title: Ventilation practices in subarachnoid hemorrhage: a cohort study exploring the use of lung protective ventilation.
abstract: BACKGROUND
  Acute respiratory distress syndrome (ARDS) is common following aneurysmal subarachnoid hemorrhage (SAH), but the influence of mechanical ventilator settings on its development is unclear. We sought to determine adherence to lung protective thresholds in ventilated patients with SAH and describe the association between ventilator settings and subsequent development of ARDS.
  
  
  METHODS
  We conducted a retrospective cohort study of consecutive patients receiving mechanical ventilation within 72 h of SAH at a single academic center. Ventilator settings and blood gas data were collected twice daily for the first 7 days of ventilation along with ICU and hospital outcomes. Lung protective ventilation was defined as follows: tidal volume ≤8 mL/kg of predicted body weight, positive end-expiratory pressure (PEEP) ≥5 cm H(2)O, and peak or plateau pressure ≤30 cm H(2)O. The development of ARDS was ascertained retrospectively by PaO(2)/FiO(2) ≤300 with new bilateral lung opacities on chest X-ray within one day of hypoxemia.
  
  
  RESULTS
  We identified 62 patients who underwent early mechanical ventilation following SAH. PS and Continuous Positive Airway Pressure were common ventilator modes with a median tidal volume of 7.8 mL/kg [interquartile range 6.8-8.8], median peak pressure of 14 cm H(2)O [IQR 12-17], and median PEEP of 5 cm H(2)O [IQR 5-6]. Adherence to tidal volumes ≤8 mL/kg was seen in 64 % of all observations and peak pressures <30 cm H(2)O were 94 % of all observations. All three lung protective criteria were seen in 58 % of all observations. Thirty-one patients (50 %) were determined to have ARDS. ARDS patients were more frequently ventilated with a peak pressure >30 cm H(2)O (11.3 % of ARDS ventilation days vs. 0 % of non-ARDS ventilation days; p < 0.01). Initial tidal volume was not associated with subsequent development of ARDS in univariate (p = 0.6) or multivariate analysis (p = 0.49). Only the number of ARDS risk factors was independently associated with the development of ARDS (Adjusted Odds Ratio 2.8 per additional risk factor [95 % CI 1.2-6.5]).
  
  
  CONCLUSIONS
  Patients with SAH requiring mechanical ventilation frequently breathe spontaneously, generating tidal volumes above usual protective thresholds regardless of meeting ARDS criteria. In patients with SAH, the presence of an additional ARDS risk factor should prompt close screening for the development of ARDS and consideration of adjustment of ventilator settings to meet lung protective thresholds.
authors.affiliation: Department of Medicine, University of Toronto, 500 University Avenue, Suite 602, Toronto, ON, M5G 1V7, Canada, jonathan.marhong@medportal.ca.
authors.forename: Jonathan D
authors.initials: JD
authors.lastname: Marhong
authors.forename: Niall D
authors.initials: ND
authors.lastname: Ferguson
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Singh
mesh_terms: D000368:Aged; D015331:Cohort Studies; D045422:Continuous Positive Airway Pressure / Q000009:adverse effects / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012121:Respiration, Artificial / Q000009:adverse effects* / Q000379:methods; D012128:Respiratory Distress Syndrome / Q000209:etiology*; D012307:Risk Factors; D013345:Subarachnoid Hemorrhage / Q000628:therapy*; D013990:Tidal Volume / Q000502:physiology*