Respiratory support in severe traumatic brain injury (literature review)

D.A. Krishtafor; O.M.  Klygunenko; O.V.  Kravets; V.V.  Yekhalov; A.A.  Krishtafor

doi:10.26641/2307-0404.2022.2.260065

Authors

D.A. Krishtafor Dnipro State Medical University, V. Vernadskyi str., 9, Dnipro, 49044, Ukraine https://orcid.org/0000-0003-0942-4099
O.M. Klygunenko Dnipro State Medical University, V. Vernadskyi str., 9, Dnipro, 49044, Ukraine https://orcid.org/0000-0001-8470-4790
O.V. Kravets Dnipro State Medical University, V. Vernadskyi str., 9, Dnipro, 49044, Ukraine https://orcid.org/0000-0003-1340-3290
V.V. Yekhalov Dnipro State Medical University, V. Vernadskyi str., 9, Dnipro, 49044, Ukraine https://orcid.org/0000-0001-5373-3820
A.A. Krishtafor Dnipro State Medical University, V. Vernadskyi str., 9, Dnipro, 49044, Ukraine https://orcid.org/0000-0002-1717-4889

DOI:

https://doi.org/10.26641/2307-0404.2022.2.260065

Keywords:

respiratory support, traumatic brain injury, mechanical ventilation, ventilator weaning, arterial blood gas

Abstract

Patients with traumatic brain injury (TBI) are the largest group of victims at the emergency departments. Up to 20% of patients with severe TBI require endotracheal intubation and prolonged mechanical ventilation. The ventilation parameters choice should be focused on the normal arterial blood gas composition. Hypoxia causes secondary damage to the brain tissue, and hyperoxia carries risks of oxygen toxicity. Hypercapnia leads to cerebral vasodilatation, increased intracranial pressure (ICP) and the risk of cerebral edema. Hypocapnia promotes cerebral vasoconstriction, which reduces cerebral blood flow and ICP, but also leads to cerebral tissue ischemia, so prolonged hyperventilation in TBI is not currently recommended. Patients with TBI often require sedation to synchronize with the respirator. The drugs of choice are propofol and midazolam. Routine use of muscle relaxants is not recommended. The initial ventilation mode should provide a certain respiration rate to achieve normocapnia, while allowing the patient to make breathing attempts. Support ventilation modes are used while weaning from mechanical ventilation. Promising in predicting extubation success is the assessment of the VISAGE score, which includes visual pursuit, swallowing, age, and the Glasgow coma score. Modern principles of respiratory support in severe TBI include: tracheal intubation by Glasgow coma score ≤8 ; early mechanical ventilation; PaO₂ 80-120 mm Hg (SaO₂ ≥95%); PaCO₂ 35-45 mm Hg; tidal volume ≤8 ml/kg; respiratory rate ≈20/min; PEEP ≥5 cm H₂O; head elevation by 30°; sedation in poor synchronization with the respirator; weaning through support ventilation modes; extubation when reaching 3 points on the VISAGE scale; early (up to 4 days) tracheotomy in predicted extubation failure.

References

Dubrov SO, Oros MM, Horanskyi YuI. [Ischemic and traumatic brain injuries: from neuroprotection to neurorepair]. Zdorovia Ukrainy. Nevrolohiia. Psykhiatriia. Psykhoterapiia. 2019;4:14-15. Ukrainian.

Dubrov SO, Suslov HH, Bylina VM, et al. [Inten-sive care for patients with traumatic brain injury: is it possible to improve treatment outcomes?] Medytsyna nevidkladnykh staniv. 2016;3(74):51-57. Ukrainian.

Dubrov SO. [Treatment of traumatic brain injury: the main goal is to save the brain]. Zdorovia Ukrainy. Khirurhiia, Ortopediia, Travmatolohiia, Intensyvna Te-rapiia. 2021;1(44):27. Ukrainian.

