Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 3733  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Resource Links
  »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
 »Related articles
  »  Article in PDF (606 KB)
  »  Citation Manager
  »  Access Statistics
  »  Reader Comments
  »  Email Alert *
  »  Add to My List *
* Registration required (free)  

  In this Article
 »  Abstract
 » Introduction
 »  Need for Mechani...
 »  Initiation of Me...
 »  Maintenance of V...
 »  Monitoring of Br...
 »  Weaning and Extu...
 » Conclusions
 »  References
 »  Article Figures
 »  Article Tables

 Article Access Statistics
    PDF Downloaded395    
    Comments [Add]    
    Cited by others 1    

Recommend this journal


Table of Contents    
Year : 2016  |  Volume : 64  |  Issue : 3  |  Page : 485-493

Mechanical ventilation in neurological and neurosurgical patients

1 Department of Neuroanesthesia, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab and Haryana, India
2 Department of Anesthesia, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab and Haryana, India
3 Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab and Haryana, India

Date of Web Publication3-May-2016

Correspondence Address:
Dr. Hemant Bhagat
Department of Neuroanesthesia, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh - 160 012, Punjab and Haryana
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.181585

Rights and Permissions

 » Abstract 

Approximately 20% of all patients requiring mechanical ventilation suffer from neurological dysfunction. It is imperative in the ventilatory management of such patients to have a thorough understanding of the disease pathology that may require institution of mechanical ventilation as well as in realizing its effects on the injured brain. These patients have unique challenges pertaining to the assessment and securing of the airway, maintenance of mechanical ventilation, as well as weaning and extubation readiness. This manuscript aims to present the current evidence in ventilatory management of the important subset of patients with neuronal injury. The indications for ventilatory management include both neurological and neurosurgical causes.

Keywords: Mechanical ventilation; neurological patient; ventilatory management; weaning

How to cite this article:
Swain A, Bhagat H, Sahni N, Salunke P. Mechanical ventilation in neurological and neurosurgical patients. Neurol India 2016;64:485-93

How to cite this URL:
Swain A, Bhagat H, Sahni N, Salunke P. Mechanical ventilation in neurological and neurosurgical patients. Neurol India [serial online] 2016 [cited 2022 Jul 3];64:485-93. Available from: https://www.neurologyindia.com/text.asp?2016/64/3/485/181585

 » Introduction Top

The association of mechanical ventilation with neurological afflictions can be historically traced to the advent of mechanical ventilation in clinical practice in the 1950s, when it was used a life-saving measure in the polio epidemic in Europe.[1] Mechanical ventilation has since evolved in tandem with the ongoing technological advancements and is being increasingly used across different subspecialties, including in those patients suffering from neurosurgical and neurological ailments. Approximately 20% of all patients requiring mechanical ventilation suffer from neurological dysfunction.[2] Hence, there is a recent trend to treat neurocritical care as a separate subspecialty.[3] The major subsets of patients suffering from neurological afflictions and requiring ventilatory support can be categorized into those suffering from either neurosurgical or neurological disorders. While patients with traumatic brain injury (TBI) and spinal cord injury (SCI) are the major subset of patients in the neurosurgical population, patients suffering from disorders such as Guillain–Barre syndrome (GBS) and myasthenia gravis (MG) form the major bulk among neurological patients requiring mechanical ventilation.[3] It is important to have a thorough knowledge of the diseases that may require mechanical ventilation. An understanding of its effects on the injured neuronal tissue is also mandated.

 » Need for Mechanical Ventilation in Neurologically Injured Patients Top

The indications for mechanical ventilation in neurologically injured patients could either be one of the four pathologies or their combinations that include loss of respiratory drive, dysfunction of lung compliance, low Glasgow Coma Scale (GCS) that is hampering gas exchange, and ventilatory failure due to disorders of the neuromuscular junction [Table 1]. The loss of consciousness and the resultant airway obstruction caused by the falling back of flaccid tongue on the posterior pharyngeal wall in neurologically obtunded patients is the major indication for airway management in such patients.[4] In addition, worsening of the upper airway muscle tone and protective reflexes predispose such patients to life-threatening sequelae such as pneumonia and acute respiratory distress syndrome (ARDS). GCS, a universally used score to measure consciousness, has been shown to have a direct correlation with the incidence of aspiration in neurologically injured patients such as those with spinal cord injury and stroke.[5],[6],[7]
Table 1: Neuronal disorders requiring mechanical ventilation

