Mechanical ventilation in brain injured patients: seeing the forest for the trees

Bruni, Andrea; Garofalo, Eugenio; Pelaia, Corrado; Longhini, Federico; Navalesi, Paolo

doi:10.21037/jtd.2017.08.149

Cited by 8 publications

(5 citation statements)

References 24 publications

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“…Thoracic complications are highly prevalent in patients with ABI [ 8 ]. BI induces changes in the mechanics of the respiratory system, such as increased elastance and airway resistance [ 9 ], and leads to systemic and pulmonary inflammation, as well as increased pulmonary hydrostatic pressures and endothelial permeability [ 8 ]. On the other hand, the effects of systemic and pulmonary inflammation in patients with BI create a systemic inflammatory environment that makes lungs more vulnerable to secondary neurointensive care procedures that enhance inflammation, such as MV [ 7 ].…”

Section: Introductionmentioning

confidence: 99%

Brain–lung interactions and mechanical ventilation in patients with isolated brain injury

Ziaka¹,

Exadaktylos

2021

Crit Care

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During the last decade, experimental and clinical studies have demonstrated that isolated acute brain injury (ABI) may cause severe dysfunction of peripheral extracranial organs and systems. Of all potential target organs and systems, the lung appears to be the most vulnerable to damage after brain injury (BI). The pathophysiology of these brain–lung interactions are complex and involve neurogenic pulmonary oedema, inflammation, neurodegeneration, neurotransmitters, immune suppression and dysfunction of the autonomic system. The systemic effects of inflammatory mediators in patients with BI create a systemic inflammatory environment that makes extracranial organs vulnerable to secondary procedures that enhance inflammation, such as mechanical ventilation (MV), surgery and infections. Indeed, previous studies have shown that in the presence of a systemic inflammatory environment, specific neurointensive care interventions—such as MV—may significantly contribute to the development of lung injury, regardless of the underlying mechanisms. Although current knowledge supports protective ventilation in patients with BI, it must be born in mind that ABI-related lung injury has distinct mechanisms that involve complex interactions between the brain and lungs. In this context, the role of extracerebral pathophysiology, especially in the lungs, has often been overlooked, as most physicians focus on intracranial injury and cerebral dysfunction. The present review aims to fill this gap by describing the pathophysiology of complications due to lung injuries in patients with a single ABI, and discusses the possible impact of MV in neurocritical care patients with normal lungs.

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Section: Introductionmentioning

confidence: 99%

Brain–lung interactions and mechanical ventilation in patients with isolated brain injury

Ziaka¹,

Exadaktylos

2021

Crit Care

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“…But studies have showed no effects of PEEP up to 15 to 20 cm H 2 O on ICP. 32,33 However, in one retrospective study, patients of TBI having severe lung injury showed a statistically significant effect on ICP (0.31 mm Hg rise in ICP for every 1 cm H 2 O rise in PEEP). 34 Use of PEEP in TBI patients with acute respiratory distress syndrome has been shown to improve cerebral oxygenation.…”

Section: Management As Per Brain Trauma Foundation Guidelinesmentioning

confidence: 95%

Critical Care Management of Traumatic Brain Injury

Bharadwaj

Naik

2019

Journal of Neuroanaesthesiology and Critical Care

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Traumatic brain injury (TBI) is a significant public health problem. It is the leading cause of death and disability despite advancements in its prevention and treatment. Treatment of a patient with head injury begins on the site of trauma and continues even during her/his transportation to the trauma care center. Knowledge of secondary brain injuries and timely management of those in the prehospital period can significantly improve the outcome and decrease mortality after TBI. Intensive care management of TBI is guided by Brain Trauma Foundation guidelines (4th edition). Seventy percent of blunt trauma patients will also suffer from some degree of head injury. The management of these extracranial injuries may influence the neurological outcomes. Damage control tactics may improve early mortality (control hemorrhage) and delayed mortality (minimize systemic inflammation and organ failure). Neuromonitoring plays an important role in the management of TBI because it is able to assess multiple aspects of cerebral physiology and guide therapeutic interventions intended to prevent or minimize secondary injury. Bedsides, multimodality monitoring predominantly comprises monitoring modalities for cerebral blood flow, cerebral oxygenation, and cerebral electrical activity. Establishing a reliable prognosis early after injury is notoriously difficult. However, TBI is a much more manageable injury today than it has been in the past, but it remains a major health problem.

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“…tem: elevated elastance and airway resistance, increased pulmonary hydrostatic pressures, endothelial permeability and as greater pulmonary inflammation as mentioned above [16,17]. Certainly, mechanical ventilation in patients with brain injury is an unusual challenge.…”

Section: Relationship With Previous Studiesmentioning

confidence: 99%

Concentration of Apoptotic Factors in Bronchoalveolar Lavage Fluid, as Potential Brain-Lung Oxygen Relationship, Correspond to the Severity of Brain Injury

Siwicka-Gieroba¹,

Terpiłowska²,

Robba³

et al. 2023

J. Integr. Neurosci.

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Background:The mechanism of acute brain injury initiates a cascade of consequences which can directly cause lung damage, and this can contribute to poor neurological outcomes. The aim of this study was to evaluate concentration of different apoptotic molecules in the bronchoalveolar lavage fluid (BALF) in patients after severe brain injury and to correlate them with selected clinical variables and mortality. Methods: Patients with brain injury receiving BALF operation were included in the study. BALF samples were collected within the first 6-8 hours after traumatic brain injury (A) and at days 3 (B) and 7 (C) after admission to the intensive care unit (ICU). Changes in the BALF nuclear-encoded protein (Bax), apoptotic regulatory protein (Bcl-2), pro-apoptotic protein (p53) and its upregulated modulator (PUMA), apoptotic protease factor 1 (APAF-1), Bcl-2 associated agonist of cell death (BAD) and caspase-activated DNase (CAD) were analysed. These values were correlated with the selected oxygenation parameters, Rotterdam computed tomography (CT) score, the Glasgow Coma Score and 28-day mortality. Results: We found a significant increase in the concentration of selected apoptotic factors at admission (A), at day 3 (B) and day 7 (C) after severe brain damage contrasted with baseline level A (p < 0.001, separately). That concentration of selected apoptotic factors was significantly correlated with the severity of the injury and mortality. Conclusions: Activation of different apoptotic pathways seems to be an important process occurring in the lungs of patients in the early phases after severe brain trauma. Levels of apoptotic factors in the BALF correlates with the severity of brain injury.

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Mechanical ventilation in brain injured patients: seeing the forest for the trees

Cited by 8 publications

References 24 publications

Brain–lung interactions and mechanical ventilation in patients with isolated brain injury

Brain–lung interactions and mechanical ventilation in patients with isolated brain injury

Critical Care Management of Traumatic Brain Injury

Concentration of Apoptotic Factors in Bronchoalveolar Lavage Fluid, as Potential Brain-Lung Oxygen Relationship, Correspond to the Severity of Brain Injury

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