title: Ventilatory strategies for patients with acute brain injury.
abstract: OBJECTIVE
  The ventilation of patients with acute brain injuries can present significant challenges. Frequently, guidelines recommending management strategies for patients with traumatic brain injuries come into conflict with what is now considered best ventilatory practice. In this review, we will explore many of these areas of conflict.
  
  
  RESULTS
  The use of ventilatory strategies to control partial pressure of carbon dioxide in patients with traumatic brain injury is associated with the development of acute lung injury. Analysis of the International Mission for Prognosis And Clinical Trial (IMPACT) database has confirmed the association between hypoxia and poor neurological outcome. Although a recent meta-analysis has suggested a survival benefit for steroids in acute lung injury, the use of steroids has been associated with a worsening of outcome in patients with traumatic brain injuries and their effects on the brain have not been fully elucidated.
  
  
  CONCLUSIONS
  There are unlikely to be randomized controlled trials advising how best to ventilate patients with acute brain injuries because of the heterogeneous nature of such injuries. Hypoxia should be avoided. The more widespread use of multimodal brain monitoring, including brain tissue oxygen and cerebral blood flow monitoring, may allow clinicians to tolerate a higher arterial partial pressure of carbon dioxide than has been traditional, allowing a less injurious ventilatory strategy. Modest positive end-expiratory pressure can be used. In severe respiratory failure, most 'rescue' strategies have been attempted in patients with acute brain injuries. Choice of rescue therapy at present is best decided on a case-by-case basis in conjunction with local expertise.
authors.affiliation: Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, UK.
authors.forename: Neil
authors.initials: N
authors.lastname: Young
authors.forename: Jonathan K J
authors.initials: JK
authors.lastname: Rhodes
authors.forename: Luciana
authors.initials: L
authors.lastname: Mascia
authors.forename: Peter J D
authors.initials: PJ
authors.lastname: Andrews
mesh_terms: D001930:Brain Injuries / Q000601:surgery; D015199:Extracorporeal Membrane Oxygenation; D006801:Humans; D007035:Hypothermia; D000860:Hypoxia; D012121:Respiration, Artificial / Q000379:methods*; D013256:Steroids / Q000627:therapeutic use; D013990:Tidal Volume / Q000502:physiology
chemical_list: D013256:Steroids