Click here to view

Disruption of the ventilatory control centers originating in the medulla oblongata as a result of CNS injury is another pathological mechanism requiring mechanical ventilation. Such insults to the respiratory drive mechanisms are commonly seen in a variety of surgical pathologies, such as traumatic brain injury (TBI), intracranial space-occupying lesions (ICSOLs), subarachnoid hemorrhage (SAH), medical illnesses such as stroke and morbid obesity. They may also be seen as the side effect of commonly administered drugs such as opioids and sedative agents. Disorders of lung compliance (which may be due to aspiration pneumonitis, neurogenic pulmonary edema, and pneumothorax or a flail chest in patients with traumatic injury) are also major indications for mechanical ventilation in the neurosurgical population.[8] While understanding the pathophysiology in patients with neurological injury requiring mechanical ventilation, it is also pertinent to note the neurological ramifications of impairment in ventilation. Hypercapnia and hypoxia, as a consequence of ventilatory dysfunction, result in an increase in cerebral blood volume. The consequent rise in intracranial pressure (ICP) often causes a concern in neurological patients with decreased intracranial compliance. Another significant aspect in the cohort of neurologically injured patients is the occurrence of systemic compromise, especially the pulmonary complications, which cause further difficulty in the ventilatory management of such patients.[9]

 » Initiation of Mechanical Ventilation Top

The initiation of mechanical ventilation in neurosurgical/neurological patients involves appropriate decision making in identifying the patients at risk, followed by prompt assessment of their airway, and culminating in the safe securing of the airway. The clinical features signifying respiratory failure in such patients include a disorder of respiratory rate (RR <6 or >30 breaths per minute), use of accessory muscles of respiration, nasal flaring, tracheal tug, paradoxical breathing, and periods of apnea. These should be used in conjunction with laboratory parameters such as vital capacity (VC), negative inspiratory force (NIF), forced expiratory volume (FEV), and minute volume (MV).[10]

Assessment of the airway has a critical role in the initiation of mechanical ventilation in such patients. The established predictors of difficult mask ventilation and laryngoscopy in the context of emergency scenarios should be carefully evaluated.[11],[12] There is an omnipresent risk of aggravation of the pre-existing cervical spine injury in patients who have suffered from major trauma and have an underlying cervical pathology. Hence, a careful perusal of the different modes of airway management is desirable.[13],[14],[15] Direct laryngoscopy is the gold standard of airway management. Direct laryngoscopy, with and without manual in-line stabilization (MILS), while offering the advantages of familiarity, accessibility, and availability, has been shown to cause significant undesirable craniocervical movement.[16],[17],[18],[19],[20] A variety of video laryngoscopes have been studied for cervical spine movement. They have shown lesser cervical spine movement in comparison to the classical blades.[21],[22],[23] The application of video laryngoscopes in day-to-day practice is limited by the availability issues and the fact that tracheal cannulation is a demonstrably arduous process with these devices.[24] While fiber optic intubation has been shown to be a reliable and safe method of securing the airway in patients with suspected cervical spine injury, it requires training and may not be a viable alternative in the emergency setting, especially in the presence of hemorrhage and swelling of the airway.[25],[26] Common adjuncts such as the jaw thrust maneuver and devices such as oral and nasal airways as well as laryngeal mask airways (LMAs) play a vital role in the maintenance of oxygenation. They act as a bridge for facilitating oxygenation before the placement of a definitive airway in the form of an endotracheal tube (ETT) or a tracheostomy tube. Patients undergoing early tracheostomy have demonstrated advantages in terms of a reduction in the overall duration of mechanical ventilation and an early weaning when compared with ETT, without any significant difference in neurological outcome.[27],[28],[29] The use of pharmacological adjuncts in the form of sedatives, analgesics, and muscle relaxants is common in neurological patients requiring mechanical ventilation. Their use, however, should be tempered with the knowledge about their effects on the brain and other organ systems. One should, therefore, take precautions so that the use of these medications does not impede neurological monitoring and weaning in neurocritical patients [Table 2].
Table 2: Pharmacology in neurocritical care

Click here to view

 » Maintenance of Ventilation Top

Appropriate delivery of mechanical ventilation to the neurological/neurosurgical patients requires a precise understanding of the various modes as well as the effects of mechanical ventilation on the injured brain and spinal cord.

