1
|
Spatenkova V, Mlcek M, Mejstrik A, Cisar L, Kuriscak E. Standard versus individualised positive end-expiratory pressure (PEEP) compared by electrical impedance tomography in neurocritical care: a pilot prospective single centre study. Intensive Care Med Exp 2024; 12:67. [PMID: 39103646 DOI: 10.1186/s40635-024-00654-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 07/24/2024] [Indexed: 08/07/2024] Open
Abstract
BACKGROUND Individualised bedside adjustment of mechanical ventilation is a standard strategy in acute coma neurocritical care patients. This involves customising positive end-expiratory pressure (PEEP), which could improve ventilation homogeneity and arterial oxygenation. This study aimed to determine whether PEEP titrated by electrical impedance tomography (EIT) results in different lung ventilation homogeneity when compared to standard PEEP of 5 cmH2O in mechanically ventilated patients with healthy lungs. METHODS In this prospective single-centre study, we evaluated 55 acute adult neurocritical care patients starting controlled ventilation with PEEPs close to 5 cmH2O. Next, the optimal PEEP was identified by EIT-guided decremental PEEP titration, probing PEEP levels between 9 and 2 cmH2O and finding the minimal amount of collapse and overdistension. EIT-derived parameters of ventilation homogeneity were evaluated before and after the PEEP titration and after the adjustment of PEEP to its optimal value. Non-EIT-based parameters, such as peripheral capillary Hb saturation (SpO2) and end-tidal pressure of CO2, were recorded hourly and analysed before PEEP titration and after PEEP adjustment. RESULTS The mean PEEP value before titration was 4.75 ± 0.94 cmH2O (ranging from 3 to max 8 cmH2O), 4.29 ± 1.24 cmH2O after titration and before PEEP adjustment, and 4.26 ± 1.5 cmH2O after PEEP adjustment. No statistically significant differences in ventilation homogeneity were observed due to the adjustment of PEEP found by PEEP titration. We also found non-significant changes in non-EIT-based parameters following the PEEP titration and subsequent PEEP adjustment, except for the mean arterial pressure, which dropped statistically significantly (with a mean difference of 3.2 mmHg, 95% CI 0.45 to 6.0 cmH2O, p < 0.001). CONCLUSION Adjusting PEEP to values derived from PEEP titration guided by EIT does not provide any significant changes in ventilation homogeneity as assessed by EIT to ventilated patients with healthy lungs, provided the change in PEEP does not exceed three cmH2O. Thus, a reduction in PEEP determined through PEEP titration that is not greater than 3 cmH2O from an initial value of 5 cmH2O is unlikely to affect ventilation homogeneity significantly, which could benefit mechanically ventilated neurocritical care patients.
Collapse
Affiliation(s)
- Vera Spatenkova
- Neurocenter, Neurointensive Care Unit, Regional Hospital Liberec, Husova 357/10, 460 01, Liberec, Czech Republic.
- Institute of Physiology, First Faculty of Medicine, Charles University in Prague, Albertov 5, 128 00, Prague, Czech Republic.
- Department of Anaesthesia and Intensive Care, Third Faculty of Medicine, Charles University, Srobarova 50, 100 34, Prague, Czech Republic.
- Faculty of Health Studies, Technical University of Liberec, Studentská 1402/2, 461 17, Liberec 1, Czech Republic.
| | - Mikulas Mlcek
- Institute of Physiology, First Faculty of Medicine, Charles University in Prague, Albertov 5, 128 00, Prague, Czech Republic
| | - Alan Mejstrik
- Institute of Physiology, First Faculty of Medicine, Charles University in Prague, Albertov 5, 128 00, Prague, Czech Republic
- 2nd Department of Medicine-Department of Cardiovascular Medicine, Charles University in Prague, U nemocnice 2, 128 08, Prague, Czech Republic
| | - Lukas Cisar
- Technical Department, Regional Hospital Liberec, Husova 357/10, 460 01, Liberec, Czech Republic
| | - Eduard Kuriscak
- Institute of Physiology, First Faculty of Medicine, Charles University in Prague, Albertov 5, 128 00, Prague, Czech Republic
| |
Collapse
|
2
|
Yan A, Torpey A, Morrisroe E, Andraous W, Costa A, Bergese S. Clinical Management in Traumatic Brain Injury. Biomedicines 2024; 12:781. [PMID: 38672137 PMCID: PMC11048642 DOI: 10.3390/biomedicines12040781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/06/2024] [Accepted: 03/14/2024] [Indexed: 04/28/2024] Open
Abstract
Traumatic brain injury is one of the leading causes of morbidity and mortality worldwide and is one of the major public healthcare burdens in the US, with millions of patients suffering from the traumatic brain injury itself (approximately 1.6 million/year) or its repercussions (2-6 million patients with disabilities). The severity of traumatic brain injury can range from mild transient neurological dysfunction or impairment to severe profound disability that leaves patients completely non-functional. Indications for treatment differ based on the injury's severity, but one of the goals of early treatment is to prevent secondary brain injury. Hemodynamic stability, monitoring and treatment of intracranial pressure, maintenance of cerebral perfusion pressure, support of adequate oxygenation and ventilation, administration of hyperosmolar agents and/or sedatives, nutritional support, and seizure prophylaxis are the mainstays of medical treatment for severe traumatic brain injury. Surgical management options include decompressive craniectomy or cerebrospinal fluid drainage via the insertion of an external ventricular drain. Several emerging treatment modalities are being investigated, such as anti-excitotoxic agents, anti-ischemic and cerebral dysregulation agents, S100B protein, erythropoietin, endogenous neuroprotectors, anti-inflammatory agents, and stem cell and neuronal restoration agents, among others.
Collapse
Affiliation(s)
- Amy Yan
- Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA; (A.Y.); (A.T.); (W.A.); (A.C.)
| | - Andrew Torpey
- Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA; (A.Y.); (A.T.); (W.A.); (A.C.)
| | - Erin Morrisroe
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA;
| | - Wesam Andraous
- Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA; (A.Y.); (A.T.); (W.A.); (A.C.)
| | - Ana Costa
- Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA; (A.Y.); (A.T.); (W.A.); (A.C.)
| | - Sergio Bergese
- Department of Anesthesiology and Neurological Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA
| |
Collapse
|
3
|
Zunino G, Battaglini D, Godoy DA. Effects of positive end-expiratory pressure on intracranial pressure, cerebral perfusion pressure, and brain oxygenation in acute brain injury: Friend or foe? A scoping review. JOURNAL OF INTENSIVE MEDICINE 2024; 4:247-260. [PMID: 38681785 PMCID: PMC11043646 DOI: 10.1016/j.jointm.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/27/2023] [Accepted: 08/05/2023] [Indexed: 05/01/2024]
Abstract
Background Patients with acute brain injury (ABI) are a peculiar population because ABI does not only affect the brain but also other organs such as the lungs, as theorized in brain-lung crosstalk models. ABI patients often require mechanical ventilation (MV) to avoid the complications of impaired respiratory function that can follow ABI; MV should be settled with meticulousness owing to its effects on the intracranial compartment, especially regarding positive end-expiratory pressure (PEEP). This scoping review aimed to (1) describe the physiological basis and mechanisms related to the effects of PEEP in ABI; (2) examine how clinical research is conducted on this topic; (3) identify methods for setting PEEP in ABI; and (4) investigate the impact of the application of PEEP in ABI on the outcome. Methods The five-stage paradigm devised by Peters et al. and expanded by Arksey and O'Malley, Levac et al., and the Joanna Briggs Institute was used for methodology. We also adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension criteria. Inclusion criteria: we compiled all scientific data from peer-reviewed journals and studies that discussed the application of PEEP and its impact on intracranial pressure, cerebral perfusion pressure, and brain oxygenation in adult patients with ABI. Exclusion criteria: studies that only examined a pediatric patient group (those under the age of 18), experiments conducted solely on animals; studies without intracranial pressure and/or cerebral perfusion pressure determinations, and studies with incomplete information. Two authors searched and screened for inclusion in papers published up to July 2023 using the PubMed-indexed online database. Data were presented in narrative and tubular form. Results The initial search yielded 330 references on the application of PEEP in ABI, of which 36 met our inclusion criteria. PEEP has recognized beneficial effects on gas exchange, but it produces hemodynamic changes that should be predicted to avoid undesired consequences on cerebral blood flow and intracranial pressure. Moreover, the elastic properties of the lungs influence the transmission of the forces applied by MV over the brain so they should be taken into consideration. Currently, there are no specific tools that can predict the effect of PEEP on the brain, but there is an established need for a comprehensive monitoring approach for these patients, acknowledging the etiology of ABI and the measurable variables to personalize MV. Conclusion PEEP can be safely used in patients with ABI to improve gas exchange keeping in mind its potentially harmful effects, which can be predicted with adequate monitoring supported by bedside non-invasive neuromonitoring tools.
