Intensive Care Medicine

, Volume 31, Issue 3, pp 373–379 | Cite as

Cerebro-pulmonary interactions during the application of low levels of positive end-expiratory pressure

  • Luciana MasciaEmail author
  • Salvatore Grasso
  • Tommaso Fiore
  • Francesco Bruno
  • Maurizio Berardino
  • Alessandro Ducati



In patients with severe brain injury and acute lung injury the use of positive end-expiratory pressure (PEEP) is limited by conflicting results on its effect on intracranial pressure. We hypothesised that the occurrence of alveolar hyperinflation during the application of PEEP would lead to an increase in PaCO2 responsible for a rise in intracranial pressure.


Prospective interventional study.


Intensive Care Unit of University Hospitals.

Patients and participants

Twelve severely brain-injured patients with acute lung injury and intracranial pressure higher than applied PEEP.


5 and 10 cmH2O of PEEP was randomly applied.

Measurements and results

In all patients intracranial pressure, flow velocity by transcranial Doppler of middle cerebral artery, and jugular oxygen saturation were recorded. Static volume-pressure curves of the respiratory system were obtained, recruited volume and elastance calculated to classify patients as recruiters and non-recruiters. In recruiters (= 6 patients), elastance decreased (P<0.01) and PaO2 increased (P<0.005), while in non-recruiters (= 6 patients) elastance and PaCO2 significantly increased (P<0.001). Intracranial pressure, Doppler flow velocity, and jugular saturation remained constant in recruiters but significantly increased (P<0.0001) in non-recruiters. A significant correlation was found between changes in intracranial pressure and elastance (r2 = 0.8 P<0.0001) and between changes in PaCO2 and intracranial pressure (P<0.001, r2 = 0.4) and elastance (P<0.001, r2 = 0.4), respectively.


When PEEP induced alveolar hyperinflation leading to a significant increase in PaCO2, intracranial pressure significantly increased, whereas when PEEP caused alveolar recruitment intracranial pressure did not change.


Brain injury Acute lung injury Positive end-expiratory pressure Intracranial pressure 