Modes of ventilation

Despite the abundance of various modes of ventilation in critical care, a basic understanding of volume, pressure, timing, and trigger should suffice to aid in the proper selection of ventilatory modes in different subsets of neurological patients. The choice of the ventilatory modes in these patients is largely governed by the site of the lesion and the severity of ventilatory impairment caused by it [Table 3].
Table 3: Modes of ventilation in neurocritical care

Click here to view

Brain stem and cortex

Cortical pathologies such as TBI, ICSOLs and hemorrhage as well as lesions of the brain stem cause an impairment of the respiratory drive and result in aberrant respiratory patterns such as hypo- and hyperventilation syndromes, apnea, and Cheyne–Stokes breathing. They usually require controlled ventilation as the initial mode, followed by a switching over to the assisted modes when there is a progressive improvement in the act of spontaneous breathing.[30],[31]

Spinal cord

Lesions of the spinal cord, more commonly spinal cord injury (SCI), present with unique ventilatory concerns. SCI at C5 and above usually causes complete paralysis of the phrenic and intercostal nerves and consequently requires long periods of controlled ventilation and an early tracheostomy.[32] Lesions below C5 show a variable course with a high incidence of delayed-onset respiratory failure that is commonly attributed to a variety of causes such as muscle fatigue, aspiration pneumonia, atelectasis, and pooling of secretions.[33],[34] The proposed mechanisms for the sudden deterioration include a rapid expansion of the lesion and cellular degeneration, but conclusive evidence is lacking.[35] An improvement in the respiratory function in patients with cervical SCI is also observed a few weeks after the primary insult as a result of development of spasticity in the intercostal muscles, which has a favorable effect on the lung mechanics.[36] Thus, patients with spinal cord injury might require either controlled or assisted modes of ventilation depending on the site and extent of the lesion, the amount of respiratory muscle compromise, the degree of respiratory drive present, and the duration of injury.

Neuromuscular diseases

Ventilatory requirements in patients with neuromuscular diseases (NMDs) such as Guillain-Barre syndrome (GBS) and myasthenia gravis (MG) are very specific as they have to compensate for a slow affliction of the respiratory system affecting oxygenation of the patient. In these conditions, an initial compensatory phase of ventilation precedes the ongoing respiratory compromise. A high index of suspicion as well as a continuous assessment using bedside pulmonary function tests (PFTs) will help the clinician in the assessment of these patients and in instituting elective intubation [at a vital capacity (VC) <10–15 mL/kg and a negative inspiratory force (NIF) <20g].[37] Noninvasive ventilation had been shown to have a limited application in patients with MG that is responsive to pharmacologic therapy and is largely redundant in the GBS population.[38],[39],[40],[41]

Brain protection versus lung protection

In patients receiving mechanical ventilation, the components such as volutrauma, atelectrauma, oxygen toxicity, and biotrauma have been found to contribute to ventilator-initiated lung injury (VILI).[42],[43],[44],[45],[46],[47] Protection from VILI has had a significant effect on outcome. This has been unequivocally demonstrated in mechanically ventilated patients who are managed based on the principles of institution of a minimal tidal volume, utilization of high levels of positive end expiratory pressure (PEEP), and avoidance of high inspired oxygen concentrations.[48],[49] These principles may occasionally act as a hindrance in the adequate management of neurosurgical patients, and the challenge is to administer lung protective ventilation without compromising the basic tenets of brain protection.

Role of hyperventilation and tidal volume

Hyperventilation and the consequent hypocapnia (PCO2 <25 mm Hg) has been postulated as a method for decreasing cerebral blood flow (CBF) and has been used in patients with a refractory increase in the intracranial pressure (ICP). The advantages should be weighed against the harmful effects of cerebral ischemia on the injured brain as has been demonstrated in various types of brain insults, and in particular, TBI.[50],[51],[52],[53],[54] On the basis of the available evidence, hyperventilation should be used only as a treatment adjunct in the cases of acute deterioration in the neurological status due to refractory causes of raised ICP, with a target PCO2 between 30 and 35 mm Hg.[55] There has been a rising incidence in the use of small-tidal-volume protocols in the ventilatory management of critical care patients with the perceived advantage of avoiding volutrauma while still achieving eucapnia.[56] However, achievement of the desirable PCO2 levels in brain-injured patients with coexisting dysfunction in the intracranial compliance often presents a clinical conundrum. We hereby present a flow chart [Figure 1] for management of ventilation in terms of the desired PCO2 titrated to the intracranial compliance.
Figure 1: Approach to management of hypercapnia in brain-injured patients on mechanical ventilation. ALI: Acute lung injury; ARDS; Acute respiratory distress syndrome; CSF: Cerebrospinal fluid; ICP: Intracranial pressure; MV: Mechanical ventilation; VILI: Ventilator associated lung injury