Alhazzani W, Belley-Cote E, Møller MH, et al. Neuromuscular blockade in patients with ARDS: a rapid practice guideline. Intensive Care Med. 2020;46(11):1977-86. doi: https://doi.org/10.1007/s00134-020-06227-8

American College of Surgeons Committee on Trauma. Advanced trauma life support: student course manual (10th ed). Illinois: American College of Surgeons; 2016. p. 474.

Apostolakis E, Papakonstantinou NA, Baikous-sis NG, et al. Intensive care unit-related generalized neuromuscular weakness due to critical illness poly-neuropathy/myopathy in critically ill patients. J Anesth. 2015;29:112-21.

doi: https://doi.org/10.1007/s00540-014-1875-x

Asehnoune K, Mrozek S, Perrigault PF, et al. A Multi-Faceted Strategy to Reduce Ventilation-Associated Mortality in Brain-Injured Patients. The BI-VILI Project: A Nationwide Quality Improvement Project. Intensive Care Med. 2017;43(7):957-70. doi: https://doi.org/10.1007/s00134-017-4764-6

Asehnoune K, Roquilly A, Cinotti R. Respiratory Management in Patients with Severe Brain Injury. Crit Care. 2018;22:76.

doi: https://doi.org/10.1186/s13054-018-1994-0

Asehnoune K, Seguin P, Lasocki S, et al. Extu-bation Success Prediction in a Multicentric Cohort of Patients with Severe Brain Injury. Critical Care Medicine. 2017;127:338-46. doi: https://doi.org/10.1097/ALN.0000000000001725

Bein T, Grasso S, Moerer O, et al. The standard of care of patients with ARDS: ventilatory settings and rescue therapies for refractory hypoxemia. Intensive Care Med. 2016;42(5):699-711.

doi: https://doi.org/10.1007/s00134-016-4325-4

Brain Trauma Foundation. Guidelines for the Ma¬nagement of Severe Traumatic Brain Injury (4th Edition). Neurosurgery. 2017;80(1):6-15. doi: https://doi.org/10.1227/NEU.0000000000001432

Bruni A, Garofalo E, Pelaia C, et al. Mechanical ventilation in brain injured patients: seeing the forest for the trees. J Thorac Dis. 2017;9(10):3483-7. doi: http://dx.doi.org/10.21037/jtd.2017.08.150

Cinotti R, Bouras M, Roquilly A, Asehnoune K. Management and weaning from mechanical ventilation in neurologic patients. Ann Transl Med. 2018;6(19):381. doi: https://doi.org/10.21037/atm.2018.08.16

Cinotti R, Dordonnat-Moynard A, Feuillet F, et al. Risk factors and pathogens involved in early ventilator-ac¬quired pneumonia in patients with severe subarachnoid he¬morrhage. Eur J Clin Microbiol Infect Dis. 2014;33(5):823-30. doi: https://doi.org/10.1007/s10096-013-2020-8

Della Torre V, Badenes R, Corradi F, et al. Acute respiratory distress syndrome in traumatic brain injury: how do we manage it? J Thorac Dis. 2017;9(12):5368-81. doi: https://doi.org/10.21037/jtd.2017.11.03

Fan E, Del Sorbo L, Goligher EC, et al. An Of¬ficial American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2017;195(9):1253-63. doi: https://doi.org/10.1164/rccm.201703-0548ST

Garg SK. Permissive hypercapnia: Is there any upper limit? Indian J Crit Care Med. 2014;18(9):612-4. doi: https://doi.org/10.4103/0972-5229.140154

Godet T, Chabanne R, Marin J, et al. Extubation Failure in Brain-injured Patients: Risk Factors and Development of a Prediction Score in a Preliminary Prospective Cohort Study. Anesthesiology. 2017;126:104-14. doi: https://doi.org/10.1097/ALN.0000000000001379

Godoy DA, Seifi A, David Garza D, et al. Hyperventilation Therapy for Control of Posttraumatic Intracranial Hypertension. Front Neurol. 2017;8:250. doi: https://doi.org/10.3389/fneur.2017.00251

Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159-68. doi: https://doi.org/10.1056/NEJMoa1214103

