 2 < 150). The most common level of highest positive end-expiratory pressure (PEEP) used was 15 cmH 2 O in patients with a PaO 2 /FiO 2 ≤ 300 without intracranial hypertension (41% if PaO 2 /FiO 2 150-300 and 50% if PaO 2 /FiO 2 < 150) and 10 cmH 2 O in patients with intracranial hypertension (32% if PaO 2 /FiO 2 150-300 and 33% if PaO 2 /FiO 2 < 150). Regardless of the presence of intracranial hypertension, the most common carbon dioxide target remained 36-40 mmHg whereas the most common PaO 2 target was 81-100 mmHg in all the 3 scenarios. The most frequent rescue strategies utilized in case of refractory respiratory failure despite conventional ventilator settings were neuromuscular blocking agents [406 (88%)], recruitment manoeuvres [319 (69%)] and prone position [292 (63%)]. Conclusions: Ventilatory management, targets and practice of adult severe TBI patients with and without respiratory failure are widely different among centres. These findings may be helpful to define future investigations in this topic.

Early effects of ventilatory rescue therapies on systemic and cerebral oxygenation in mechanically ventilated COVID-19 patients with acute respiratory distress syndrome: a prospective observational study

“…The concept of protective ventilation and the use of rescue therapies is slowly gaining interest even in this population, although evidence is still lacking [ 20 , 56 , 57 ]; small studies and a recent expert consensus on mechanical ventilation in acute brain injury suggested considering at least prone position in patients who have concurrent ARDS and acute brain injury but no significant ICP elevation, whereas the role of RMs, CO 2 removal systems, and ECMO is still uncertain [ 20 , 52 , 53 ].…”

Pathophysiology of Brain Injury and Neurological Outcome in Acute Respiratory Distress Syndrome: A Scoping Review of Preclinical to Clinical Studies

“…Interestingly, the hippocampal region has a high density of IL-1 receptors, which may explain the common occurrence of hippocampal injury seen in patients with ARDS given its vulnerability to inflammation as well as hypoxic insult [42]. Second, although ARDS mechanical ventilatory strategies have demonstrated to improve survival, they may contribute or worsen brain injury in some patients [14,43,44]. Lung-protective strategy with low tidal ventilation to reduce lung strain is associated with hypercapnia and subsequent cerebral vasodilation, increased cerebral blood flow, and increased ICP, which may further worsen ABI and increase risk for cerebral ischemia [14].…”

Lung Protective Ventilation in Brain-Injured Patients: Low Tidal Volumes or Airway Pressure Release Ventilation?

“…A recent international survey of intensivists caring for patients with severe traumatic brain injury suggested that low tidal volume (LTV) ventilation is the favored ventilator strategy. 3 LTV ventilation refers to a volume-assist-control mode of mechanical ventilation in which tidal volumes are set to 6 mL/ kg of predicted body weight with an absolute plateau pressure ceiling of 30 cm of H 2 O popularized by a landmark RCT. 1 Airway pressure release ventilation (APRV) is a pressure-limited, time-cycled, assisted mode of mechanical ventilation that allows unrestricted spontaneous breathing independent of ventilator cycling.…”

“…A recent international survey of intensivists caring for patients with severe traumatic brain injury suggested that low tidal volume (LTV) ventilation is the favored ventilator strategy. 3 time (T high ), low time (T low ), and fraction of inspired oxygen (FiO 2 ) are the parameters set in APRV (►Fig. 1).…”