Click here to view

Positive end expiratory pressure (PEEP), oxygen therapy, and newer modalities

The inherent concerns of using PEEP in brain-injured patients that includesits proposed effect in decreasing the cerebral blood flow and causing a consequent raised in ICP as well as a decrease in the mean arterial pressure has not been reflected in the clinical trials. Indeed, the application of mild-to-moderate levels of PEEP does not seem to result in any clinically relevant effects on ICP.[57],[58],[59],[60],[61] Another significant and favorable observation is the demonstration of either no change or minimal change in the ICP in patients with decreased lung compliance. This is the particular subset of patients where the use of lung recruitment properties of PEEP are of benefit.[62],[63]

Hyperoxia therapy has not been shown to improve the outcome in patients with neurologic injury and is currently not recommended.[64],[65] Newer modalities such as prone positioning, high frequency oscillatory ventilation, high frequency percussive ventilation, and extracorporeal lung assist have only recently been investigated in the neurocritical patients and may be considered in patients refractory to the standard modalities of ventilatory management.[66],[67],[68],[69]

 » Monitoring of Brain-Injured Patents Top

In addition to the routine monitoring of critical care patients (that includes monitoring of the vital signs, hemodynamics, arterial blood gases, and neurological status), certain specific parameters such as ICP, brain tissue oxygenation, and electrical activity of the brain are being investigated as part of the multimodality monitoring in brain-injured patients.[70] Continuous invasive monitoring of the ICP has been extensively studied as a guide to instituting treatment and in decision making, especially in TBI patients, even though its beneficial effects on the mortality and other outcome measures are yet to be proven.[71] Noninvasive measures of ICP such as optic nerve sheath diameter (ONSD) have recently been investigated in neurocritical patients and have shown a good level of diagnostic accuracy for detecting intracranial hypertension.[72],[73]

Brain tissue oxygen monitoring (jugular venous oximetry) offers the advantage of being a more direct measure of tissue hypoxia. It has shown encouraging signs as a monitoring tool with the potential of influencing decision making and outcome in neurologically injured patients (especially in patients with TBI).[74],[75],[76],[77] Available evidence is presently lacking to support the routine use of sedation scores such as the Ramsay score, Richmond agitation–sedation score, and sedation–agitation score as well as electroencephalography (EEG)-derived parameters such as entropy and bispectral index (BIS) in the neurocritical care of patients receiving sedation.[78],[79]

 » Weaning and Extubation Top

Weaning and extubation in neurocritical patients poses unique challenges, and, indeed, the incidence of extubation failure and reintubation in such patients has been observed to be approximately 10%–15%.[80] Extubation failure in such patients has been associated with a longer hospital and critical care stay as well as poor functional outcomes.[81],[82] The causes of extubation failure in these patients include weakening of protective airway reflexes, neuromuscular weakness, deteriorating consciousness, inappropriate intravenous fluid administration, and deranged respiratory mechanics.[83],[84] The traditional weaning parameters have not been found to be good predictors of a successful outcome in neurocritical care patients.[85] Weaning in these patients should be initiated only after amelioration of the disease pathology and careful consideration of the risks and benefits of continuing the ventilatory support. Although there are a number of protocols to assess the readiness for ventilator withdrawal in non-neurological patients, there are surprisingly very few studies addressing this issue in neurocritical cohorts.[86],[87],[88]

The interruption of sedation and weaning according to set protocols has been shown to facilitate shorter durations of ventilation and is desirable in neurologically injured populations.[89] Spontaneous breathing trials have been shown to have a significant impact on decision making in weaning of patients from mechanical ventilation, especially when used in conjunction with ancillary measures such as rapid shallow breathing index (RSBI).[90],[91],[92] Numerous studies have shown that a GCS <8, absence of spontaneous cough, the presence of copious secretions, and the existence of lesions in the posterior fossa and upper cervical spine are associated with difficulties in maintenance of airway and the consequent extubation failure.[93] While a recent meta-analysis does not show any advantages in employing the cuff leak test prior to extubation in neurocritical patients, recent data suggest the usefulness of employing corticosteroids, especially low doses of methyl prednisolone (15–20 mg/kg), before planned extubation of difficult-to-wean patients.[94],[95] Weaning of patients with neuromuscular disorders such as GBS and MG should be attempted only after the disease has run its full course and immunological recovery is complete. The predictors of successful extubation in such patients are nonspecific, and the use of noninvasive ventilation has generally proven to be ineffective, especially in the MG population.[96],[97],[98]

