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Mechanical Ventilation in Patients with Traumatic Brain Injury: Is it so Different?

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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.

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Authors and Affiliations

  1. Division of Respirology, Department of Medicine, University Health Network, Toronto, ON, Canada

    Shaurya Taran

  2. Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada

    Shaurya Taran

  3. Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Johns Hopkins Medicine, Phipps 455 Suite, 600 N Wolfe Street, Baltimore, MD, 21287, USA

    Sung-Min Cho & Robert D. Stevens

  4. Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA

    Sung-Min Cho & Robert D. Stevens

  5. Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA

    Robert D. Stevens

  6. Department of Radiology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA

    Robert D. Stevens

  7. Department of Biomedical Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA

    Robert D. Stevens

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ST: manuscript organization, outline generation, review of the literature, writing of successive versions. S-MC: review of the literature, critical review of manuscript drafts. RD.S: manuscript conception and organization, critical review of manuscript drafts, reworking of final version for submission.

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Taran, S., Cho, SM. & Stevens, R.D. Mechanical Ventilation in Patients with Traumatic Brain Injury: Is it so Different?. Neurocrit Care 38, 178–191 (2023). https://doi.org/10.1007/s12028-022-01593-1

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