  1. 1.
    Contant CF, Valadka AB, Gopinath SP, Hannay HJ, Robertson CS (2001) Adult respiratory distress syndrome: a complication of induced hypertension after severe head injury. J Neurosurg 95:560–568Google Scholar
  2. 2.
    Gruber A, Reinprecht AU, Illievich M, Fitzgerald R, Dietrich W, Czech T, Richling B (1999) Extracerebral organ dysfunction and neurologic outcome after aneurysmal subarachnoid hemorrhage. Crit Care Med 27:505–514Google Scholar
  3. 3.
    Bratton SL, Davis RL (1997) Acute lung injury in isolated traumatic brain injury. Crit Care Med 40:707–712Google Scholar
  4. 4.
    Holland MC, Mackersie RC, Morabito D, Campbell AR, Kivett VA, Patel R, Erickson VR, Pittet JF (2003) The development of acute lung injury is associated with worse neurologic outcome in patients with severe traumatic brain injury. J Trauma 55:106–111Google Scholar
  5. 5.
    Ranieri VM, Eissa NT, Corbeil C, Chasse M, Braidy J, Matar N, Milic-Emili J (1991) Effects of positive end-expiratory pressure on alveolar recruitment and gas exchange in patients with the adult respiratory distress syndrome. Am Rev Respir Dis 544–551Google Scholar
  6. 6.
    Miller JD, Sweet RC, Narayan R, Becker DP (1978) Early insults to the injured brain. JAMA 240:439–442Google Scholar
  7. 7.
    Cooper KR, Boswell PA, Choi SC (1985) Safe use of PEEP in patients with severe head injury. J Neurosurg 63:552–555Google Scholar
  8. 8.
    Doblar DD, Santiago TV, Kahn AU, Edelman NH (1981) The effect of positive end-expiratory pressure ventilation (PEEP) on cerebral blood flow and cerebrospinal fluid pressure in goats. Anesthesiology 55:244–250Google Scholar
  9. 9.
    Feldman Z, Robertson CS, Contant CF, Gopinath SP, Grossman RG (1997) Positive end-expiratory pressure reduces intracranial compliance in the rabbit. J Neurosurg Anesthesiol 9:175–179Google Scholar
  10. 10.
    Burchiel KJ, Steege TD, Wyler AR (1981) Intracranial pressure changes in brain-injured patients requiring positive end-expiratory pressure ventilation. Neurosurgery 8:443–449Google Scholar
  11. 11.
    Shapiro HM, Marshall LF (1978) Intracranial pressure responses to PEEP in head-injured patients. J Trauma 18:254–256PubMedGoogle Scholar
  12. 12.
    Frost EA (1977) Effects of positive end-expiratory pressure on intracranial pressure and compliance in brain-injured patients. J Neurosurg 47:195–200Google Scholar
  13. 13.
    Aidinis SJ, Lafferty J, Shapiro HM (1976) Intracranial responses to PEEP. Anesthesiology 45:275–286Google Scholar
  14. 14.
    Huseby JS, Luce JM, Cary JM, Pavlin EG, Butler J (1981) Effects of positive end-expiratory pressure on intracranial pressure in dogs with intracranial hypertension. J Neurosurg 55:704–705Google Scholar
  15. 15.
    Huseby JS, Pavlin EG, Butler J (1978) Effect of positive end-expiratory pressure on intracranial pressure in dogs. J Appl Physiol 44:25–27Google Scholar
  16. 16.
    Apuzzo M, Weiss M, Petersons V, Small B, Kurze T, Heiden J (1977) Effect of positive end-expiratory pressure on intracranial pressure in man. J Neurosurg 46:227–232Google Scholar
  17. 17.
    Georgiadis D, Schwarz S, Baumgartner RW, Veltkamp R, Schwab S (2001) Influence of positive end-expiratory pressure on intracranial pressure and cerebral perfusion pressure in patients with acute stroke. Stroke 32:2088–2092Google Scholar
  18. 18.
    McGuire G, Crossley D, Richards J, Wong D (1997) Effects of varying levels of positive end-expiratory pressure on intracranial pressure and cerebral perfusion pressure. Crit Care Med 25:1059–1062CrossRefPubMedGoogle Scholar
  19. 19.
    Luce JM, Huseby JS, Kirk W, Butler J (1982) A Starling resistor regulates cerebral venous outflow in dogs. J Appl Physiol 53:1496–1503Google Scholar
  20. 20.
    Blanch L, Fernandez R, Benito S, Mancebo J, Net A (1987) Effect of PEEP on the arterial minus end-tidal carbon dioxide gradient. Chest 92:451–454Google Scholar
  21. 21.
    Mascia L, Grasso S, Puntillo F, Majorano M, Cafarelli A, Bruno F, Fiore T, Ancona G, Brienza A, Ranieri VM (2000) The effects of PEEP on cerebral hemodynamics in severe brain injured patients with acute lung injury. Int Care Med S123Google Scholar
  22. 22.