 » Conclusions Top

Patients with neurological and neurosurgical diseases requiring mechanical ventilation present with unique considerations because of the complex interplay of the systemic effects of neuronal injury and the effects of mechanical ventilation. The management of such patients requires a multidisciplinary approach incorporating the practices of lung protective ventilation, rigorous monitoring, adequate care of the injured brain, as well as comprehensive support of other affected body systems. The advent of neurocritical care as a distinct subspecialty would go a long way in fostering research into contentious areas such as weaning and extubation of these patients. Focus in the future should be on generating further evidence to improve patient outcomes with an optimum utilization of the existing health care resources.

Financial support and sponsorship

No financial support or grants received.

Conflicts of interest

There are no conflicts of interest.

 » References Top

Sykes K. Mechanical Ventilation goes Full Circle. World Anaesthesia 1999.2. Available from: http://www.nda.ox.ac.uk/wfsa/html/wa02_01/wa02_008.htm. [Last accessed on 2006 Aug 2006].  Back to cited text no. 1
Esteban A, Anzueto A, Alia I, Gordo F, Apezteguía C, Pálizas F, et al. How is mechanical ventilation employed in the intensive care unit? An international utilization review. Am J Respir Crit Care Med 2000;161:1450-8.  Back to cited text no. 2
Rincon F, Mayer SA. Neurocritical care: A distinct discipline? Curr Opin Crit Care 2007;3:115-21.  Back to cited text no. 3
Safar P, Escarraga LA, Chang F. Upper airway obstruction in the unconscious patient. J Appl Physiol 1959;14:760-4.  Back to cited text no. 4
Jackson AB, Groomes TE. Incidence of respiratory complications following spinal cord injury. Arch Phys Med Rehabil 1994;75:270-5.  Back to cited text no. 5
Adnet F, Baud F. Relation between Glasgow Coma Scale and aspiration pneumonia. Lancet 1996;348:123-4.  Back to cited text no. 6
Horner J, Brazer SR, Massey EW. Aspiration in bilateral stroke patients: A validation study. Neurology 1993;43:430-3.  Back to cited text no. 7
Pocock G, Richards CD. Human Physiology: The Basis of Medicine. 2nd ed. Oxford, UK: Oxford University Press; 2004. p. 312-347.  Back to cited text no. 8
Alvarez JM, Quevedo OP, Furelos LR, González IS, Llapur EC, Valeron ME, et al. Pulmonary complications in patients with brain injury. Pulm Res Respir Med Open J 2015;2:69-74.  Back to cited text no. 9
Pierson DJ. Indications for mechanical ventilation in adults with acute respiratory failure. Respir Care 2002;47:249-65.  Back to cited text no. 10
Langeron O, Masso E, Huraux C, Guggiari M, Bianchi A, Coriat P, et al. Prediction of difficult mask ventilation. Anesthesiology 2000;92:1229-36.  Back to cited text no. 11
Reed MJ, Dunn MJ, McKeown DW. Can an airway assessment score predict difficulty at intubation in the emergency department? Emerg Med J 2005;22:99-102.  Back to cited text no. 12
Powell RM, Heath KJ. Quadraplegia in a patient with an undiagnosed odontoid peg fracture: The importance of cervical spine immobilization in patients with head injuries. J R Army Med Corps 1996;142:79-81.  Back to cited text no. 13
Hastings RH, Kelley SD. Neurologic deterioration associated with airway management in a cervical spine-injured patient. Anesthesiolgy 1993;78:580-3.  Back to cited text no. 14
Muckart DJ, Bhagwanjee S, van der Merwe R. Spinal cord injury as a result of endotracheal intubation in patients with undiagnosed cervical spine fractures. Anesthesiology 1997;87:418-20.  Back to cited text no. 15
Maruyama K, Yamada T, Kawakami R, Hara K. Randomized cross-over comparison of cervical-spine motion with the AirWay Scope or Macintosh laryngoscope with in-line stabilization: A video-fluoroscopic study. Br J Anesth 2008;101:563-7.  Back to cited text no. 16