Collapse
Affiliation(s)
- Greta Zunino
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Dipartimento di Scienze Diagnostiche e Chirurgiche Integrate, Università degli Studi di Genova, Genova, Italy
| | | | | |
Collapse
|
4
|
Sanfilippo F, Uryga A, Ball L, Battaglini D, Iavarone IG, Smielewski P, Beqiri E, Czosnyka M, Patroniti N, Robba C. The Effect of Recruitment Maneuvers on Cerebrovascular Dynamics and Right Ventricular Function in Patients with Acute Brain Injury: A Single-Center Prospective Study. Neurocrit Care 2024:10.1007/s12028-024-01939-x. [PMID: 38351299 DOI: 10.1007/s12028-024-01939-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/03/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Optimization of ventilatory settings is challenging for patients in the neurointensive care unit, requiring a balance between precise gas exchange control, lung protection, and managing hemodynamic effects of positive pressure ventilation. Although recruitment maneuvers (RMs) may enhance oxygenation, they could also exert profound undesirable systemic impacts. METHODS The single-center, prospective study investigated the effects of RMs (up-titration of positive end-expiratory pressure) on multimodal neuromonitoring in patients with acute brain injury. Our primary focus was on intracranial pressure and secondarily on cerebral perfusion pressure (CPP) and other neurological parameters: cerebral autoregulation [pressure reactivity index (PRx)] and regional cerebral oxygenation (rSO2). We also assessed blood pressure and right ventricular (RV) function evaluated using tricuspid annular plane systolic excursion. Results are expressed as the difference (Δ) from baseline values obtained after completing the RMs. RESULTS Thirty-two patients were enrolled in the study. RMs resulted in increased intracranial pressure (Δ = 4.8 mm Hg) and reduced CPP (ΔCPP = -12.8 mm Hg) and mean arterial pressure (difference in mean arterial pressure = -5.2 mm Hg) (all p < 0.001). Cerebral autoregulation worsened (ΔPRx = 0.31 a.u.; p < 0.001). Despite higher systemic oxygenation (difference in partial pressure of O2 = 4 mm Hg; p = 0.001) and unchanged carbon dioxide levels, rSO2 marginally decreased (ΔrSO2 = -0.5%; p = 0.031), with a significant drop in arterial content and increase in the venous content. RV systolic function decreased (difference in tricuspid annular plane systolic excursion = -0.1 cm; p < 0.001) with a tendency toward increased RV basal diameter (p = 0.06). Grouping patients according to ΔCPP or ΔPRx revealed that those with poorer tolerance to RMs had higher CPP (p = 0.040) and a larger RV basal diameter (p = 0.034) at baseline. CONCLUSIONS In patients with acute brain injury, RMs appear to have adverse effects on cerebral hemodynamics. These findings might be partially explained by RM's impact on RV function. Further advanced echocardiography monitoring is required to prove this hypothesis.
Collapse
Affiliation(s)
- Filippo Sanfilippo
- Department of General Surgery and Medico-Surgical Specialties, School of Anaesthesia and Intensive Care, University of Catania, Catania, Italy
| | - Agnieszka Uryga
- Department of Biomedical Engineering, Wroclaw University of Science and Technology, Wrocław, Poland
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- Anesthesia and Intensive Care, IRCCS Policlinico San Martino, Largo Rosanna Benzi, 16100, Genoa, Italy
| | - Denise Battaglini
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Ida Giorgia Iavarone
- Anesthesia and Intensive Care, IRCCS Policlinico San Martino, Largo Rosanna Benzi, 16100, Genoa, Italy
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Nicolò Patroniti
- Department of Biomedical Engineering, Wroclaw University of Science and Technology, Wrocław, Poland
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.
- Anesthesia and Intensive Care, IRCCS Policlinico San Martino, Largo Rosanna Benzi, 16100, Genoa, Italy.
| |
Collapse
|
5
|
Gouvea Bogossian E, Cantos J, Farinella A, Nobile L, Njimi H, Coppalini G, Diosdado A, Salvagno M, Oliveira Gomes F, Schuind S, Anderloni M, Robba C, Taccone FS. The effect of increased positive end expiratory pressure on brain tissue oxygenation and intracranial pressure in acute brain injury patients. Sci Rep 2023; 13:16657. [PMID: 37789100 PMCID: PMC10547811 DOI: 10.1038/s41598-023-43703-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/27/2023] [Indexed: 10/05/2023] Open
Abstract
Cerebral hypoxia is an important cause of secondary brain injury. Improving systemic oxygenation may increase brain tissue oxygenation (PbtO2). The effects of increased positive end-expiratory pressure (PEEP) on PbtO2 and intracranial pressure (ICP) needs to be further elucidated. This is a single center retrospective cohort study (2016-2021) conducted in a 34-bed Department of Intensive Care unit. All patients with acute brain injury under mechanical ventilation who were monitored with intracranial pressure and brain tissue oxygenation (PbtO2) catheters and underwent at least one PEEP increment were included in the study. Primary outcome was the rate of PbtO2 responders (increase in PbtO2 > 20% of baseline) after PEEP increase. ΔPEEP was defined as the difference between PEEP at 1 h and PEEP at baseline; similarly ΔPbtO2 was defined as the difference between PbtO2 at 1 h after PEEP incrementation and PbtO2 at baseline. We included 112 patients who underwent 295 episodes of PEEP increase. Overall, the median PEEP increased form 6 (IQR 5-8) to 10 (IQR 8-12) cmH2O (p = 0.001), the median PbtO2 increased from 21 (IQR 16-29) mmHg to 23 (IQR 18-30) mmHg (p = 0.001), while ICP remained unchanged [from 12 (7-18) mmHg to 12 (7-17) mmHg; p = 0.42]. Of 163 episode of PEEP increments with concomitant PbtO2 monitoring, 34 (21%) were PbtO2 responders. A lower baseline PbtO2 (OR 0.83 [0.73-0.96)]) was associated with the probability of being responder. ICP increased in 142/295 episodes of PEEP increments (58%); no baseline variable was able to identify this response. In PbtO2 responders there was a moderate positive correlation between ΔPbtO2 and ΔPEEP (r = 0.459 [95% CI 0.133-0.696]. The response in PbtO2 and ICP to PEEP elevations in brain injury patients is highly variable. Lower PbtO2 values at baseline could predict a significant increase in brain oxygenation after PEEP increase.
Collapse
Affiliation(s)
- Elisa Gouvea Bogossian
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Joaquin Cantos
- Critical Care Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Anita Farinella
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Leda Nobile
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Hassane Njimi
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Giacomo Coppalini
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Alberto Diosdado
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Michele Salvagno
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Fernando Oliveira Gomes
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Sophie Schuind
- Department of Neurosurgery, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Université Libre de Bruxelles, Brussels, Belgium
| | - Marco Anderloni
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Chiara Robba
- Dipartimento di Scienze Chirurgiche e Diagnostiche, IRCCS Policlinico San Martino, Università di Genova, Genova, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| |
Collapse
|
6
|
Mechanical Ventilation in Patients with Traumatic Brain Injury: Is it so Different? Neurocrit Care 2023; 38:178-191. [PMID: 36071333 DOI: 10.1007/s12028-022-01593-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/16/2022] [Indexed: 10/14/2022]
Abstract
Patients with traumatic brain injury (TBI) frequently require invasive mechanical ventilation and admission to an intensive care unit. Ventilation of patients with TBI poses unique clinical challenges, and careful attention is required to ensure that the ventilatory strategy (including selection of appropriate tidal volume, plateau pressure, and positive end-expiratory pressure) does not cause significant additional injury to the brain and lungs. Selection of ventilatory targets may be guided by principles of lung protection but with careful attention to relevant intracranial effects. In patients with TBI and concomitant acute respiratory distress syndrome (ARDS), adjunctive strategies include sedation optimization, neuromuscular blockade, recruitment maneuvers, prone positioning, and extracorporeal life support. However, these approaches have been largely extrapolated from studies in patients with ARDS and without brain injury, with limited data in patients with TBI. This narrative review will summarize the existing evidence for mechanical ventilation in patients with TBI. Relevant literature in patients with ARDS will be summarized, and where available, direct data in the TBI population will be reviewed. Next, practical strategies to optimize the delivery of mechanical ventilation and determine readiness for extubation will be reviewed. Finally, future directions for research in this evolving clinical domain will be presented, with considerations for the design of studies to address relevant knowledge gaps.
