How to ventilate brain-injured patients in respiratory failure

  • P. Pelosi
  • P. Severgnini
  • M. Chiaranda
Conference paper


It is common knowledge that in brain-injured patients the principal morbidity and mortality are most frequently caused by the primary disease, i.e. cerebral nervous system injury and its neurological consequences [1]. Nevertheless, extracerebral organ dysfunctions are frequent in brain-injured patients, in creasing morbidity and mortality [2, 3]. Among them, the most frequent complication is respiratory dysfunction including pulmonary oedema and pneumonia. It is now clear that there is an entire spectrum of pulmonary abnormalities caused either directly or indirectly by acute brain injury. Although respiratory problems seem to play a relevant role in the clinical management of brain-injured patients, very few studies have investigated respiratory function abnormalities in this category of patients [4].


Acute Lung Injury Cerebral Perfusion Pressure Respir Crit Severe Traumatic Brain Injury Severe Head Injury 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Kassell NF, Torner JC, Haley EC et al (1990) The international cooperative study on the timing of aneurysm surgery. 1, 2. Overall management results. J Neurosurg 73:18–47PubMedCrossRefGoogle Scholar
  2. 2.
    Solenski N, Haley C, Kassell NF et al (1995) Medical complications of aneurysmal subarachnoid hemorrhage: a report of the multicenter, cooperative aneurysm study. Crit Care Med 23:1007–1017PubMedCrossRefGoogle Scholar
  3. 3.
    Clifton GC, Miller ER, Choi SC et al (2000) Lack of effect of induction of hypothermia after acute brain injury. N Engl J Med 344:556–563CrossRefGoogle Scholar
  4. 4.
    Demling R, Riessen R (1990) Pulmonary dysfunction after cerebral injury. Crit Care Med 18:768–774PubMedCrossRefGoogle Scholar
  5. 5.
    Gruber A, Reinprecht A, Illievich UM et al (1999) Extracerebral organ dysfunction and neurologic outcome after aneurysmal subarachnoid hemorrhage. Crit Care Med 27:505–514PubMedCrossRefGoogle Scholar
  6. 6.
    Holland MC, Mackersie RC, Morabito D et al (2003) The development of acute lung injury is associated with worse neurologic outcome in patients with severe traumatic brain injury. J Trauma 55:106–111PubMedGoogle Scholar
  7. 7.
    Simmons RL, Martin AM, Heisterkamp CA et al (1969) Respiratory insufficiency in combat casualties. Pulmonary edema following head injury. Ann Surg 170:39–44PubMedCrossRefGoogle Scholar
  8. 8.
    Schumaker P, Rhodes G, Newell J et al (1979) Ventilation perfusion imbalance after head injury. Am Rev Respir Dis 119:33–43Google Scholar
  9. 9.
    North J, Jennett S (1974) Abnormal breathing patterns associated with acute brain damage. Arch Neurol 31:338–344PubMedGoogle Scholar
  10. 10.
    Holmin S, Schalling M, Hojeberg B et al (1997) Delayed cytokines expression in rat brain following experimental contusion. J Neurosurg 86:493–504PubMedGoogle Scholar
  11. 11.
    Mathiesen T, Anderson B, Loftenius A et al (1993) Increased interleukin-6 levels in cerebrospinal fluid following subarachnoid hemorrhage. J Neurosurg 78:562–567PubMedGoogle Scholar
  12. 12.
    Aguilar JL, Villagrà A, Bernabè F et al (2005) Massive brain injury enhances lung damage in an isolated lung model of ventilator induced lung injury. Crit Care Med 33:1077–1083CrossRefGoogle Scholar
  13. 13.
    Fries M, Bickenbach J, Henzler D et al (2005) S-100 Protein and neurohyshopathologic changes in a porcine model of acute lung injury. Anesthesiology 102:761–767PubMedCrossRefGoogle Scholar
  14. 14.
    Woolf PD, Hamill RW, Lee LA et al (1987) The predictive value of catecholamines in assessing outcome in traumatic brain injury. J Neurosurg 66:875–882PubMedCrossRefGoogle Scholar
  15. 15.
    Sirvent JM, Torres A, Vidaur L et al (2000) Tracheal colonisation within 24 hrs of intubation in patients with head trauma: risk factor for developing early onset ventilator associated pneumonia. Intensive Care Med 26:1369–1372PubMedCrossRefGoogle Scholar
  16. 16.
    Ewig S, Torres A, El-Ebiary M et al (1999) Bacterial colonization pattern in mechanically ventilated patients with traumatic and medical head injury. Incidence, risk factors, and association with ventilator associated pneumonia. Am J Respir Crit Care Med 159:188–198PubMedGoogle Scholar
  17. 17.
    Dreyfuss D, Saumon G (1998) Ventilator-induced lung injury: lessons from experimental studies. Am J Respir Crit Care Med 157:294–323PubMedGoogle Scholar
  18. 18.