Legrand SA, Hindman BJ, Dexter F, Weeks JB, Todd MM. Craniocervical motion during direct laryngoscopy and orotracheal intubation with the Macintosh and Miller blades: An in vivo cine fluoroscopic study. Anesthesiology 2007;107:884-91.  Back to cited text no. 17
Hastings RH, Wood PR. Head extension and laryngeal view during laryngoscopy with cervical spine stabilization maneuvers. Anesthesiology 1994;80:825-31.  Back to cited text no. 18
Sawin PD, Todd MM, Traunelis VC, Farrell SB, Nader A, Sato Y, et al. Cervical spine motion with direct laryngoscopy and orotracheal intubation: An in vivo cine fluoroscopic study of subjects without cervical abnormality. Anesthesiology 1996;85:26-36.  Back to cited text no. 19
Kihara S, Watanabe S, Brimacombe J, Taguchi N, Yaguchi Y, Yamasaki Y. Segmental cervical spine movement with the intubating laryngeal mask during manual in-line stabilization in patients with cervical pathology undergoing cervical spine surgery. Anesth Analg 2000;91:195-200.  Back to cited text no. 20
Turkstra TP, Craen RA, Pelz DM, Gelb AW. Cervical spine motion: A fluoroscopic comparison during intubation with lighted stylet, GlideScope, and Macintosh laryngoscope. Anesth Analg 2005;101:910-5.  Back to cited text no. 21
Robitaille A, Williams SR, Tremblay MH, Guilbert F, Thériault M, Drolet P. Cervical spine motion during tracheal intubation with manual in-line stabilization: Direct laryngoscopy versus GlideScope videolaryngoscopy. Anesth Analg 2008;106:935-41.  Back to cited text no. 22
Wong DM, Prabhu A, Chakraborty S, Tan G, Massicotte EM, Cooper R. Cervical spine motion during flexible bronchoscopy compared with the Lo-Pro GlideScope. Br J Anaesth 2009;102:424-30.  Back to cited text no. 23
Wetsch WA, Carlitscheck M, Spelten O, Teschendorf P, Hellmich M, Genzwürker HV, et al. Success rates and endotracheal tube insertion times of experienced emergency physicians using five video laryngoscopes: A randomised trial in a simulated trapped car accident victim. Eur J Anaesthesiol 2011;28:849-58.  Back to cited text no. 24
Sahin A, Salman MA, Erden IA, Aypar U. Upper cervical vertebrae movement during intubating laryngeal mask, fiberoptic and direct laryngoscopy: A video-fluoroscopic study. Eur J Anaesthesiol 2004;21:819-23.  Back to cited text no. 25
Mlinek EJ Jr, Clinton JE, Plummer D, Ruiz E. Fiberoptic intubation in the emergency department. Ann Emerg Med 1990;19:359-62.  Back to cited text no. 26
Teoh WH, Goh KY, Chan C. The role of early tracheostomy in critically ill neurosurgical patients. Ann Acad Med Singapore 2001;30:234-8.  Back to cited text no. 27
Goettler CE, Fugo JR, Bard MR, Newell MA, Sagraves SG, Toschlog EA, et al. Predicting the need for early tracheostomy: A multifactorial analysis of 992 intubated trauma patients. J Trauma 2006;60:991-6.  Back to cited text no. 28
Griffiths J, Barber VS, Morgan L, Young JD. Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. Br Med J 2005;330:1243.  Back to cited text no. 29
Lane DJ, Rout MW, Williamson DH. Mechanism of hyperventilation in acute cerebrovascular accidents. Br Med J 1971;3:9-12.  Back to cited text no. 30
Lee MC, Klassen AC, Heaney LM, Resch JA. Respiratory rate and pattern disturbances in acute brain stem infarction. Stroke 1976;7:382-5.  Back to cited text no. 31
Como JJ, Sutton ER, McCunn M, Dutton RP, Johnson SB, Aarabi B, et al. Characterizing the need for mechanical ventilation following cervical spinal cord injury with neurologic deficit. J Trauma 2005;59:912-6.  Back to cited text no. 32
Reines HD, Harris RC. Pulmonary complications of acute spinal cord injuries. Neurosurgery 1987;21:193-6.  Back to cited text no. 33