Collapse
|
7
|
Zhou D, Li T, Fei S, Wang C, Lv Y. The effect of positive end-expiratory pressure on intracranial pressure in obese and non-obese severe brain injury patients: a retrospective observational study. BMC Anesthesiol 2022; 22:388. [PMID: 36522657 PMCID: PMC9753360 DOI: 10.1186/s12871-022-01934-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The effect of positive end-expiratory pressure (PEEP) on intracranial pressure (ICP) had never been studied in obese patients with severe brain injury (SBI). The main aim was to evaluate the effect of PEEP on ICP in SBI patients with mechanical ventilation according to obesity status. METHODS SBI patients admitted to the ICU with mechanical ventilation between 2014 and 2015 were included. Demographic, hemodynamic, arterial blood gas, and ventilator data at the time of the paired PEEP and ICP observations were recorded and compared between obese (body mass index ≥ 30 kg/m2) and non-obese SBI patients. Generalized estimating equation (GEE) model was used to assess the relationship between PEEP and ICP in obese and non-obese SBI patients, respectively. RESULTS Six hundred twenty-seven SBI patients were included, 407 (65%) non-obese and 220 (35%) obese patients. A total of 30,415 paired PEEP and ICP observations were recorded in these patients, 19,566 (64.3%) for non-obese and 10,849 (35.7%) for obese. In the multivariable analysis, a statistically significant relationship between PEEP and ICP was found in obese SBI patients, but not in non-obese ones. For every cmH2O increase in PEEP, there was a 0.19 mmHg increase in ICP (95% CI [0.05, 0.33], P = 0.007) and a 0.15 mmHg decrease in CPP (95% CI [-0.29, -0.01], P = 0.036) in obese SBI patients after adjusting for confounders. CONCLUSIONS The results suggested that, contrary to non-obese SBI patients, the application of PEEP may produce an increase in ICP in obese SBI patients. However, the effect was modest and may be clinically inconsequential.
Collapse
Affiliation(s)
- Dawei Zhou
- grid.24696.3f0000 0004 0369 153XDepartment of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Tong Li
- grid.24696.3f0000 0004 0369 153XDepartment of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Shuyang Fei
- grid.24696.3f0000 0004 0369 153XDepartment of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Chao Wang
- grid.24696.3f0000 0004 0369 153XDepartment of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yi Lv
- grid.24696.3f0000 0004 0369 153XDepartment of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
8
|
Taran S, McCredie VA, Goligher EC. Noninvasive and invasive mechanical ventilation for neurologic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2022; 189:361-386. [PMID: 36031314 DOI: 10.1016/b978-0-323-91532-8.00015-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Patients with acute neurologic injuries frequently require mechanical ventilation due to diminished airway protective reflexes, cardiopulmonary failure secondary to neurologic insults, or to facilitate gas exchange to precise targets. Mechanical ventilation enables tight control of oxygenation and carbon dioxide levels, enabling clinicians to modulate cerebral hemodynamics and intracranial pressure with the goal of minimizing secondary brain injury. In patients with acute spinal cord injuries, neuromuscular conditions, or diseases of the peripheral nerve, mechanical ventilation enables respiratory support under conditions of impending or established respiratory failure. Noninvasive ventilatory approaches may be carefully considered for certain disease conditions, including myasthenia gravis and amyotrophic lateral sclerosis, but may be inappropriate in patients with Guillain-Barré syndrome or when relevant contra-indications exist. With regard to discontinuing mechanical ventilation, considerable uncertainty persists about the best approach to wean patients, how to identify patients ready for extubation, and when to consider primary tracheostomy. Recent consensus guidelines highlight these and other knowledge gaps that are the focus of active research efforts. This chapter outlines important general principles to consider when initiating, titrating, and discontinuing mechanical ventilation in patients with acute neurologic injuries. Important disease-specific considerations are also reviewed where appropriate.
Collapse
Affiliation(s)
- Shaurya Taran
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Medicine, University Health Network, Toronto, ON, Canada.
| |
Collapse
|
9
|
Robba C, Ball L, Nogas S, Battaglini D, Messina A, Brunetti I, Minetti G, Castellan L, Rocco PRM, Pelosi P. Effects of Positive End-Expiratory Pressure on Lung Recruitment, Respiratory Mechanics, and Intracranial Pressure in Mechanically Ventilated Brain-Injured Patients. Front Physiol 2021; 12:711273. [PMID: 34733173 PMCID: PMC8558243 DOI: 10.3389/fphys.2021.711273] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 09/09/2021] [Indexed: 01/17/2023] Open
Abstract
Background: The pathophysiological effects of positive end-expiratory pressure (PEEP) on respiratory mechanics, lung recruitment, and intracranial pressure (ICP) in acute brain-injured patients have not been completely elucidated. The primary aim of this study was to assess the effects of PEEP augmentation on respiratory mechanics, quantitative computed lung tomography (qCT) findings, and its relationship with ICP modifications. Secondary aims included the assessment of the correlations between different factors (respiratory mechanics and qCT features) with the changes of ICP and how these factors at baseline may predict ICP response after greater PEEP levels. Methods: A prospective, observational study included mechanically ventilated patients with acute brain injury requiring invasive ICP and who underwent two-PEEP levels lung CT scan. Respiratory system compliance (Crs), arterial partial pressure of carbon dioxide (PaCO2), mean arterial pressure (MAP), data from qCT and ICP were obtained at PEEP 5 and 15 cmH2O. Results: Sixteen examinations (double PEEP lung CT and neuromonitoring) in 15 patients were analyzed. The median age of the patients was 54 years (interquartile range, IQR = 39–65) and 53% were men. The median Glasgow Coma Scale (GCS) at intensive care unit (ICU) admission was 8 (IQR = 3–12). Median alveolar recruitment was 2.5% of total lung weight (−1.5 to 4.7). PEEP from 5 to 15 cmH2O increased ICP [median values from 14.0 (11.2–17.5) to 23.5 (19.5–26.8) mmHg, p < 0.001, respectively]. The amount of recruited lung tissue on CT was inversely correlated with the change (Δ) in ICP (rho = −0.78; p = 0.0006). Additionally, ΔCrs (rho = −0.77, p = 0.008), ΔPaCO2 (rho = 0.81, p = 0.0003), and ΔMAP (rho = −0.64, p = 0.009) were correlated with ΔICP. Baseline Crs was not predictive of ICP response to PEEP. Conclusions: The main factors associated with increased ICP after PEEP augmentation included reduced Crs, lower MAP and lung recruitment, and increased PaCO2, but none of these factors was able to predict, at baseline, ICP response to PEEP. To assess the potential benefits of increased PEEP in patients with acute brain injury, hemodynamic status, respiratory mechanics, and lung morphology should be taken into account.
Collapse
Affiliation(s)
- Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Lorenzo Ball
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Stefano Nogas
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genoa, Italy
| | - Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genoa, Italy
| | - Antonio Messina
- Humanitas Clinical and Research Center-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rozzano, Italy
| | - Iole Brunetti
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genoa, Italy
| | - Giuseppe Minetti
- Radiology Department San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genoa, Italy
| | - Lucio Castellan
- Radiology Department San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| |
Collapse
|
10
|
Robba C, Citerio G, Taccone FS, Galimberti S, Rebora P, Vargiolu A, Pelosi P. Multicentre observational study on practice of ventilation in brain injured patients: the VENTIBRAIN study protocol. BMJ Open 2021; 11:e047100. [PMID: 34380722 PMCID: PMC8359464 DOI: 10.1136/bmjopen-2020-047100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Mechanical ventilatory is a crucial element of acute brain injured patients' management. The ventilatory goals to ensure lung protection during acute respiratory failure may not be adequate in case of concomitant brain injury. Therefore, there are limited data from which physicians can draw conclusions regarding optimal ventilator management in this setting. METHODS AND ANALYSIS This is an international multicentre prospective observational cohort study. The aim of the 'multicentre observational study on practice of ventilation in brain injured patients'-the VENTIBRAIN study-is to describe the current practice of ventilator settings and mechanical ventilation in acute brain injured patients. Secondary objectives include the description of ventilator settings among different countries, and their association with outcomes. Inclusion criteria will be adult patients admitted to the intensive care unit (ICU) with a diagnosis of traumatic brain injury or cerebrovascular diseases (intracranial haemorrhage, subarachnoid haemorrhage, ischaemic stroke), requiring intubation and mechanical ventilation and admission to the ICU. Exclusion criteria will be the following: patients aged <18 years; pregnant patients; patients not intubated or not mechanically ventilated or receiving only non-invasive ventilation. Data related to clinical examination, neuromonitoring if available, ventilator settings and arterial blood gases will be recorded at admission and daily for the first 7 days and then at day 10 and 14. The Glasgow Outcome Scale Extended on mortality and neurological outcome will be collected at discharge from ICU, hospital and at 6 months follow-up. ETHICS AND DISSEMINATION The study has been approved by the Ethic committee of Brianza at the Azienda Socio Sanitaria Territoriale-Monza. Data will be disseminated to the scientific community by abstracts submitted to the European Society of Intensive Care Medicine annual conference and by original articles submitted to peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04459884.
