Ventilating the Patient with Traumatic Brain Injury
Many patients with acute TBI will require intubation and mechanical ventilation for a variety of reasons.
Ventilating the patient with TBI becomes a balancing act between maintaining adequate cerebral perfusion and minimizing lung injury.
Some pearls to consider:
Avoid hypoxia: although guidelines recommend a PaO2 > 60 mm Hg, most suggest a higher PaO2 (> 80 mm Hg) be initially targeted.
Avoid hypercapnia: many patients will develop hypercapnia when ventilated using the low tidal volume strategy (6 ml/kg) of the ARDSnet trial; titrate TVs to maintain a PaCO2 between 32-35 mm Hg.
PEEP: the application of PEEP remains controversial in patients with TBI given the theoretical risk of increasing ICP through reductions in venous return; if PEEP is applied pay close attention to the cerebral perfusion pressure to ensure it remains > 60 mm Hg.
Young N, Rhodes JKJ, Mascia L, Andrews PJD. Ventilatory strategies for patients with acute brain injury. Curr Opin Crit Care 2010; 16:45-52