Strategies for providing mechanical ventilation and other means of respiratory support in critically ill patients with acute brain injury have been widely debated. Many factors must be weighed when choosing what type of intervention to use, including the patient’s level of consciousness, intracranial pressure, and respiratory drive, and whether the patient has concurrent acute respiratory failure.
To address these uncertainties, Dr. Robert Stevens convened an international consensus panel of 29 clinician-scientists. The panel, which met in Berlin in October of 2019 and by videoconferencing, broke into seven subpanels to deliberate on the following seven domains of clinical practice for this patient population: (1) indications for endotracheal intubation; (2) noninvasive interventions to ensure oxygenation and ventilation; (3) settings of mechanical ventilation; (4) targets for arterial blood gases; (5) rescue interventions in patients with concurrent acute brain injury and severe respiratory failure; (6) criteria for ventilator liberation and tracheal extubation; and (7) criteria and timing for tracheostomy.
Dr. Jose Suarez of ACCM was on the panel to determine if specific values of blood oxygen and carbon dioxide should be targeted (domain 4). After performing rigorous domain-specific systematic reviews and four rounds of iterative voting, the panel produced 36 evidence-based recommendations. In addition, it identified many gaps in research and proposed a comprehensive research agenda.
Dr. Stevens indicated that the final recommendations, published in the journal Intensive Care Medicine, represent the current state of science and also map out significant areas of uncertainty (knowledge gaps). He expects that this work will incite new investigators and research programs to improve the outcomes and process of care for critically ill neurological patients. Anyone who is interested in this research should contact Dr. Stevens or Dr. Suarez.