Collapse
Affiliation(s)
- Chiara Robba
- Anesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genova, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, University of Genoa, Genova, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, Università Miano - Bicocca, Milano, Italy
- Neuroscience Department, NeuroIntensive Care Unit, Hospital San Gerardo, ASST Monza, Monza, Italy
| | - Fabio S Taccone
- Dpt of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Stefania Galimberti
- School of Medicine and Surgery, Università Miano - Bicocca, Milano, Italy
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy
| | - Paola Rebora
- School of Medicine and Surgery, Università Miano - Bicocca, Milano, Italy
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy
| | - Alessia Vargiolu
- School of Medicine and Surgery, Università Miano - Bicocca, Milano, Italy
| | - Paolo Pelosi
- Anesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genova, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, University of Genoa, Genova, Italy
| |
Collapse
|
11
|
Prone Position Ventilation in Neurologically Ill Patients: A Systematic Review and Proposed Protocol. Crit Care Med 2021; 49:e269-e278. [PMID: 33481406 DOI: 10.1097/ccm.0000000000004820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Prone positioning has been shown to be a beneficial adjunctive supportive measure for patients who develop acute respiratory distress syndrome. Studies have excluded patients with reduced intracranial compliance, whereby patients with concomitant neurologic diagnoses and acute respiratory distress syndrome have no defined treatment algorithm or recommendations for management. In this study, we aim to determine the safety and feasibility of prone positioning in the neurologically ill patients. DESIGN AND SETTING A systematic review of the literature, performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses 2009 guidelines, yielded 10 articles for analysis. Using consensus from these articles, in combination with review of multi-institutional proning protocols for patients with nonneurologic conditions, a proning protocol for patients with intracranial pathology and concomitant acute respiratory distress syndrome was developed. MEASUREMENTS AND MAIN RESULTS Among 10 studies included in the final analysis, we found that prone positioning is safe and feasible in the neurologically ill patients with acute respiratory distress syndrome. Increased intracranial pressure and compromised cerebral perfusion pressure may occur with prone positioning. We propose a prone positioning protocol for the neurologically ill patients who require frequent neurologic examinations and intracranial monitoring. CONCLUSIONS Although elevations in intracranial pressure and reductions in cerebral perfusion pressure do occur during proning, they may not occur to a degree that would warrant exclusion of prone ventilation as a treatment modality for patients with acute respiratory distress syndrome and concomitant neurologic diagnoses. In cases where intracranial pressure, cerebral perfusion pressure, and brain tissue oxygenation can be monitored, prone position ventilation should be considered a safe and viable therapy.
Collapse
|
12
|
Lung-protective ventilation and adjunctive strategies to manage respiratory failure: are they safe in the neurological patient? Curr Opin Crit Care 2021; 27:115-119. [PMID: 33480618 DOI: 10.1097/mcc.0000000000000809] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The coexistence of neurological injury and respiratory failure is common in intensive care. This article provides a contemporary overview of the safety and efficacy of different strategies for mechanical ventilation and adjunctive respiratory approaches in patients with acute brain injury. RECENT FINDINGS Available evidence indicates that lung-protective ventilation (LPV) can be implemented safely in a range of patients with concurrent respiratory failure and brain injury of different etiologies; however, the clinical efficacy of LPV in this setting needs to be established. In patients who have severe acute respiratory distress syndrome (ARDS) and brain injury, adjunctive measures (neuromuscular blocker drug infusions, prone positioning, extracorporeal membrane oxygenation) may be considered, although the neurophysiological impact and safety of these techniques need further investigation. Intracranial pressure and other neuromonitoring techniques may be of value to ensure optimal management of mechanical ventilation and adjunctive measures in this population. SUMMARY Research is needed to determine the safety, feasibility, and efficacy of LPV and adjunctive approaches for managing patients with concurrent brain injury and respiratory failure.
Collapse
|
13
|
Shi ZH, Jonkman AH, Tuinman PR, Chen GQ, Xu M, Yang YL, Heunks LMA, Zhou JX. Role of a successful spontaneous breathing trial in ventilator liberation in brain-injured patients. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:548. [PMID: 33987246 PMCID: PMC8105847 DOI: 10.21037/atm-20-6407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 12/18/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Spontaneous breathing trials (SBTs) have been shown to improve outcomes in critically ill patients. However, in patients with brain injury, indications for intubation and mechanical ventilation are different from those of non-neurological patients, and the role of an SBT in patients with brain injury is less established. The aim of the present study was to compare key respiratory variables acquired during a successful SBT between patients with successful ventilator liberation versus failed ventilator liberation. METHODS In this prospective study, patients with brain injury (≥18 years of age), who completed a 30-min SBT, were enrolled. Airway pressure, flow, esophageal pressure, and diaphragm electrical activity (ΔEAdi) were recorded before (baseline) and during the SBT. Respiratory rate (RR), tidal volume, inspiratory muscle pressure (ΔPmus), ΔEAdi, and neuromechanical efficiency (ΔPmus/ΔEAdi) of the diaphragm were calculated breath by breath and compared between the liberation success and failure groups. Failed liberation was defined as the need for invasive ventilator assistance within 48 h after the SBT. RESULTS In total, 46 patients (51.9±13.2 years, 67.4% male) completed the SBT. Seventeen (37%) patients failed ventilator liberation within 48 h. Another 11 patients required invasive ventilation within 7 days after completing the SBT. There were no differences in baseline characteristics between the success and failed groups. In-depth analysis showed similar changes in patterns and values of respiratory physiological parameters between the groups. CONCLUSIONS In patients with brain injury, ventilator liberation failure was common after successful SBT. In-depth physiological analysis during the SBT did not provide data to predict successful liberation in these patients. TRIAL REGISTRATION The trial was registered at ClinicalTrials.gov (No. NCT02863237).
Collapse
Affiliation(s)
- Zhong-Hua Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Annemijn H. Jonkman
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Guang-Qiang Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Xu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yan-Lin Yang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Leo M. A. Heunks
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
14
|
Shoaib MH, Ahmed FR, Sikandar M, Yousuf RI, Saleem MT. A Journey From SARS-CoV-2 to COVID-19 and Beyond: A Comprehensive Insight of Epidemiology, Diagnosis, Pathogenesis, and Overview of the Progress into Its Therapeutic Management. Front Pharmacol 2021; 12:576448. [PMID: 33732150 PMCID: PMC7957225 DOI: 10.3389/fphar.2021.576448] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 01/11/2021] [Indexed: 01/10/2023] Open
Abstract
The 2019 novel coronavirus (2019-nCoV), commonly known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or coronavirus disease 2019 (COVID-19), was first revealed in late 2019 in Wuhan city, Hubei province, China. It was subsequently spread globally and thereby declared as a pandemic by WHO in March 2020. The disease causes severe acute respiratory illness and is highly contagious due to the fast-onward transmission. As of the mid of November 2020, the disease has affected 220 countries with more than 16 million active cases and 1.3 million deaths worldwide. Males, pregnant women, the elderly, immunosuppressed patients, and those with underlying medical conditions are more vulnerable to the disease than the general healthy population. Unfortunately, no definite treatment is available. Although remdesivir as an antiviral had been approved for use in those above 12 years of age and 40 kg weight group, it has been observed to be ineffective in large-scale SOLIDARITY trials by WHO. Moreover, dexamethasone has been found to increase the recovery rate of ventilated patients; oxygen and inhaled nitric oxide as a vasodilator have been given emergency expanded access. In addition, more than 57 clinical trials are being conducted for the development of the vaccines on various platforms. Two vaccines were found to be significantly promising in phase III results. It is concluded that till the approval of a specific treatment or development of a vaccine against this deadly disease, the preventive measures should be followed strictly to reduce the spread of the disease.