Lu K, Lee TC, Liang CL, Chen HJ. Delayed apnea in patients with mid-to lower cervical spinal cord injury. Spine (Phila Pa 1976) 2000;25:1332-8.  Back to cited text no. 34
Hagg T, Oudega M. Degenerative and spontaneous regenerative processes after spinal cord injury. J Neurotrauma 2006;23:264-80.  Back to cited text no. 35
Ball PA. Critical care of spinal cord injury. Spine (Phila Pa 1976) 2001;26 (24 Suppl):S27-30.  Back to cited text no. 36
Ropper AH. Critical care of Guillian-Barre syndrome. In: Ropper AH, editor. Neurological and Neurosurgical Intensive Care. 3rd ed. New York, NY: Raven Press; 1993. p. 363-82.  Back to cited text no. 37
Seneviratne J, Mandrekar J, Wijdicks EF, Rabinstein AA. Noninvasive ventilation in myasthenia crisis. Arch Neurol 2008; 65:54-8.  Back to cited text no. 38
Wijdicks EF, Roy TK. BiPAP in early Guillian-Barré syndrome may fail. Can J Neurol Sci 2006;33:105-6.  Back to cited text no. 39
Bhagat H, Dash HH, Chauhan RS, Khanna P, Bithal PK. Intensive care management of Guillain-Barre syndrome: A retrospective outcome study and review of literature. J Neuroanaesthesiol Crit Care 2014;1:188-97.  Back to cited text no. 40
  Medknow Journal  
Bhagat H, Grover VK, Jangra K. What is optimal in patients with myasthenic crisis: Invasive or non-invasive ventilation? J Neuroanaesthesiol Crit Care 2014;1:116-20.  Back to cited text no. 41
  Medknow Journal  
Dreyfuss D, Saumon G. Ventilator-induced lung injury: Lessons from experimental studies. Am J Respir Crit Care Med 1998;157:294-323.  Back to cited text no. 42
Bryan CL, Jenkinson SG. Oxygen toxicity. Clin Chest Med 1988;9:141-52.  Back to cited text no. 43
Ranieri VM, Suter PM, Tortorella C, De Tullio R, Dayer JM, Brienza A, et al. Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: A randomized controlled trial. JAMA 1999;282:54-61.  Back to cited text no. 44
Slutsky AS, Tremblay LN. Multiple system organ failure. Is mechanical ventilation a contributing factor? Am J Respir Crit Care Med 1998;157:1721-5.  Back to cited text no. 45
Tremblay LN, Slutsky AS. Ventilation-induced injury: From barotrauma to biotrauma. Proc Assoc Am Physicians 1998;110:482-8.  Back to cited text no. 46
Imai Y, Parodo J, Kajikawa O, de Perrot M, Fischer S, Edwards V, et al. Injurious mechanical ventilation and end-organ epithelial cell apoptosis and organ dysfunction in an experimental model of acute respiratory distress syndrome. JAMA 2003;289:2104-12.  Back to cited text no. 47
Lachmann B. Open up the lung and keep the lung open. Intensive Care Med 1992;18:319-21  Back to cited text no. 48
The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000;342:1301-8.  Back to cited text no. 49
Ghajar J, Hariri RJ, Narayan RK, Iacono LA, Firlik K, Patterson RH. Survey of critical care management of comatose, head-injured patients in the United States. Crit Care Med 1995;23:560-7.  Back to cited text no. 50
Stocchetti N, Maas AI, Chieregato A, van der Plas AA. Hyperventilation in head injury: A review. Chest 2005;127:1812-27.  Back to cited text no. 51
Diringer MN, Videen TO, Yundt K, Zazulia AR, Aiyagari V, Dacey RG Jr, et al. Regional cerebrovascular and metabolic effects of hyperventilation after severe traumatic brain injury. J Neurosurg 2002;96:103-8.  Back to cited text no. 52
Muizelaar JP, Marmarou A, Ward JD, Kontos HA, Choi SC, Becker DP, et al. Adverse effects of prolonged hyperventilation in patients with severe head injury: A randomized clinical trial. J Neurosurg 1991;75:731-9.  Back to cited text no. 53
The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care. Critical pathway for the treatment of established intracranial hypertension. J Neurotrauma 2000;17:537-8.  Back to cited text no. 54
Bendo AA, Luba K. Recent changes in the management of intracranial hypertension. Int Anesthesiol Clin 2000;38:69-85.  Back to cited text no. 55
