Department of Anesthesia and Intensive Care, Parma University Hospital, Via Gramsci 14, 43100, Parma, Italy.
Department of Anesthesia and Intensive Care, IRCCS for Oncology and Neurosciences, Genoa, Italy.
Crit Care. 2020 Apr 17;24(1):158. doi: 10.1186/s13054-020-02875-w.
Severe traumatic brain injury (TBI) patients often develop acute respiratory failure. Optimal ventilator strategies in this setting are not well established. We performed an international survey to investigate the practice in the ventilatory management of TBI patients with and without respiratory failure.
An electronic questionnaire, including 38 items and 3 different clinical scenarios [arterial partial pressure of oxygen (PaO)/inspired fraction of oxygen (FiO) > 300 (scenario 1), 150-300 (scenario 2), < 150 (scenario 3)], was available on the European Society of Intensive Care Medicine (ESICM) website between November 2018 and March 2019. The survey was endorsed by ESICM.
There were 687 respondents [472 (69%) from Europe], mainly intensivists [328 (48%)] and anesthesiologists [206 (30%)]. A standard protocol for mechanical ventilation in TBI patients was utilized by 277 (40%) respondents and a specific weaning protocol by 198 (30%). The most common tidal volume (TV) applied was 6-8 ml/kg of predicted body weight (PBW) in scenarios 1-2 (72% PaO/FIO > 300 and 61% PaO/FiO 150-300) and 4-6 ml/kg/PBW in scenario 3 (53% PaO/FiO < 150). The most common level of highest positive end-expiratory pressure (PEEP) used was 15 cmHO in patients with a PaO/FiO ≤ 300 without intracranial hypertension (41% if PaO/FiO 150-300 and 50% if PaO/FiO < 150) and 10 cmHO in patients with intracranial hypertension (32% if PaO/FiO 150-300 and 33% if PaO/FiO < 150). Regardless of the presence of intracranial hypertension, the most common carbon dioxide target remained 36-40 mmHg whereas the most common PaO target was 81-100 mmHg in all the 3 scenarios. The most frequent rescue strategies utilized in case of refractory respiratory failure despite conventional ventilator settings were neuromuscular blocking agents [406 (88%)], recruitment manoeuvres [319 (69%)] and prone position [292 (63%)].
Ventilatory management, targets and practice of adult severe TBI patients with and without respiratory failure are widely different among centres. These findings may be helpful to define future investigations in this topic.
严重创伤性脑损伤（TBI）患者常发生急性呼吸衰竭。在这种情况下，最佳的呼吸机策略尚未得到很好的确立。我们进行了一项国际调查，以调查有和没有呼吸衰竭的 TBI 患者的呼吸机管理实践。
2018 年 11 月至 2019 年 3 月，一项包括 38 个项目和 3 个不同临床场景[动脉血氧分压（PaO）/吸入氧分数（FiO）>300（场景 1）、150-300（场景 2）、<150（场景 3）]的电子问卷可在欧洲重症监护医学学会（ESICM）网站上获取。该调查得到了 ESICM 的认可。
共有 687 名受访者[472 名（69%）来自欧洲]，主要是重症监护医师[328 名（48%）]和麻醉师[206 名（30%）]。277 名受访者（40%）使用了机械通气的标准方案，198 名受访者（30%）使用了特定的脱机方案。在场景 1-2（72%的 PaO/FIO>300，61%的 PaO/FiO 150-300）中，最常用的潮气量（TV）为 6-8ml/kg 预测体重（PBW），在场景 3（53%的 PaO/FiO<150）中为 4-6ml/kg/PBW。在没有颅内高压的情况下，PaO/FiO≤300 的患者最常用的最高呼气末正压（PEEP）水平为 15cmHO（如果 PaO/FiO 为 150-300，则为 41%；如果 PaO/FiO<150，则为 50%），而颅内高压患者的最高 PEEP 水平为 10cmHO（如果 PaO/FiO 为 150-300，则为 32%；如果 PaO/FiO<150，则为 33%）。无论是否存在颅内高压，在所有 3 个场景中，最常见的二氧化碳目标仍然是 36-40mmHg，而最常见的 PaO 目标是 81-100mmHg。在常规呼吸机设置下，尽管存在顽固性呼吸衰竭，但最常使用的抢救策略是神经肌肉阻滞剂[406 名（88%）]、募集操作[319 名（69%）]和俯卧位[292 名（63%）]。
有和没有呼吸衰竭的成人严重 TBI 患者的通气管理、目标和实践在各中心之间存在很大差异。这些发现可能有助于确定该主题的未来研究。