Collapse
Affiliation(s)
- Muhammad Harris Shoaib
- Department of Pharmaceutics, Faculty of Pharmacy and Pharmaceutical Sciences, University of Karachi, Karachi, Pakistan
| | | | | | | | | |
Collapse
|
15
|
Robba C, Poole D, McNett M, Asehnoune K, Bösel J, Bruder N, Chieregato A, Cinotti R, Duranteau J, Einav S, Ercole A, Ferguson N, Guerin C, Siempos II, Kurtz P, Juffermans NP, Mancebo J, Mascia L, McCredie V, Nin N, Oddo M, Pelosi P, Rabinstein AA, Neto AS, Seder DB, Skrifvars MB, Suarez JI, Taccone FS, van der Jagt M, Citerio G, Stevens RD. Mechanical ventilation in patients with acute brain injury: recommendations of the European Society of Intensive Care Medicine consensus. Intensive Care Med 2020; 46:2397-2410. [PMID: 33175276 PMCID: PMC7655906 DOI: 10.1007/s00134-020-06283-0] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 10/05/2020] [Indexed: 12/29/2022]
Abstract
Purpose To provide clinical practice recommendations and generate a research agenda on mechanical ventilation and respiratory support in patients with acute brain injury (ABI). Methods An international consensus panel was convened including 29 clinician-scientists in intensive care medicine with expertise in acute respiratory failure, neurointensive care, or both, and two non-voting methodologists. The panel was divided into seven subgroups, each addressing a predefined clinical practice domain relevant to patients admitted to the intensive care unit (ICU) with ABI, defined as acute traumatic brain or cerebrovascular injury. The panel conducted systematic searches and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was used to evaluate evidence and formulate questions. A modified Delphi process was implemented with four rounds of voting in which panellists were asked to respond to questions (rounds 1–3) and then recommendation statements (final round). Strong recommendation, weak recommendation, or no recommendation were defined when > 85%, 75–85%, and < 75% of panellists, respectively, agreed with a statement. Results The GRADE rating was low, very low, or absent across domains. The consensus produced 36 statements (19 strong recommendations, 6 weak recommendations, 11 no recommendation) regarding airway management, non-invasive respiratory support, strategies for mechanical ventilation, rescue interventions for respiratory failure, ventilator liberation, and tracheostomy in brain-injured patients. Several knowledge gaps were identified to inform future research efforts. Conclusions This consensus provides guidance for the care of patients admitted to the ICU with ABI. Evidence was generally insufficient or lacking, and research is needed to demonstrate the feasibility, safety, and efficacy of different management approaches. Electronic supplementary material The online version of this article (10.1007/s00134-020-06283-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Chiara Robba
- San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Daniele Poole
- Anesthesia and Intensive Care Operative Unit, S. Martino Hospital, Belluno, Italy
| | - Molly McNett
- Implementation Science, The Helene Fuld Health Trust National Institute for EBP, College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Karim Asehnoune
- Department of Anaesthesia and Critical Care, Hôtel Dieu, University Hospital of Nantes, Nantes, France
| | - Julian Bösel
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
- Department of Neurology, Klinikum Kassel, Kassel, Germany
| | - Nicolas Bruder
- Anesthesiology-Intensive Care Department, Aix-Marseille University, APHM, CHU Timone, Marseille, France
| | - Arturo Chieregato
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Raphael Cinotti
- Department of Anaesthesia and Critical Care, Hôpital Guillaume et René Laennec, University Hospital of Nantes, Saint-Herblain, France
| | - Jacques Duranteau
- Department of Anesthesiology and Perioperative Intensive Care Medicine, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris, Paris-Saclay University, Paris, France
| | - Sharon Einav
- Faculty of Medicine, Intensive Care Unit of the Shaare Zedek Medical Centre and Hebrew University, Jerusalem, Israel
| | - Ari Ercole
- University of Cambridge Division of Anaesthesia, Addenbrooke's Hospital, Cambridge, UK
| | - Niall Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Physiology, University of Toronto, Toronto, ON, Canada
| | - Claude Guerin
- Medecine Intensive-Réanimation, Hopital Edouard Herriot, University of Lyon, Lyon, France
- INSERM 955, Créteil, France
| | - Ilias I Siempos
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, USA
| | - Pedro Kurtz
- Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Olvg Hospital, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Jordi Mancebo
- Servei Medicina Intensiva, Hospital Sant Pau, Barcelona, Spain
| | - Luciana Mascia
- Alma Mater Studiorum, Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Victoria McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Nicolas Nin
- Department of Intensive Care Medicine, Hospital Español, Montevideo, Uruguay
| | - Mauro Oddo
- Department of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Paolo Pelosi
- San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | | | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Critical Care Medicine, Hospital Israelita Alberto Einstein, São Paulo, Brazil
| | - David B Seder
- Department of Critical Care Services, Neuroscience Institute, Maine Medical Center, 22 Bramhall Street, Portland, ME, 04102, USA
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Meilahden sairaala, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
| | - Jose I Suarez
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Phipps 455, Baltimore, MD, 21287, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabio Silvio Taccone
- Department of Intensive Care Medicine, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy
| | - Robert D Stevens
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Phipps 455, Baltimore, MD, 21287, USA.
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
16
|
Towner JE, Rahmani R, Zammit CG, Khan IR, Paul DA, Bhalla T, Roberts DE. Mechanical ventilation in aneurysmal subarachnoid hemorrhage: systematic review and recommendations. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:575. [PMID: 32972406 PMCID: PMC7512211 DOI: 10.1186/s13054-020-03269-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 09/02/2020] [Indexed: 02/04/2023]
Abstract
Objective Mechanical ventilation (MV) has a complex interplay with the pathophysiology of aneurysmal subarachnoid hemorrhage (aSAH). We aim to provide a review of the physiology of MV in patients with aSAH, give recommendations based on a systematic review of the literature, and highlight areas that still need investigation. Data sources PubMed was queried for publications with the Medical Subject Headings (MeSH) terms “mechanical ventilation” and “aneurysmal subarachnoid hemorrhage” published between January 1, 1990, and March 1, 2020. Bibliographies of returned articles were reviewed for additional publications of interest. Study selection Study inclusion criteria included English language manuscripts with the study population being aSAH patients and the exposure being MV. Eligible studies included randomized controlled trials, observational trials, retrospective trials, case-control studies, case reports, or physiologic studies. Topics and articles excluded included review articles, pediatric populations, non-aneurysmal etiologies of subarachnoid hemorrhage, mycotic and traumatic subarachnoid hemorrhage, and articles regarding tracheostomies. Data extraction Articles were reviewed by one team member, and interpretation was verified by a second team member. Data synthesis Thirty-one articles met the inclusion criteria for this review. Conclusions We make recommendations on oxygenation, hypercapnia, PEEP, APRV, ARDS, and intracranial pressure monitoring.
Collapse
Affiliation(s)
- James E Towner
- Department of Neurosurgery, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Redi Rahmani
- Department of Neurosurgery, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.
| | - Christopher G Zammit
- Department of Neurosurgery, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.,Division of Neurocritical Care, Department of Neurology, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.,Division of Pulmonary Diseases and Critical Care, Department of Medicine, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.,TriHealth Critical Care, 10506 Montgomery Road, Suite 301, Cincinnatir, OH, 45242, USA
| | - Imad R Khan
- Department of Neurosurgery, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.,Division of Neurocritical Care, Department of Neurology, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.,Division of Pulmonary Diseases and Critical Care, Department of Medicine, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - David A Paul
- Department of Neurosurgery, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.,Department of Imaging Sciences, University of Rochester Medical Center, 601 Elmwood Ave, Box 670, Rochester, NY, 14642, USA.,Department of Neurology, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Debra E Roberts
- Department of Neurosurgery, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.,Division of Neurocritical Care, Department of Neurology, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.,Division of Pulmonary Diseases and Critical Care, Department of Medicine, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.,Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| |
Collapse
|
17
|
Impact of Altered Airway Pressure on Intracranial Pressure, Perfusion, and Oxygenation: A Narrative Review. Crit Care Med 2019; 47:254-263. [PMID: 30653472 DOI: 10.1097/ccm.0000000000003558] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES A narrative review of the pathophysiology linking altered airway pressure and intracranial pressure and cerebral oxygenation. DATA SOURCES Online search of PubMed and manual review of articles (laboratory and patient studies) of the altered airway pressure on intracranial pressure, cerebral perfusion, or cerebral oxygenation. STUDY SELECTION Randomized trials, observational and physiologic studies. DATA EXTRACTION Our group determined by consensus which resources would best inform this review. DATA SYNTHESIS In the normal brain, positive-pressure ventilation does not significantly alter intracranial pressure, cerebral oxygenation, or perfusion. In injured brains, the impact of airway pressure on intracranial pressure is variable and determined by several factors; a cerebral venous Starling resistor explains much of the variability. Negative-pressure ventilation can improve cerebral perfusion and oxygenation and reduce intracranial pressure in experimental models, but data are limited, and mechanisms and clinical benefit remain uncertain. CONCLUSIONS The effects of airway pressure and ventilation on cerebral perfusion and oxygenation are increasingly understood, especially in the setting of brain injury. In the face of competing mechanisms and priorities, multimodal monitoring and individualized titration will increasingly be required to optimize care.
