• Edoardo Picetti, Paolo Pelosi, Fabio Silvio Taccone, Giuseppe Citerio, Jordi Mancebo, Chiara Robba, and on the behalf of the ESICM NIC/ARF sections.
• Department of Anesthesia and Intensive Care, Parma University Hospital, Via Gramsci 14, 43100, Parma, Italy. edoardopicetti@hotmail.com.
• Crit Care. 2020 Apr 17; 24 (1): 158.

BackgroundSevere traumatic brain injury (TBI) patients often develop acute respiratory failure. Optimal ventilator strategies in this setting are not well established. We performed an international survey to investigate the practice in the ventilatory management of TBI patients with and without respiratory failure.MethodsAn electronic questionnaire, including 38 items and 3 different clinical scenarios [arterial partial pressure of oxygen (PaO2)/inspired fraction of oxygen (FiO2) > 300 (scenario 1), 150-300 (scenario 2), < 150 (scenario 3)], was available on the European Society of Intensive Care Medicine (ESICM) website between November 2018 and March 2019. The survey was endorsed by ESICM.ResultsThere were 687 respondents [472 (69%) from Europe], mainly intensivists [328 (48%)] and anesthesiologists [206 (30%)]. A standard protocol for mechanical ventilation in TBI patients was utilized by 277 (40%) respondents and a specific weaning protocol by 198 (30%). The most common tidal volume (TV) applied was 6-8 ml/kg of predicted body weight (PBW) in scenarios 1-2 (72% PaO2/FIO2 > 300 and 61% PaO2/FiO2 150-300) and 4-6 ml/kg/PBW in scenario 3 (53% PaO2/FiO2 < 150). The most common level of highest positive end-expiratory pressure (PEEP) used was 15 cmH2O in patients with a PaO2/FiO2 ≤ 300 without intracranial hypertension (41% if PaO2/FiO2 150-300 and 50% if PaO2/FiO2 < 150) and 10 cmH2O in patients with intracranial hypertension (32% if PaO2/FiO2 150-300 and 33% if PaO2/FiO2 < 150). Regardless of the presence of intracranial hypertension, the most common carbon dioxide target remained 36-40 mmHg whereas the most common PaO2 target was 81-100 mmHg in all the 3 scenarios. The most frequent rescue strategies utilized in case of refractory respiratory failure despite conventional ventilator settings were neuromuscular blocking agents [406 (88%)], recruitment manoeuvres [319 (69%)] and prone position [292 (63%)].ConclusionsVentilatory management, targets and practice of adult severe TBI patients with and without respiratory failure are widely different among centres. These findings may be helpful to define future investigations in this topic.

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