    Teasdale G, Jennett B (1974) Assessment of coma and impaired consciousness. A practical scale. Lancet 13:81–84Google Scholar
  23. 23.
    Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, Lamy M, Legall JR, Morris A, Spragg R (1994) The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 149:818–824PubMedGoogle Scholar
  24. 24.
    Brain Trauma Foundation, American Association of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care (1996) Guidelines for the management of severe head injury. J Neurotrauma 13:641–734PubMedGoogle Scholar
  25. 25.
    Chan KH, Miller JD, Dearden NM, Andrews PJ, Midgley S (1992) The effect of changes in cerebral perfusion pressure upon middle cerebral artery blood flow velocity and jugular bulb venous oxygen saturation after severe brain injury. J Neurosurg 77:55–61Google Scholar
  26. 26.
    Gattinoni L, Vagginelli F, Carlesso E, Taccone P, Conte V, Chiumello D, Valenza F, Caironi P, Pesenti A, for the Prone-Supine Study Group (2004) Decrease in PaCO2 with prone position is predictive of improved outcome in acute respiratory distress syndrome. Crit Care Med 31:2727–2733Google Scholar
  27. 27.
    Pinsky M, Desmet JM, Vincent JL (1991) Effects of PEEP on right ventricular function in humans. Am Rev Respir Dis 143:25–31Google Scholar
  28. 28.
    Markwalder TM, Grolimund P, Seiler RW, Roth F, Aaslid R (1984) Dependency of blood flow velocity in the middle cerebral artery on end tidal carbon dioxide partial pressure—a transcranial ultrasound Doppler study. J Cereb Blood Flow Metab 4:368–372Google Scholar
  29. 29.
    Toung TJ, Aizawa H, Traystman RJ (2000) Effects of positive end-expiratory pressure ventilation on cerebral venous pressure with head elevation in dogs. J Appl Physiol 88:655–661Google Scholar
  30. 30.
    Rosner MJ, Rosner SD, Johnson AH (1995) Cerebral perfusion pressure: management protocol and clinical results. J Neurosurg 83:949–962PubMedGoogle Scholar
  31. 31.
    Robertson CS, Gopinath S, Goodman C, Contant CF, Valadka A, Narayan RK (1995) SjvO2 monitoring in head injured patients. J Neurotrauma 12:891–896Google Scholar
  32. 32.
    Buunk G, van der Hoeven JG, Meinders AE (1997) Cerebrovascular reactivity in comatose patients resuscitated from a cardiac arrest. Stroke 28:1569–1573Google Scholar
  33. 33.
    Permutt S, Riley RL (1963) Hemodynamics of collapsible vessels with tone: the vascular waterfall. J Appl Physiol Sep 18:924–932Google Scholar
  34. 34.
    Lodrini S, Montolivo M, Pluchino F, Borroni V (1989) Positive end-expiratory pressure in supine and sitting positions: its effects on intrathoracic and intracranial pressures. Neurosurgery 24:873–877Google Scholar
  35. 35.
    Moraine JJ, Berre J, Melot C (2000) Is cerebral perfusion pressure a major determinant of cerebral blood flow during head elevation in comatose patients with severe intracranial lesions? J Neurosurg 92:606–614Google Scholar
  36. 36.
    Feldman Z, Kanter MJ, Robertson CS, Contant CF, Hayes C, Sheinberg MA, Villareal C, Narayan R, Grossman R (1992) Effect of head elevation on intracranial pressure, cerebral perfusion pressure, and cerebral blood flow in head-injured patients. J Neurosurg 76:207–211Google Scholar
  37. 37.
    Epstein HM, Linde HW, Crampton AR, Ciric IS, Eckenhoff JE (1970) The vertebral venous plexus as a major cerebral venous outflow tract. Anesthesiology 32:332–338Google Scholar

Copyright information

© Springer-Verlag 2005

Authors and Affiliations

  • Luciana Mascia
    • 1
    Email author
  • Salvatore Grasso
    • 2
  • Tommaso Fiore
    • 3
  • Francesco Bruno
    • 3
  • Maurizio Berardino
    • 4
  • Alessandro Ducati
    • 5
  1. 1.Università di Torino, Dipartimento di Discipline Medico-Chirurgiche, Sezione di Anestesiologia e RianimazioneOspedale S. Giovanni BattistaTorinoItaly
  2. 2.Servizio di Anestesiologia e RianimazioneOspedale Di VenereBariItaly
  3. 3.Sezione di Anestesiologia e Rianimazione, Dipartimento di Emergenza e Trapianti d’Organo, Università di BariOspedale PoliclinicoBariItaly
  4. 4.Servizio di Neuroanestesia e RianimazioneOspedale S. Giovanni BattistaTorinoItaly
  5. 5.Sezione di Neurochirurgia, Dipartimento di Neuroscienze, Università di TorinoOspedale S. Giovanni BattistaTorinoItaly

Personalised recommendations