Collapse
|
18
|
Bruni A, Garofalo E, Pelaia C, Longhini F, Navalesi P. Mechanical ventilation in brain injured patients: seeing the forest for the trees. J Thorac Dis 2017; 9:3483-3487. [PMID: 29268322 DOI: 10.21037/jtd.2017.08.149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Andrea Bruni
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Eugenio Garofalo
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Corrado Pelaia
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Federico Longhini
- Anesthesia and Intensive Care, Sant'Andrea Hospital, Vercelli, Italy
| | - Paolo Navalesi
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| |
Collapse
|
19
|
Kutchak FM, Rieder MDM, Victorino JA, Meneguzzi C, Poersch K, Forgiarini LA, Bianchin MM. Simple motor tasks independently predict extubation failure in critically ill neurological patients. J Bras Pneumol 2017; 43:183-189. [PMID: 28746528 PMCID: PMC5687948 DOI: 10.1590/s1806-37562016000000155] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 11/18/2016] [Indexed: 01/01/2023] Open
Abstract
Objective: To evaluate the usefulness of simple motor tasks such as hand grasping and tongue protrusion as predictors of extubation failure in critically ill neurological patients. Methods: This was a prospective cohort study conducted in the neurological ICU of a tertiary care hospital in the city of Porto Alegre, Brazil. Adult patients who had been intubated for neurological reasons and were eligible for weaning were included in the study. The ability of patients to perform simple motor tasks such as hand grasping and tongue protrusion was evaluated as a predictor of extubation failure. Data regarding duration of mechanical ventilation, length of ICU stay, length of hospital stay, mortality, and incidence of ventilator-associated pneumonia were collected. Results: A total of 132 intubated patients who had been receiving mechanical ventilation for at least 24 h and who passed a spontaneous breathing trial were included in the analysis. Logistic regression showed that patient inability to grasp the hand of the examiner (relative risk = 1.57; 95% CI: 1.01-2.44; p < 0.045) and protrude the tongue (relative risk = 6.84; 95% CI: 2.49-18.8; p < 0.001) were independent risk factors for extubation failure. Acute Physiology and Chronic Health Evaluation II scores (p = 0.02), Glasgow Coma Scale scores at extubation (p < 0.001), eye opening response (p = 0.001), MIP (p < 0.001), MEP (p = 0.006), and the rapid shallow breathing index (p = 0.03) were significantly different between the failed extubation and successful extubation groups. Conclusions: The inability to follow simple motor commands is predictive of extubation failure in critically ill neurological patients. Hand grasping and tongue protrusion on command might be quick and easy bedside tests to identify neurocritical care patients who are candidates for extubation.
Collapse
Affiliation(s)
- Fernanda Machado Kutchak
- . Programa de Pós-Graduação em Ciências Médicas, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil.,. Pesquisa Básica e Investigações Avançadas em Neurologia, Centro de Pesquisa Experimental, Hospital de Clínicas de Porto Alegre, Porto Alegre (RS) Brasil.,. Universidade do Vale do Rio dos Sinos - UNISINOS - São Leopoldo (RS) Brasil.,. Unidade de Terapia Intensiva, Hospital Cristo Redentor, Porto Alegre (RS) Brasil
| | - Marcelo de Mello Rieder
- . Programa de Pós-Graduação em Ciências Médicas, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil.,. Pesquisa Básica e Investigações Avançadas em Neurologia, Centro de Pesquisa Experimental, Hospital de Clínicas de Porto Alegre, Porto Alegre (RS) Brasil.,. Unidade de Terapia Intensiva, Hospital Cristo Redentor, Porto Alegre (RS) Brasil
| | - Josué Almeida Victorino
- . Programa de Pós-Graduação em Ciências Médicas, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil.,. Unidade de Terapia Intensiva, Hospital Cristo Redentor, Porto Alegre (RS) Brasil
| | - Carla Meneguzzi
- . Unidade de Terapia Intensiva, Hospital Cristo Redentor, Porto Alegre (RS) Brasil
| | - Karla Poersch
- . Universidade do Vale do Rio dos Sinos - UNISINOS - São Leopoldo (RS) Brasil
| | - Luiz Alberto Forgiarini
- . Curso de Fisioterapia, Programa de Pós-Graduação em Reabilitação e Inclusão e Biociências e Reabilitação, Centro Universitário Metodista - IPA - Porto Alegre (RS) Brasil
| | - Marino Muxfeldt Bianchin
- . Programa de Pós-Graduação em Ciências Médicas, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil.,. Pesquisa Básica e Investigações Avançadas em Neurologia, Centro de Pesquisa Experimental, Hospital de Clínicas de Porto Alegre, Porto Alegre (RS) Brasil.,. Divisão de Neurologia, Hospital de Clínicas de Porto Alegre, Porto Alegre (RS) Brasil
| |
Collapse
|
20
|
Steidl C, Bösel J, Suntrup-Krueger S, Schönenberger S, Al-Suwaidan F, Warnecke T, Minnerup J, Dziewas R. Tracheostomy, Extubation, Reintubation: Airway Management Decisions in Intubated Stroke Patients. Cerebrovasc Dis 2017; 44:1-9. [PMID: 28395275 DOI: 10.1159/000471892] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 03/20/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Both delayed and premature extubation increase complication rate, the need for tracheostomy (TT), the duration of intensive care unit stay, and mortality. In this study, we therefore investigated factors associated with primary TT and predictors for extubation failure (EF) in a sample of severely affected ventilated stroke patients. METHODS One hundred eighty five intubated stroke patients were prospectively analyzed in this observational study. Patients not meeting predefined clinical and respiratory extubation criteria received a TT. All other patients were extubated and followed up for the need of reintubation. Characteristics of patients with and without extubation attempt were examined. Additionally, within the group of extubated patients, subgroups of successfully vs. unsuccessfully extubated patients were compared. Clinical factors associated with reintubation, including a previously established semi-quantitative airway score, were determined and predictors of EF were assessed. RESULTS Ninety-eight of 185 patients (53%) were primarily extubated; EF rate was 37% (36 patients). Eighty-seven (47%) were tracheostomized without a prior extubation attempt. Primarily tracheostomized patients had more severe strokes, which were more often hemorrhagic, presented with a lower level of consciousness, needed neurosurgical intervention more often, had a higher rate of obesity, and were more frequently intubated because of suspicion of compromised protective reflexes. EF was independently predicted by prior neurosurgical treatment and low airway management scores. No differences were found for the ability to follow simple commands and classical weaning criteria. CONCLUSION Airway management decisions in intubated stroke patients represent a clinical challenge. Classical weaning criteria and parameters reflecting the patient's state of consciousness are not reliably predictive of extubation success. Criteria more closely related to airway safety and secretion handling may provide the most relevant information and should therefore be assessed by specific clinical scoring systems.
Collapse
|
21
|
Boone MD, Jinadasa SP, Mueller A, Shaefi S, Kasper EM, Hanafy KA, O'Gara BP, Talmor DS. The Effect of Positive End-Expiratory Pressure on Intracranial Pressure and Cerebral Hemodynamics. Neurocrit Care 2017; 26:174-181. [PMID: 27848125 PMCID: PMC6613349 DOI: 10.1007/s12028-016-0328-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Lung protective ventilation has not been evaluated in patients with brain injury. It is unclear whether applying positive end-expiratory pressure (PEEP) adversely affects intracranial pressure (ICP) and cerebral perfusion pressure (CPP). We aimed to evaluate the effect of PEEP on ICP and CPP in a large population of patients with acute brain injury and varying categories of acute lung injury, defined by PaO2/FiO2. METHOD Retrospective data were collected from 341 patients with severe acute brain injury admitted to the ICU between 2008 and 2015. These patients experienced a total of 28,644 paired PEEP and ICP observations. Demographic, hemodynamic, physiologic, and ventilator data at the time of the paired PEEP and ICP observations were recorded. RESULTS In the adjusted analysis, a statistically significant relationship between PEEP and ICP and PEEP and CPP was found only among observations occurring during periods of severe lung injury. For every centimeter H2O increase in PEEP, there was a 0.31 mmHg increase in ICP (p = 0.04; 95 % CI [0.07, 0.54]) and a 0.85 mmHg decrease in CPP (p = 0.02; 95 % CI [-1.48, -0.22]). CONCLUSION Our results suggest that PEEP can be applied safely in patients with acute brain injury as it does not have a clinically significant effect on ICP or CPP. Further prospective studies are required to assess the safety of applying a lung protective ventilation strategy in brain-injured patients with lung injury.