    Tremblay LN, Slutsky AS (1998) Ventilation-induced lung injury: from barotrauma to biotrauma. Proc Assoc Am Physicians 110:482–488PubMedGoogle Scholar
  19. 19.
    The Acute Respiratory Distress Syndrome Network (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 342:1301–1308CrossRefGoogle Scholar
  20. 20.
    Jeevaratnam DR, Menon DK (1996) Survey of intensive care of severely head injured patients in the United Kingdom. BMJ 312:944–947PubMedGoogle Scholar
  21. 21.
    Stocchetti N, Maas AI, Chieregato A, van der Plas AA (2005) Hyperventilation in head injury: a review. Chest 127:1812–1827PubMedCrossRefGoogle Scholar
  22. 22.
    Coles JP, Minhas PS, Fryer TD et al (2002) Effect of hyperventilation on cerebral blood flow in traumatic head injury: clinical relevance and monitoring correlates. Crit Care Med 30:1950–1959PubMedCrossRefGoogle Scholar
  23. 23.
    Imberti R, Bellinzona G, Langer M (2002) Cerebral tissue PO2 and SjvO2 changes during moderate hyperventilation in patients with severe traumatic brain injury. J Neurosurg 96:97–102PubMedCrossRefGoogle Scholar
  24. 24.
    Letarte PB, Puccio AM, Brown SD, Marion DW (1999) Effect of hypocapnea on CBF and extracellular intermediates of secondary brain injury. Acta Neurochir Suppl 75:45–47PubMedGoogle Scholar
  25. 25.
    Diringer MN, Videen TO, Yundt K et al (2002) Regional cerebrovascular and metabolic effects of hyperventilation after severe traumatic brain injury. J Neurosurg 96:103–108PubMedGoogle Scholar
  26. 26.
    The Brain Trauma Foundation, The American Association of Neurological Surgeons, The Joint Section on Neurotrauma and Critical Care (2000) Critical pathway for the treatment of established intracranial hypertension. J Neurotrauma 17:537–538CrossRefGoogle Scholar
  27. 27.
    Roberts I (2005) Hyperventilation therapy for acute traumatic brain injury. Cochrane Database Syst Rev 3:123–135Google Scholar
  28. 28.
    Reinert M, Barth A, Rothen HU et al (2003) Effects of cerebral perfusion pressure and increased fraction of inspired oxygen on brain tissue oxygen, lactate and glucose in patients with severe head injury. Acta Neurochir (Wien) 145:341–349Google Scholar
  29. 29.
    Magnoni S, Ghisoni L, Locatelli M et al (2003) Lack of improvement in cerebral metabolism after hyperoxia in severe head injury: a microdialysis study. J Neurosurg 98:952–958PubMedGoogle Scholar
  30. 30.
    Andrews PJ (2005) Pressure, flow and Occam’s razor: a matter of’ steal’? Intensive Care Med 31:323–324PubMedCrossRefGoogle Scholar
  31. 31.
    Huynh T, Messer M, Sing RF et al (2002) Positive end-expiratory pressure alters intracranial and cerebral perfusion pressure in severe traumatic brain injury. J Trauma 53:488–492PubMedGoogle Scholar
  32. 32.
    Caricato A, Conti G, Della Corte F et al (2005) Effects of PEEP on the intracranial system of patients with head injury and subarachnoid hemorrhage: the role of respiratory system compliance. J Trauma 58:571–576PubMedGoogle Scholar
  33. 33.
    Mascia L, Grasso S, Fiore T et al (2005) Cerebro-pulmonary interactions during the application of low levels of positive end-expiratory pressure. Intensive Care Med 31:373–379PubMedCrossRefGoogle Scholar
  34. 34.
    Wolf S, Shurer L, Trost HA, Lumenta CB (2002) The safety of open lung approach in neurosurgical patients. Acta Neurochir Suppl 81:99–101PubMedGoogle Scholar
  35. 35.
    Pelosi P, Brazzi L, Gattinoni L (2002) Prone position in acute respiratory distress syndrome. Eur Respir J 20:1017–1028PubMedCrossRefGoogle Scholar
  36. 36.
    Beuret P, Carton MJ, Nourdine K et al (2004) Prone position as prevention of lung injury in comatose patients: a prospective, randomised, controlled trial. Intensive Care Med 28:564–569CrossRefGoogle Scholar
  37. 37.
    Voggenreiter G, Neudeck F, Aufmkolk M et al (1999) Intermittent prone positioning in the treatment of severe and moderate post traumatic lung injury. Crit Care Med 27:2375–2382PubMedCrossRefGoogle Scholar
  38. 38.
    Reinprecht A, Greber H, Wolfsberger S et al (2003) Prone position in subarachnoid hemorrhage patients with acute respiratory distress syndrome: effects on cerebral tissue oxygenation and ICP. Crit Care Med 31:1831–1838PubMedCrossRefGoogle Scholar
  39. 39.
    Bein T, Kuhr LP, Bele S et al (2002) Lung recruitment manoeuvre in patients with cerebral injury: effects on intracranial pressure and cerebral metabolism. Intensive Care Med 28:554–558PubMedCrossRefGoogle Scholar
  40. 40.
    Diringer MN (2003) Subarachnoid haemorrhage: a multiple organ system disease. Crit Care Med 31:1884–1885PubMedCrossRefGoogle Scholar
