Cerebro-pulmonary interactions during the application of low levels of positive end-expiratory pressure.
OBJECTIVE
In patients with severe brain injury and acute lung injury the use of positive end-expiratory pressure (PEEP) is limited by conflicting results on its effect on intracranial pressure. We hypothesised that the occurrence of alveolar hyperinflation during the application of PEEP would lead to an increase in PaCO(2) responsible for a rise in intracranial pressure.


METHODS
Prospective interventional study.


METHODS
Intensive Care Unit of University Hospitals.


METHODS
Twelve severely brain-injured patients with acute lung injury and intracranial pressure higher than applied PEEP.


METHODS
5 and 10 cmH(2)O of PEEP was randomly applied.


RESULTS
In all patients intracranial pressure, flow velocity by transcranial Doppler of middle cerebral artery, and jugular oxygen saturation were recorded. Static volume-pressure curves of the respiratory system were obtained, recruited volume and elastance calculated to classify patients as recruiters and non-recruiters. In recruiters (= 6 patients), elastance decreased (P<0.01) and PaO(2) increased (P<0.005), while in non-recruiters (= 6 patients) elastance and PaCO(2) significantly increased (P<0.001). Intracranial pressure, Doppler flow velocity, and jugular saturation remained constant in recruiters but significantly increased (P<0.0001) in non-recruiters. A significant correlation was found between changes in intracranial pressure and elastance (r(2) = 0.8 P<0.0001) and between changes in PaCO(2) and intracranial pressure (P<0.001, r(2) = 0.4) and elastance (P<0.001, r(2) = 0.4), respectively.


CONCLUSIONS
When PEEP induced alveolar hyperinflation leading to a significant increase in PaCO(2), intracranial pressure significantly increased, whereas when PEEP caused alveolar recruitment intracranial pressure did not change.
Mascia
Luciana
L
Università di Torino, Dipartimento di Discipline Medico-Chirurgiche, Sezione di Anestesiologia e Rianimazione, Ospedale S. Giovanni Battista, Italy. luciana.mascia@unito.it
Grasso
Salvatore
S
Fiore
Tommaso
T
Bruno
Francesco
F
Berardino
Maurizio
M
Ducati
Alessandro
A
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001930:Brain Injuries / Q000150:complications / Q000503:physiopathology* / Q000628:therapy*; D002245:Carbon Dioxide / Q000378:metabolism; D005260:Female; D006801:Humans; D019586:Intracranial Hypertension / Q000209:etiology* / Q000378:metabolism; D008176:Lung Volume Measurements; D008297:Male; D008875:Middle Aged; D010313:Partial Pressure; D011175:Positive-Pressure Respiration / Q000379:methods*; D012128:Respiratory Distress Syndrome / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology* / Q000628:therapy*
D002245:Carbon Dioxide