Collapse
Affiliation(s)
- Myles D Boone
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.
| | - Sayuri P Jinadasa
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Ariel Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Ekkehard M Kasper
- Department of Surgery, Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Khalid A Hanafy
- Department of Neurology, Division of Neurocritical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Brian P O'Gara
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Daniel S Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| |
Collapse
|
22
|
Abstract
Neuropulmonology refers to the complex interconnection between the central nervous system and the respiratory system. Neurologic injury includes traumatic brain injury, hemorrhage, stroke, and seizures, and in each there are far-reaching effects that can result in pulmonary dysfunction. Systemic changes can induce impairment of pulmonary function due to changes in the core structure and function of the lung. The conditions and disorders that often occur in these patients include aspiration pneumonia, neurogenic pulmonary edema, and acute respiratory distress syndrome, but also several abnormal respiratory patterns and sleep-disordered breathing. Lung infections, pulmonary edema - neurogenic or cardiogenic - and pulmonary embolus all are a serious barrier to recovery and can have significant effects on outcomes such as hospital course, prognosis, and mortality. This review presents the spectrum of pulmonary abnormalities seen in neurocritical care.
Collapse
|
23
|
Fletcher JJ, Wilson TJ, Rajajee V, Davidson SB, Walsh JC. Changes in Therapeutic Intensity Level Following Airway Pressure Release Ventilation in Severe Traumatic Brain Injury. J Intensive Care Med 2016; 33:196-202. [PMID: 27651443 DOI: 10.1177/0885066616669315] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Airway pressure release ventilation (APRV) utilizes high levels of airway pressure coupled with brief expiratory release to facilitate open lung ventilation. The aim of our study was to evaluate the effects of APRV-induced elevated airway pressure mean in patients with severe traumatic brain injury. MATERIALS AND METHODS This was a retrospective cohort study at a 424-bed Level I trauma center. Linear mixed effects models were developed to assess the difference in therapeutic intensity level (TIL), intracranial pressure (ICP), and cerebral perfusion pressure (CPP) over time following the application of APRV. RESULTS The study included 21 epochs of APRV in 21 patients. In the 6-hour epoch following the application of APRV, the TIL was significantly increased ( P = .002) and the ICP significantly decreased ( P = .041) compared to that before 6 hours. There was no significant change in CPP ( P = .42) over time. The baseline static compliance and time interaction was not significant for TIL (χ2 = 0.2 [ df 1], P = .655), CPP (χ2 = 0 [ df 1], P = 1), or ICP (χ2 = 0.1 [ df 1], P = .752). CONCLUSIONS Application of APRV in patients with severe traumatic brain injury was associated with significantly, but not clinically meaningful, increased TIL and decreased ICP. No significant change in CPP was observed. No difference was observed based on the baseline pulmonary static compliance.
Collapse
Affiliation(s)
- Jeffrey J Fletcher
- 1 Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.,2 Bronson Neuroscience Center, Bronson Methodist Hospital, Kalamazoo, MI, USA
| | - Thomas J Wilson
- 1 Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Venkatakrishna Rajajee
- 1 Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.,3 Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Scott B Davidson
- 4 Trauma, Burn, and Surgical Critical Care Program, Bronson Methodist Hospital, Kalamazoo, MI, USA
| | - Jon C Walsh
- 4 Trauma, Burn, and Surgical Critical Care Program, Bronson Methodist Hospital, Kalamazoo, MI, USA
| |
Collapse
|
24
|
Gradisek P, Dolenc S. Isoflurane rescue therapy for bronchospasm reduces intracranial pressure in a patient with traumatic brain injury. Brain Inj 2016; 30:1035-40. [PMID: 27120554 DOI: 10.3109/02699052.2016.1147598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PRIMARY OBJECTIVE To assess the unusual use of a volatile anaesthetic for treatment of life-threatening bronchospasm in a patient with traumatic brain injury (TBI). RESEARCH DESIGN Case report. METHODS AND PROCEDURES This study presents a previously healthy 30-year-old man with severe TBI and bronchospasm-induced acute hypercapnia. He was treated with inhaled isoflurane in combination with monitoring of intracranial pressure (ICP) and regional cerebral blood flow (rCBF). RESULTS Three-day-long isoflurane treatment resolved drug-refractory bronchospasm, decreased airway pressure and improved gas exchange, even at a low end-tidal concentration (0.3-0.5 vol%). Although rCBF was increased by 18 ml min(-1) 100 g(-1) during isoflurane treatment, there was a significant decrease in ICP (21 (SD = 3) mmHg, 9 (SD = 5) mmHg, 2 (SD = 3) mmHg; during pre-treatment, treatment and post-treatment, respectively; p < 0.001). Improved autoregulation due to lower partial pressure of carbon dioxide, restoration of carbon dioxide reactivity, isoflurane-induced regional differences in rCBF and improved microcirculation may have been responsible for the prompt and long-lasting normalization of ICP. The patient had no TBI-related disability at 6 months post-injury. CONCLUSIONS Isoflurane at a low dose can be an effective and safe treatment option for drug-refractory bronchospasm in a patient with traumatic intracranial hypertension, provided that multimodality neuromonitoring is used.
Collapse
Affiliation(s)
- Primoz Gradisek
- a Clinical Department of Anaesthesiology and Intensive Therapy , Centre for Intensive Therapy, University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Simon Dolenc
- a Clinical Department of Anaesthesiology and Intensive Therapy , Centre for Intensive Therapy, University Medical Centre Ljubljana , Ljubljana , Slovenia
| |
Collapse
|
25
|
Kutchak FM, Debesaitys AM, Rieder MDM, Meneguzzi C, Skueresky AS, Forgiarini Junior LA, Bianchin MM. Reflex cough PEF as a predictor of successful extubation in neurological patients. J Bras Pneumol 2016; 41:358-64. [PMID: 26398756 PMCID: PMC4635956 DOI: 10.1590/s1806-37132015000004453] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objective: To evaluate the use of reflex cough PEF as a predictor of successful extubation in neurological patients who were candidates for weaning from mechanical ventilation. Methods: This was a cross-sectional study of 135 patients receiving mechanical ventilation for more than 24 h in the ICU of Cristo Redentor Hospital, in the city of Porto Alegre, Brazil. Reflex cough PEF, the rapid shallow breathing index, MIP, and MEP were measured, as were ventilatory, hemodynamic, and clinical parameters. Results: The mean age of the patients was 47.8 ± 17 years. The extubation failure rate was 33.3%. A reflex cough PEF of < 80 L/min showed a relative risk of 3.6 (95% CI: 2.0-6.7), and the final Glasgow Coma Scale score showed a relative risk of 0.64 (95% CI: 0.51-0.83). For every 1-point increase in a Glasgow Coma Scale score of 8, there was a 36% reduction in the risk of extubation failure. Conclusions: Reflex cough PEF and the Glasgow Coma Scale score are independent predictors of extubation failure in neurological patients admitted to the ICU.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Marino Muxfeldt Bianchin
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, BR
| |
Collapse
|
26
|
Abstract
Patients with refractory intracranial hypertension often require short-term mechanical ventilation because they cannot protect their airway. Airway pressure release ventilation (APRV) is less commonly used than other modes because it is thought to increase intracranial pressure. However, this case study describes how APRV improved alveolar recruitment and functional residual capacity in a patient with refractory intracranial hypertension secondary to severe traumatic brain injury.
Collapse
|
27
|
Kapinos G, Chichra A. Lung-protective ventilation for SAH patients: are these measures truly protective? Neurocrit Care 2015; 21:175-7. [PMID: 25208682 DOI: 10.1007/s12028-014-0058-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Gregory Kapinos
- Departments of Neurosurgery & Neurology, Hofstra North Shore-LIJ School of Medicine, North Shore-LIJ Health System, 300 Community Drive, Tower, 9th floor, Manhasset, NY, 11030, USA,
| | | |
Collapse
|
28
|
dos Reis HFC, Almeida MLO, da Silva MF, Moreira JO, Rocha MDS. Association between the rapid shallow breathing index and extubation success in patients with traumatic brain injury. Rev Bras Ter Intensiva 2015; 25:212-7. [PMID: 24213084 PMCID: PMC4031850 DOI: 10.5935/0103-507x.20130037] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Accepted: 09/05/2013] [Indexed: 11/20/2022] Open
Abstract
Objective To investigate the association between the rapid shallow breathing index and
successful extubation in patients with traumatic brain injury. Methods This study was a prospective study conducted in patients with traumatic brain
injury of both genders who underwent mechanical ventilation for at least two days
and who passed a spontaneous breathing trial. The minute volume and respiratory
rate were measured using a ventilometer, and the data were used to calculate the
rapid shallow breathing index (respiratory rate/tidal volume). The dependent
variable was the extubation outcome: reintubation after up to 48 hours (extubation
failure) or not (extubation success). The independent variable was the rapid
shallow breathing index measured after a successful spontaneous breathing trial.
