High-Frequency Oscillation as a Rescue Strategy for Brain-Injured Adult Patients with Acute Lung Injury and Acute Respiratory Distress Syndrome

Abstract

Acute lung injury and acute respiratory distress syndrome (ARDS) occur frequently in brain-injured patients. Single organ dysfunction ventilator strategies result in a conflict between lung protective ventilation and the prevention of secondary neurological insult(s). The objectives of this study were to determine if clinical and physiological benefits of high-frequency oscillatory ventilation (HFOV) exist compared to conventional ventilation and to determine what data there are on the effects of HFOV on cerebral perfusion pressure and intracranial pressure. Systematic review was designed. An optimally sensitive search strategy was used that included; OVID MEDLINE, OVID EMBASE, Cochrane Clinical Trials Register, and hand searching of references of retrieved articles and proceedings of meetings. Study selection includes published randomized controlled trials comparing HFOV with conventional ventilation in adults with ARDS and observational studies of the use of HFOV in adults with ARDS and traumatic brain injury (TBI). Both authors reviewed all trials. A data extraction form was used. In adults with ARDS no mortality benefit has been shown with HFOV, oxygenation improves, arterial partial pressure of CO(2) may increase and there is no change in mean arterial blood pressure. There are few data describing HFOV in adults with TBI. In the small, low quality, studies that have been reported there have not been uncontrollable changes in intracranial pressure. HFOV has not been shown to have any mortality benefit in adults with ARDS. There are insufficient data to clarify the role, or safety, of HFOV in adults with TBI and concurrent ARDS.

Pulmonary Complications in Patients with Severe Brain Injury

“…Several authors advocate for determination of cerebral autoregulation to determine if patients may tolerate abrupt changes in PEEP that could result in increased ICP, in those with lost cerebral autoregulation [37]. Finally, the use of steroids in the proliferative phase of ARDS is of questionable use [35, 38–40]. …”

Topical respiratory strategies in neurocritical care

“…Исследования, посвященные РДС, проведенные в популяции общереанимационных пациентов, показали, что исходы заболевания достоверно улучшают следующие терапевтические опции: 1) протективная ИВЛ; 2) прон-позиция; 3) использование мышечных релаксантов [55]. Вместе с этим есть достаточно агрессивные пути коррекции гипоксемии, которые не доказали своей эффективности, но тем не менее применяются при тяжелом РДС: 1) высокочастотная ИВЛ (ВЧ ИВЛ); 2) ингаляции оксида азота [56]. В последние годы становятся все более востребованными и популярными в общереанимационной практике методики экстракорпорального газообмена.…”

“…Высокочастотная ИВЛ. Применение ВЧ ИВЛ при РДС в общереанимационной практике приводит к увеличению оксигенации крови, однако при этом не происходит уменьшения летальности и улучшения исходов заболевания [72][73][74]. ВЧ ИВЛ используется в рутинной общереанимационной практике только при резистентной гипоксемии [75].…”

Lung protective ventilation (ARDSNet) versus airway pressure release ventilation

“…Invasive mechanical ventilatory management of these patients is complicated. Currently, the brain trauma foundation recommends achieving normal arterial partial pressure of O 2 and low normal arterial partial pressure of CO 2 to maintain intracranial pressure (ICP) below 20 mmHg and cerebral perfusion pressure (CPP) above 60 mmHg (10-13). While ARDSNet is ideal for managing ARDS, permissive hypercapnea results in increased cerebral perfusion leading to elevated ICP and cerebral ischemia, further compounding TBI (9, 14, 15).…”