Respiratory care

Pathophysiology of acute lung injury in patients with acute brain injury: the triple-hit hypothesis

It has been convincingly demonstrated in recent years that isolated acute brain injury (ABI) may cause severe dysfunction of peripheral extracranial organs and systems. Of all potential target organs and systems, the lung appears to be the most vulnerable to damage after ABI. The pathophysiology of the bidirectional brain-lung interactions is multifactorial and involves inflammatory cascades, immune suppression, and dysfunction of the autonomic system. Indeed, the systemic effects of inflammatory mediators in patients with ABI create a systemic inflammatory environment ("first hit") that makes extracranial organs vulnerable to secondary procedures that enhance inflammation, such as mechanical ventilation (MV), surgery, and infections ("second hit"). Moreover, accumulating evidence supports the knowledge that gut microbiota constitutes a critical superorganism and an organ on its own, potentially modifying various physiological functions of the host. Furthermore, experimental and clinical data suggest the existence of a communication network among the brain, gastrointestinal tract, and its microbiome, which appears to regulate immune responses, gastrointestinal function, brain function, behavior, and stress responses, also named the "gut-microbiome-brain axis." Additionally, recent research evidence has highlighted a crucial interplay between the intestinal microbiota and the lungs, referred to as the "gut-lung axis," in which alterations during critical illness could result in bacterial translocation, sustained inflammation, lung injury, and pulmonary fibrosis. In the present work, we aimed to further elucidate the pathophysiology of acute lung injury (ALI) in patients with ABI by attempting to develop the "double-hit" theory, proposing the "triple-hit" hypothesis, focused on the influence of the gut-lung axis on the lung. Particularly, we propose, in addition to sympathetic hyperactivity, blast theory, and double-hit theory, that dysbiosis and intestinal dysfunction in the context of ABI alter the gut-lung axis, resulting in the development or further aggravation of existing ALI, which constitutes the "third hit."

Focused Management of Patients With Severe Acute Brain Injury and ARDS

Considering the COVID-19 pandemic where concomitant occurrence of ARDS and severe acute brain injury (sABI) has increasingly coemerged, we synthesize existing data regarding the simultaneous management of both conditions. Our aim is to provide readers with fundamental principles and concepts for the management of sABI and ARDS, and highlight challenges and conflicts encountered while managing concurrent disease. Up to 40% of patients with sABI can develop ARDS. Although there are trials and guidelines to support the mainstays of treatment for ARDS and sABI independently, guidance on concomitant management is limited. Treatment strategies aimed at managing severe ARDS may at times conflict with the management of sABI. In this narrative review, we discuss the physiological basis and risks involved during simultaneous management of ARDS and sABI, summarize evidence for treatment decisions, and demonstrate these principles using hypothetical case scenarios. Use of invasive or noninvasive monitoring to assess brain and lung physiology may facilitate goal-directed treatment strategies with the potential to improve outcome. Understanding the pathophysiology and key treatment concepts for comanagement of these conditions is critical to optimizing care in this high-acuity patient population.

Resource utilization in the management of traumatic brain injury patients in a critical care unit: An audit from a rural set-up of a developing country

Background:

Neurosurgical patients including patients with severe head injury are at risk of developing respiratory complications. These can adversely affect the outcome and can result in poor survival. Many studies confirm that tracheostomy is a safe, effective method of airway management for patients with severe head, facial and multisystem organ trauma.

Aims:

To know the indications for performing early tracheostomy and its outcome.

Settings and Design:

Retrospective data analysis.

Materials and Methods:

The present study is a retrospective analysis of all patients who were admitted with the diagnosis of head injury between January 2007 and December 2009 and underwent tracheostomy at a rural tertiary care trauma center of Central India.

Results:

During the study period, a total of 40 patients with head injury underwent tracheostomy. All the patients sustained head injury in road traffic accidents. The mean age of the patients was 37.6 years (range 14–75 years, standard deviation 14 ± 14.9 years). Maximum number of patients were in their third decade of life, followed by those in the fifth and fourth decades. There were 36 males and 4 females. Tracheostomy was performed in 30 patients with severe head injury, 9 patients with moderate head injury and in only one case of mild head injury as the patient had multiple facial injuries compromising the airway.

Conclusions:

Neurocritical care is a relatively new field in India, and the facilities for critical neurosurgical patients are available only in a very few tertiary care centers mainly serving the urban areas. In the present study, we discuss our limited experience with tracheostomy in patients with head injury while facing the challenge of limited resources.

A decision-algorithm defining the rehabilitation approach: 'Facial oral tract therapy'

AIM

The aim of this study was to describe and define the rehabilitation approach: 'Facial Oral Tract Therapy' (F.O.T.T.).

METHOD

We defined the content and process of the rehabilitation approach (F.O.T.T.) in a decision-algorithm supported by a manual with supplementary material. The algorithm was developed by a research occupational therapist and an F.O.T.T. senior instructor. We used an inductive approach combining existing knowledge from: F.O.T.T. instructors, therapists trained in using the F.O.T.T. approach, and existing literature. A group of F.O.T.T. instructors and the originator of the treatment approach Mrs. Kay Coombes has given comments to and approved the algorithm.

RESULT

The algorithm consist of five flowcharts: 'one assessment' chart guiding the therapist in the examination of the patient and four 'treatment charts', one for each of the four areas of F.O.T.T.: swallowing and eating; oral hygiene; breathing, voice, and speech articulation; facial expression, giving guidance on interventions. The algorithm outlines all important components in the treatment that the therapist should decide to use or not to use in the intervention. The algorithm is supported by a manual with criteria of when to use which components.

CONCLUSION

This algorithm is designed to be a practical guideline to therapists using F.O.T.T. in clinical practice and in educational settings. The use of this algorithm may support standardization of F.O.T.T. and thereby promote and maintain the quality in the treatment. This in turn will facilitate research that addresses F.O.T.T. and outcomes.