  41. 41.
    York J, Arrillaga A, Graham R et al (2000) Fluid resuscitation of patients with multiple injuries and severe closed head injury: experience with an aggressive fluid resuscitation strategy. J Trauma 48:376–380PubMedGoogle Scholar
  42. 42.
    Contant CF, Valadka AB, Gopinath SP et al (2001) Adult respiratory distress syndrome: a complication of induced hypertension after severe head injury. J Neurosurg 95:560–568PubMedGoogle Scholar
  43. 43.
    Rocco PR, Souza AB, Faffe DS et al (2003) Effect of corticosteroid on lung parenchyma remodelling at an early phase of acute lung injury. Am J Respir Crit Care Med 168:677–684PubMedCrossRefGoogle Scholar
  44. 44.
    Asgeirsson B, Grande PO, Nordstrom CH et al (1995) Effects of hypotensive treatment with α2 agonist and β1 antagonist on cerebral hemodynamic in severely injured patients. Acta Anaesthesiol Scand 39:347–351PubMedCrossRefGoogle Scholar
  45. 45.
    Sirvent JM, Torres A, El-Ebiabry M et al (1997) Protective effect of intravenously administered cefuroxime again nosocomial pneumonia in patients with structural coma. Am J Respir Crit Care Med 155:1729–1734PubMedGoogle Scholar
  46. 46.
    Korinek AM, Laisne MJ, Nicolas MH et al (1993) Selective decontamination of the digestive tract in neurosurgical intensive care patients: a double blind, randomised placebo controlled trial. Crit Care Med 21:1466–1473PubMedCrossRefGoogle Scholar
  47. 47.
    Leone M, Bougoin A, Giuly E et al (2002) Influence on outcome of ventilator associated pneumonia in multiple trauma patients with head trauma treated with selected digestive decontamination. Crit Care Med 30:1741–1746PubMedCrossRefGoogle Scholar
  48. 48.
    Drakulovic MB, Torres A, Bauer TT et al (1999) Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomized trial. Lancet 354:1851–1858PubMedCrossRefGoogle Scholar
  49. 49.
    Shorr AF, O’Malley PG (2001) Continuous subglottic suctioning for the prevention of ventilator associated pneumonia: potential economic implications. Chest 119:228–235PubMedCrossRefGoogle Scholar
  50. 50.
    Kamada T, Fusamoto H, Kawano S et al (1977) Gastrointestinal bleeding following head injury: a clinical study of 433 cases. J Trauma 17:44–47PubMedGoogle Scholar
  51. 51.
    Taylor SJ, Fettes SB, Jewkes C et al (1999) Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition clinical outcome in mechanically ventilated patients suffering head injury. Crit Care Med 27:2525–2531PubMedCrossRefGoogle Scholar
  52. 52.
    Rapp RP, Young B, Twyman D et al (1983) The favourable effect of early parenteral feeding on survival in head injured patients. J Neurosurg 58:906–912PubMedGoogle Scholar
  53. 53.
    Bischoff WE, Reynolds TM, Sessler CN et al (2000) Hand-washing compliance by health care workers: the impact of introducing an accessible, alcohol-based hand antiseptic. Arch Intern Med 160:1017–1021PubMedCrossRefGoogle Scholar
  54. 54.
    Rumbak MJ, Newton M, Truncale T et al (2004) A prospective randomised study comparing early percutaneous dilational tracheostomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med 32:1689–1694PubMedCrossRefGoogle Scholar
  55. 55.
    Arabi Y, Haddad S, Shirawi N, Al Shimemeri A (2004) Early tracheostomy timing and duration of weaning in patients with respiratory failure. Crit Care 8:R347–R352PubMedCrossRefGoogle Scholar
  56. 56.
    Pelosi P, Severgnini P (2004) Tracheostomy must be individualized! Crit Care 8:322–324PubMedCrossRefGoogle Scholar
  57. 57.
    Coplin WM, Pierson DJ, Cooley KD et al (2000) Implications of extubation delay in brain injured patients meeting standard weaning criteria. Am J Respir Crit Care Med 161:1530–1536PubMedGoogle Scholar
  58. 58.
    Namen AH, Ely EW, Tatter SB et al (2001) Predictors of successful extubation in neurosurgical patients. Am J Respir Crit Care Med 163:658–664PubMedGoogle Scholar
  59. 59.
    Kress JP, Pohlman AS, O’Connor MF, Hall JB (2000) Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 342:1471–1477PubMedCrossRefGoogle Scholar
  60. 60.
    Lowe GJ, Ferguson ND (2006) Lung protective ventilation in neurosurgical patients. Curr Opin Crit Care Med 12:3–7CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2007

Authors and Affiliations

  • P. Pelosi
    • 1
  • P. Severgnini
    • 1
  • M. Chiaranda
    • 1
  1. 1.Department for the Environment, Health and SafetyUniversity of Insubria — Anaesthesia and Intensive Care Unit B, District Hospital and Macchi FoundationVareseItaly

Personalised recommendations