Intensive Care Medicine

, 34:1676 | Cite as

The use of hyperventilation therapy after traumatic brain injury in Europe: an analysis of the BrainIT database

  • J.-O. NeumannEmail author
  • I. R. Chambers
  • G. Citerio
  • P. Enblad
  • B. A. Gregson
  • T. Howells
  • J. Mattern
  • P. Nilsson
  • I. Piper
  • A. Ragauskas
  • J. Sahuquillo
  • Y. H. Yau
  • K. Kiening
  • on behalf of the BrainIT Group



To assess the use of hyperventilation and the adherence to Brain Trauma Foundation-Guidelines (BTF-G) after traumatic brain injury (TBI).


Twenty-two European centers are participating in the BrainIT initiative.


Retrospective analysis of monitoring data.

Patients and participants

One hundred and fifty-one patients with a known time of trauma and at least one recorded arterial blood–gas (ABG) analysis.

Measurements and results

A total number of 7,703 ABGs, representing 2,269 ventilation episodes (VE) were included in the analysis. Related minute-by-minute ICP data were taken from a 30 min time window around each ABG collection. Data are given as mean with standard deviation. (1) Patients without elevated intracranial pressure (ICP) (<20 mmHg) manifested a statistically significant higher PaCO2 (36 ± 5.7 mmHg) in comparison to patients with elevated ICP (≥20 mmHg; PaCO2: 34 ± 5.4 mmHg, P < 0.001). (2) Intensified forced hyperventilation (PaCO2 ≤ 25 mmHg) in the absence of elevated ICP was found in only 49 VE (2%). (3) Early prophylactic hyperventilation (<24 h after TBI; PaCO2 ≤ 35 mmHg, ICP < 20 mmHg) was used in 1,224 VE (54%). (4) During forced hyperventilation (PaCO2 ≤ 30 mmHg), simultaneous monitoring of brain tissue pO2 or SjvO2 was used in only 204 VE (9%).


While overall adherence to current BTF-G seems to be the rule, its recommendations on early prophylactic hyperventilation as well as the use of additional cerebral oxygenation monitoring during forced hyperventilation are not followed in this sample of European TBI centers.




Traumatic brain injury Hyperventilation 



We would like to thank all the staff of the BrainIT centers for the time and help in collecting the data. This work was supported by European Community, Frame Work Five Programme, Quality of Life and Management of Living Resources—brain-monitoring with information technology; an open, internet based trans-national collaborative infrastructure for supporting assessment of health care technologies in brain-injured patients, developing and testing an improved coordination structure/grant no. QLRT-2001-01160.


