ABSTRACT
Pulmonary disorders are common findings in neurocritically ill patients. Unfortunately, these complications are associated with longer length of stay in the Intensive Care Unit (ICU) and with a poor outcome. Airway and chest injury are often present in patients with traumatic brain injury (TBI).
The first section of the chapter will briefly review trauma-related non-neurologic injuries and respiratory complications (eg, lung infections, neurogenic pulmonary edema, pulmonary embolism, acute respiratory distress syndrome [ARDS]) that may develop in this setting.
In the second section, the mechanical ventilation setting will be reviewed. Low tidal volume ventilation should be implemented. The effect of positive end expiratory pressure (PEEP) on intracranial pressure should be cautiously monitored. A continuous intracranial pressure monitoring is mandatory in brain injury patients who suffer an extracranial disorder and may benefit from higher PEEP. However, there is no evidence to support eubaric hyperoxia or hyperbaric oxygen in neurotrauma patients. Hyperventilation should be used in patients who present a clinical sign of high intracranial pressure or with raised ICP measured through an intracranial device. Prolonged prophylactic hyperventilation to obtain extreme hypocapnias is not recommended. Clinicians should be aware of intrinsic PEEP and dynamic hyperinflation that may occur in patients ventilated with a high respiratory rate and tidal volume.
In the third section, airway management will be implemented. The goals of airway management in brain-injured patients are to prevent aspiration and to ensure adequate oxygenation and ventilation. Tracheal intubation (performed providing in-line cervical spine immobilization) is recommended for neurotrauma patients with Glasgow Coma Scale < 9. Patients with impending respiratory arrest or vomiting should be intubated without delay. Indications to tracheostomy, liberation of mechanical ventilation, and ventilation in spinal cord injury will also be a focus.