Helmerhorst HJ, Roos-Blom MJ, van Wes-terloo DJ, et al. Association Between Arterial Hyperoxia and Outcome in Subsets of Critical Illness: A Systematic Review, Meta-Analysis, and Meta-Regres¬sion of Cohort Studies. Crit Care Med. 2015;43:1508-19. doi: https://doi.org/10.1097/CCM.0000000000000998

Hyde GA, Savage SA, Zarzaur BL, et al. Early tra¬cheostomy in trauma patients saves time and money. Injury. 2015;46(1):110-14. doi: https://doi.org/10.1016/j.injury.2014.08.049

Koutsoukou A, Katsiari M, Orfanos SE, et al. Res-piratory mechanics in brain injury: A review. World J Crit Care Med. 2016;5:65-73. doi: https://doi.org/10.5492/wjccm.v5.i1.65

Liu S, Wan X, Wang S, et al. Posttraumatic cere-bral infarction in severe traumatic brain injury: charac-teristics, risk factors and potential mechanisms. Acta Neurochir (Wien). 2015;157(10):1697-704. doi: https://doi.org/10.1007/s00701-015-2559-5

Luo XY, He X, Zhou YM, et al. Patient-ventilator asynchrony in acute brain-injured patients: a prospective observational study. Ann. Intensive Care. 2020;10:144. doi: https://doi.org/10.1186/s13613-020-00763-8

Madan A. Correlation between the levels of SpO2 and PaO2. Lung India. 2017;34(3):307-8. doi: https://doi.org/10.4103/lungindia.lungindia_106_17

Ni YN, Wang YM, Liang BM, Liang ZA. The effect of hyperoxia on mortality in critically ill patients: a systematic review and meta analysis. BMC Pulm Med. 2019;19(1):53.

doi: https://doi.org/10.1186/s12890-019-0810-1

Oddo M, Citerio G. ARDS in the brain-injured pa-tient: what's different? Intensive Care Med. 2016;42(5):790-3. doi: https://doi.org/10.1007/s00134-016-4298-3

Oddo M, Crippa IA, Mehta S, et al. Optimizing sedation in patients with acute brain injury. Crit Care. 2016;20(1):128.

doi: https://doi.org/10.1186/s13054-016-1294-5

Price DR, Mikkelsen ME, Umscheid CA, Arm-strong EJ. Neuromuscular Blocking Agents and Neuro-muscular Dysfunction Acquired in Critical Illness: A Systematic Review and Meta-Analysis. Crit Care Med. 2016;44(11):2070-2078. doi: https://doi.org/10.1097/CCM.0000000000001839

Rajajee V, Riggs B, Seder DB. Emergency Neuro-logical Life Support: Airway, Ventilation, and Sedation. Neurocrit Care. 2017;27(Suppl 1):4-28. doi: https://doi.org/10.1007/s12028-017-0451-2

Robba C, Poole D, McNett M. et al. Mechanical ventilation in patients with acute brain injury: recom-mendations of the European Society of Intensive Care Medi¬cine consensus. Intensive Care Med. 2020;46(12):2397-410. doi: https://doi.org/10.1007/s00134-020-06283-0

Sanfilippo F, Santonocito C, Veenith T, et al. The Role of Neuromuscular Blockade in Patients with Trau-matic Brain Injury: A Systematic Review. Maybauer Neurocrit Care. 2015;22:325-334. doi: https://doi.org/10.1007/s12028-014-0061-1

Torbic H, Duggal A. Neuromuscular blocking agents for acute respiratory distress syndrome. J Crit Care. 2019;49:179-84. doi: https://doi.org/10.1016/j.jcrc.2018.10.019

Vincent JL, Taccone FS, He X. Harmful Effects of Hyperoxia in Postcardiac Arrest, Sepsis, Traumatic Brain Injury, or Stroke: The Importance of Individualized Oxy¬gen Therapy in Critically Ill Patients. Can Respir J. 2017;2017. doi: https://doi.org/10.1155/2017/2834956

Young D, Harrison DA, Cuthbertson BH, et al. Ef-fect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA. 2013;309(20):2121-9. doi: https://doi.org/10.1001/jama.2013.5154