  1. 1.
    Heffner JE, Sahn SA (1983) Controlled hyperventilation in patients with intracranial hypertension. Application and management. Arch Intern Med 143:765–769PubMedCrossRefGoogle Scholar
  2. 2.
    Stringer WA, Hasso AN, Thompson JR, Hinshaw DB, Jordan KG (1993) Hyperventilation-induced cerebral ischemia in patients with acute brain lesions: demonstration by xenon-enhanced CT. AJNR Am J Neuroradiol 14:475–484PubMedGoogle Scholar
  3. 3.
    Lundberg N, Kjallquist A, Bien C (1959) Reduction of increased intracranial pressure by hyperventilation. A therapeutic aid in neurological surgery. Acta Psychiatr Scand 34:1–64CrossRefGoogle Scholar
  4. 4.
    Oertel M, Kelly DF, Lee JH, Glenn TC, Vespa PM, Martin NA (2002) Can hyperventilation improve cerebral microcirculation in patients with high ICP? Acta Neurochir Suppl 81:71–72PubMedGoogle Scholar
  5. 5.
    Oertel M, Kelly DF, Lee JH, McArthur DL, Glenn TC, Vespa P, Boscardin WJ, Hovda DA, Martin NA (2002) Efficacy of hyperventilation, blood pressure elevation, and metabolic suppression therapy in controlling intracranial pressure after head injury. J Neurosurg 97:1045–1053PubMedGoogle Scholar
  6. 6.
    Muizelaar JP, Marmarou A, Ward JD, Kontos HA, Choi SC, Becker DP, Gruemer H, Young HF (1991) Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial. J Neurosurg 75:731–739PubMedGoogle Scholar
  7. 7.
    Marion DW, Puccio A, Wisniewski SR, Kochanek P, Dixon CE, Bullian L, Carlier P (2002) Effect of hyperventilation on extracellular concentrations of glutamate, lactate, pyruvate, and local cerebral blood flow in patients with severe traumatic brain injury. Crit Care Med 30:2619–2625PubMedCrossRefGoogle Scholar
  8. 8.
    Coles JP, Fryer TD, Coleman MR, Smielewski P, Gupta AK, Minhas PS, Aigbirhio F, Chatfield DA, Williams GB, Boniface S, Carpenter TA, Clark JC, Pickard JD, Menon DK (2007) Hyperventilation following head injury: effect on ischemic burden and cerebral oxidative metabolism. Crit Care Med 35:568–578PubMedCrossRefGoogle Scholar
  9. 9.
    Coles JP, Minhas PS, Fryer TD, Smielewski P, Aigbirihio F, Donovan T, Downey SP, Williams G, Chatfield D, Matthews JC, Gupta AK, Carpenter TA, Clark JC, Pickard JD, Menon DK (2002) Effect of hyperventilation on cerebral blood flow in traumatic head injury: clinical relevance and monitoring correlates. Crit Care Med 30:1950–1959PubMedCrossRefGoogle Scholar
  10. 10.
    Manley GT, Hemphill JC, Morabito D, Derugin N, Erickson V, Pitts LH, Knudson MM (2000) Cerebral oxygenation during hemorrhagic shock: perils of hyperventilation and the therapeutic potential of hypoventilation. J Trauma 48:1025–1032PubMedGoogle Scholar
  11. 11.
    Clausen T, Scharf A, Menzel M, Soukup J, Holz C, Rieger A, Hanisch F, Brath E, Nemeth N, Miko I, Vajkoczy P, Radke J, Henze D (2004) Influence of moderate and profound hyperventilation on cerebral blood flow, oxygenation and metabolism. Brain Res 1019:113–123PubMedCrossRefGoogle Scholar
  12. 12.
    Bullock MR, Chesnut RM, Clifton GL, Ghajar J, Marion DW, Narayan RK, Newell DW, Pitts LH, Rosner MJ, Walters BC, Wilberger JE (2000) Management and prognosis of severe traumatic brain injury. Part I: guidelines for the management of severe traumatic brain injury. J Neurotrauma 17:513–520Google Scholar
  13. 13.
    Bouma GJ, Muizelaar JP, Choi SC, Newlon PG, Young HF (1991) Cerebral circulation and metabolism after severe traumatic brain injury: the elusive role of ischemia. J Neurosurg 75:685–693PubMedGoogle Scholar
  14. 14.
    Bullock MR, Povlishock JT (2007) Guidelines for the management of severe traumatic brain injury. J Neurotrauma 24(Suppl 1):S87–S90Google Scholar
  15. 15.
    Piper I, Citerio G, Chambers I, Contant C, Enblad P, Fiddes H, Howells T, Kiening K, Nilsson P, Yau YH (2003) The BrainIT group: concept and core dataset definition. Acta Neurochir (Wien) 145:615–628CrossRefGoogle Scholar
  16. 16.
    Chambers IR, Barnes J, Piper I, Citerio G, Enblad P, Howells T, Kiening K, Matterns J, Nilsson P, Ragauskas A, Sahuquillo J, Yau YH (2006) BrainIT: a trans-national head injury monitoring research network. Acta Neurochir Suppl 96:7–10PubMedCrossRefGoogle Scholar
  17. 17.
    Barnes J, Chambers I, Piper I, Citerio G, Contant C, Enblad P, Fiddes H, Howells T, Kiening K, Nilsson P, Yau YH (2005) Accurate data collection for head injury monitoring studies: a data validation methodology. Acta Neurochir Suppl 95:39–41PubMedCrossRefGoogle Scholar
  18. 18.
    Marion DW, Spiegel TP (2000) Changes in the management of severe traumatic brain injury: 1991–1997. Crit Care Med 28:16–18PubMedCrossRefGoogle Scholar
  19. 19.
    Wilkins IA, Menon DK, Matta BF (2001) Management of comatose head-injured patients: are we getting any better? Anaesthesia 56:350–352PubMedCrossRefGoogle Scholar
  20. 20.
    Thomas SH, Orf J, Wedel SK, Conn AK (2002) Hyperventilation in traumatic brain injury patients: inconsistency between consensus guidelines and clinical practice. J Trauma 52:47–52PubMedCrossRefGoogle Scholar
  21. 21.
    Warner KJ, Cuschieri J, Copass MK, Jurkovich GJ, Bulger EM (2007) The impact of prehospital ventilation on outcome after severe traumatic brain injury. J Trauma 62:1330–1336PubMedGoogle Scholar
  22. 22.
    Kerr ME, Zempsky J, Sereika S, Orndoff P, Rudy EB (1996) Relationship between arterial carbon dioxide and end-tidal carbon dioxide in mechanically ventilated adults with severe head trauma. Crit Care Med 24:785–790PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2008

Authors and Affiliations

  • J.-O. Neumann
    • 1
    Email author
  • I. R. Chambers
    • 2
  • G. Citerio
    • 3
  • P. Enblad
    • 4
  • B. A. Gregson
    • 5
  • T. Howells
    • 4
  • J. Mattern
    • 1
  • P. Nilsson
    • 4
  • I. Piper
    • 6
  • A. Ragauskas
    • 7
  • J. Sahuquillo
    • 8
  • Y. H. Yau
    • 9
  • K. Kiening
    • 1
  • on behalf of the BrainIT Group
  1. 1.Department of NeurosurgeryUniversitätsklinikum HeidelbergHeidelbergGermany
  2. 2.Regional Medical Physics DepartmentJames Cook University HospitalMiddlesboroughUK
  3. 3.Department of Perioperative Medicine and Intensive CareNeuroICU, Hospital San GerardoMonzaItaly
  4. 4.Department of Clinical Neurosciences, Section of NeurosurgeryUppsala University HospitalUppsalaSweden
  5. 5.Department of NeurosurgeryNewcastle General HospitalNewcastle upon TyneUK
  6. 6.Department of Clinical PhysicsInstitute of Neurological Sciences, Southern General HospitalGlasgowScotland
  7. 7.Telematics Science LaboratoryKaunas University of TechnologyKaunasLithuania
  8. 8.Department of NeurosurgeryNeurotraumatology Research Unit, Vall d’Hebron University HospitalBarcelonaSpain
  9. 9.Department of NeurosurgeryWestern General HospitalEdinburghScotland

Personalised recommendations