Results The sample comprised 119 individuals, including 111 (93.3%) males. The average age
of the sample was 35.0±12.9 years old. The average duration of mechanical
ventilation was 8.1±3.6 days. A total of 104 (87.4%) participants achieved
successful extubation. No association was found between the rapid shallow
breathing index and extubation success. Conclusion The rapid shallow breathing index was not associated with successful extubation in
patients with traumatic brain injury.
Collapse
|
29
|
Ngubane T. Mechanical ventilation and the injured brain. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2011.10872737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- T Ngubane
- Department of Anaesthesiology, Neurosurgical Intensive Care Unit, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand
| |
Collapse
|
30
|
Ventilation Practices in Subarachnoid Hemorrhage: A Cohort Study Exploring the Use of Lung Protective Ventilation. Neurocrit Care 2014; 21:178-85. [DOI: 10.1007/s12028-014-0014-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
31
|
Marik PE, Young A, Sibole S, Levitov A. The effect of APRV ventilation on ICP and cerebral hemodynamics. Neurocrit Care 2013; 17:219-23. [PMID: 22829002 DOI: 10.1007/s12028-012-9739-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Airway pressure release ventilation (APRV) is an alternative approach to the low-tidal volume "open-lung" ventilation strategy. APRV is associated with a higher mean airway pressure than conventional ventilation and has therefore not been evaluated in patients with acute neurological injuries. METHODS Case report. RESULTS We report a patient with severe progressive hypoxemia following a subarachnoid hemorrhage who was converted from pressure-controlled mechanical ventilation to APRV. This change in ventilatory mode was associated with a significant improvement in oxygenation and alveolar ventilation with an associated increase in cerebral blood flow and a negligible increase in intracranial pressure. CONCLUSION APRV may safely be applied to neurocritically ill patients, and that this mode of ventilation may increase cerebral blood flow without increasing intracranial pressure.
Collapse
Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Department of Respiratory Services, Eastern Virginia Medical School, 825 Fairfax Ave, Suite 410, Norfolk, VA 23507, USA.
| | | | | | | |
Collapse
|
32
|
Kearns M, Shimabukuro D. Respiratory Complications and Management of Mechanical Ventilation in Cervical Spine Injury. ACTA ACUST UNITED AC 2012. [DOI: 10.1177/1944451612457568] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
It is estimated that the annual incidence of spinal cord injury in the United States is 12 000 new cases per year. Victims of spinal cord injury are prone to developing respiratory complications such as atelectasis, pneumonia, and ventilatory failure secondary to physiologic derangements resulting from spinal shock and paralysis. Respiratory complications are the leading cause of death in those who survive the initial injury. The goal in ventilator management of spinal cord injury patients in the intensive care unit setting is to prevent these complications and optimize patients for early transfer to a spinal cord rehabilitation facility. To minimize atelectasis, current guidelines recommend the use of very high tidal volumes (15 mL/kg) or setting high tidal volumes (10 mL/kg) in addition to using positive end-expiratory pressure. In this article, the authors discuss the pulmonary complications that affect the mortality of these patients and review the evidence behind the current high tidal volume ventilation strategy.
Collapse
Affiliation(s)
- Michel Kearns
- Fellow in Critical Care Medicine, University of California, San Francisco
| | - David Shimabukuro
- Associate Professor, Medical Director, 13 ICU, University of California, San Francisco
| |
Collapse
|
33
|
Abstract
Injury is a major cause of critical illness worldwide. Severely injured patients often require mechanical ventilation not only to manage primary respiratory failure but also as adjunct to manage other conditions. Injury induces fundamental changes in multiple organ systems which directly impact ventilator management; these changes are not shared by patients without concomitant tissue injury. In this article, we review the physiologic changes after injury and discuss the impact of injury on ventilator strategies and management. We also explore the special considerations in patients with traumatic brain injury, thermal injury, blast injury or bronchopleural fistula.
Collapse
Affiliation(s)
- Adrian A Maung
- Department of Surgery, Section of Trauma, Surgical Critical Care and Surgical Emergencies, Yale University School of Medicine, New Haven, CT, USA
| | | |
Collapse
|
34
|
Mascia L, Mazzeo AT. Ventilatory management in head injury patients. Is there any conflict? TRENDS IN ANAESTHESIA AND CRITICAL CARE 2011. [DOI: 10.1016/j.tacc.2011.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
35
|
Abstract
Fortunately, the incidence of acute kidney injury (AKI) in neurotrauma is low and decreasing. Whereas the majority of AKI occurs in older patients with pre-existing chronic kidney disease, neurotrauma typically occurs in children and young adults with normal renal function. The development of outreach trauma teams has improved initial resuscitation, reducing both volume responsive and volume unresponsive cases of AKI. Most cases occur in the setting of multiple organ trauma with muscle injury, or patients who subsequently develop multiple organ failure. Once AKI has developed and renal replacement therapy is required, continuous modalities of renal replacement therapy offer an advantage to the patient with compromised cerebral perfusion and intracranial hypertension, by reducing the rate of change in serum urea, compared with standard intermittent therapies of hemodialysis and hemofiltration, thus minimizing abrupt changes in serum osmolality. Continuous hemodialysis and hemofiltration are better suited to maintain a normal or high serum sodium and thermal losses through the extracorporeal circuit, than peritoneal dialysis. Dialyzers should preferably be minimally bioincompatible and of a small surface area. In patients at risk of intracranial hemorrhage and those with invasive intracranial monitoring, systemic anticoagulants should either be avoided or regional anticoagulants should be used.
Collapse
Affiliation(s)
- Andrew Davenport
- UCL Center for Nephrology, University College London Medical School, London, UK.
| |
Collapse
|
36
|
Alveolar recruitment maneuver in patients with subarachnoid hemorrhage and acute respiratory distress syndrome: a comparison of 2 approaches. J Crit Care 2010; 26:22-7. [PMID: 20646904 DOI: 10.1016/j.jcrc.2010.04.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 04/23/2010] [Accepted: 04/25/2010] [Indexed: 01/07/2023]
Abstract
PURPOSE The purpose of the study was to compare 2 alveolar recruitment maneuvers (ARMs) approaches in patients with subarachnoid hemorrhage (SAH) and acute respiratory distress syndrome (ARDS). MATERIAL AND METHODS Sixteen SAH patients with ARDS were randomized in 2 similar groups. One received ARM with continuous positive airway pressure (CPAP) of 35 cm H(2)O for 40 seconds (CPAP recruitment), whereas the other received pressure control ventilation with positive-end expiratory pressure of 15 cm H(2)O and pressure control above positive end-expiratory pressure of 35 cm H(2)O for 2 minutes (pressure control recruitment maneuver [PCRM]). Intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were measured before and after ARM. The ratio of arterial oxygen tension to fraction of inspired oxygen was measured before and 1 hour after the ARM. RESULTS After ARM, ICP was higher in CPAP recruitment (20.50 ± 4.75 vs 13.13 ± 3.56 mm Hg; P = .003); and CPP was lower in CPAP recruitment (62.38 ± 9.81 vs 79.60 ± 6.8 mm Hg; P = .001). One hour after the ARM, the ratio of arterial oxygen tension to fraction of inspired oxygen increased significantly only in PCRM (108.5 to 203.6; P = .0078). CONCLUSION In SAH patients with ARDS, PCRM did not affect ICP and decreased CPP in safe levels, besides improving oxygenation.
Collapse
|
37
|
Abstract
Acute neurological injury may occur in patients with end-stage kidney disease on dialysis. Less frequently, acute kidney injury requiring renal dialytic support develops following acute neurological injury. Surrounding any site of neurological injury there is a penumbra of damage which is potentially reversible. To maximize full potential neurological recovery in patients requiring renal dialytic support, it is important that treatments do not themselves cause further cerebral ischemia. Standard intermittent hemodialysis is associated with cerebral swelling even in healthy outpatients and often with episodes of intradialytic hypotension. Continuous modes of renal replacement therapy have been shown to cause fewer surges in intracranial pressure and greater stability of cerebral perfusion pressure than standard intermittent techniques. In patients with acute neurological injury, renal replacement therapy should be carefully adapted to minimize cardiovascular instability and reduce the rate of change of serum osmolality.
Collapse
Affiliation(s)
- Andrew Davenport
- UCL Center for Nephrology, Royal Free & University College Medical School, Hampstead Campus, Rowland Hill Street, London, UK.
| |
Collapse
|