Topical respiratory strategies in neurocritical care

Abstract

Management of the respiratory tract and maintenance of adequate gas exchange are the basic goals of critical care. Injury to the nervous system is often accompanied by development of respiratory disorders. On the other hand, changes in the gas composition of arterial blood can cause brain damage. In addition, approaches to the patient with respiratory failure, which are used in general critical care and neurocritical care, may differ. The presented literature review is devoted to modern respiratory strategies used in neurocritical care.

Pulmonary complications and respiratory management in neurocritical care: a narrative review

“…The results of tracheostomy performed later in time may exclude a certain percentage of those patients who would have undergone an early-stage tracheostomy, but postponed tracheostomy may be accompanied by a higher incidence of complications [68] . Progress has been made in improving the way tracheostomy is performed to prevent intracranial hypertension by avoiding hyperextension of the neck and shortening the duration of the procedure [5,73] . Different types of tracheos-tomy equipment may have similar outcomes in general patients, but percutaneous/puncture-dilated tracheostomy has been recommended in NCC patients as a safe and quick treatment, as it has the advantages of reducing the incidence of bleeding, tracheal stenosis, and infections [73,74] …”

“…To reduce discomfort and sedation during intubation, better oral and tracheobronchial care that does not hinder the ability to communicate should be provided. [ 5 , 62 ]…”

“…[ 68 ] Progress has been made in improving the way tracheostomy is performed to prevent intracranial hypertension by avoiding hyperextension of the neck and shortening the duration of the procedure. [ 5 , 73 ] Different types of tracheos-tomy equipment may have similar outcomes in general patients, but percutaneous/puncture-dilated tracheostomy has been recommended in NCC patients as a safe and quick treatment, as it has the advantages of reducing the incidence of bleeding, tracheal stenosis, and infections. [ 73 , 74 ]…”

“…The inflated cuff of the endotracheal tube is designed to prevent microaspiration; thus, the cuff pressure should be at a moderate level at 20 to 30 cm of water, as air leakage or aspiration occurs when it is too low, and tracheal or subglottic stenosis occurs when it is too high. [ 5 , 76 , 77 ] In NCC patients, the cuff pressure may decline with extubation and the transition to a prone position. [ 78 ] In addition, the high incidence of pneumonia further emphasized the necessity of determining and monitoring cuff pressure.…”

“…[ 4 ] Strategies for respiratory support and management, including artificial airways, the prone position, protective mechanical ventilation (MV), and drugs for airway management, have been summarized in previous studies. [ 5 ] Controversies still exist concerning the proper timing of a tracheostomy and levels of positive end-expiratory pressure (PEEP) in neurocritical patients. Although these topics have been widely studied in the general ICU, detailed guidelines on respiratory management in the NCC unit are not available.…”