Amato MB, Barbas CS, Medeiros DM, Magaldi RB, Schettino GP, Lorenzi-Filho G, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med 1998;338:347-54.  Back to cited text no. 56
Frost EA. Effects of positive end-expiratory pressure on intracranial pressure and compliance in brain-injured patients. J Neurosurg 1977;47:195-200.  Back to cited text no. 57
Burchiel KJ, Steege TD, Wyler AR. Intracranial pressure changes in brain-injured patients requiring positive end-expiratory pressure ventilation. Neurosurgery 1981;8:443-9.  Back to cited text no. 58
Cooper KR, Boswell PA, Choi SC. Safe use of PEEP in patients with severe head injury. J Neurosurg 1985;63:552-5.  Back to cited text no. 59
McGuire G, Crossley D, Richards J, Wong D. Effects of varying levels of positive end-expiratory pressure on intracranial pressure and cerebral perfusion pressure. Crit Care Med 1997;25:1059-62.  Back to cited text no. 60
Andrews PJ. Pressure, flow and Occam's razor: A matter of “steal”? Intensive Care Med 2005;31:323-4.  Back to cited text no. 61
Caricato A, Conti G, Della Corte F, Mancino A, Santilli F, Sandroni C, et al. Effects of PEEP on the intracranial system of patients with head injury and subarachnoid hemorrhage: The role of respiratory system compliance. J Trauma 2005;58:571-6.  Back to cited text no. 62
Mascia L, Grasso S, Fiore T, Bruno F, Berardino M, Ducati A. Cerebro-pulmonary interactions during the application of low levels of positive end-expiratory pressure. Intensive Care Med 2005;31:373-9.  Back to cited text no. 63
Magnoni S, Ghisoni L, Locatelli M, Caimi M, Colombo A, Valeriani V, et al. Lack of improvement in cerebral metabolism after hyperoxia in severe head injury: A microdialysis study. J Neurosurg 2003;98:952-8.  Back to cited text no. 64
Reinert M, Barth A, Rothen HU, Schaller B, Takala J, Seiler RW. Effects of cerebral perfusion pressure and increased fraction of inspired oxygen on brain tissue oxygen, lactate and glucose in patients with severe head injury. Acta Neurochir (Wien) 2003;145:341-50.  Back to cited text no. 65
Reinprecht A, Greher M, Wolfsberger S, Dietrich W, Illievich UM, Gruber A. Prone position in subarachnoid hemorrhage patients with acute respiratory distress syndrome: Effects on cerebral tissue oxygenation and intracranial pressure. Crit Care Med 2003;31:1831-8.  Back to cited text no. 66
David M, Karmrodt J, Weiler N, Scholz A, Markstaller K, Eberle B. High-frequency oscillatory ventilation in adults with traumatic brain injury and acute respiratory distress syndrome. Acta Anaesthesiol Scand 2005;49:209-14.  Back to cited text no. 67
Salim A, Miller K, Dangleben D, Cipolle M, Pasquale M. High-frequency percussive ventilation: An alternative mode of ventilation for head-injured patients with adult respiratory distress syndrome. J Trauma 2004;57:542-6.  Back to cited text no. 68
Bein T, Scherer MN, Philipp A, Weber F, Woertgen C. Pumpless extracorporeal lung assist (pECLA) in patients with acute respiratory distress syndrome and severe brain injury. J Trauma 2005;58:1294-7.  Back to cited text no. 69
Wartenberg KE, Schmidt JM, Mayer SA. Multimodality monitoring in neurocritical care. Crit Care Clin 2007;23:507-38.  Back to cited text no. 70
Chesnut RM, Temkin N, Carney N, Dikmen S, Rondina C, Videtta W, et al. Global Neurotrauma Research Group. A trial of intracranial-pressure monitoring in traumatic brain injury. N Engl J Med 2012;367:2471-81.  Back to cited text no. 71
Dubourg J, Javouhey E, Geeraerts T, Messerer M, Kassai B. Ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure: A systematic review and meta-analysis. Intensive Care Med 2011;37:1059-68.  Back to cited text no. 72
Geeraerts T, Merceron S, Benhamou D, Vigué B, Duranteau J. Non-invasive assessment of intracranial pressure using ocular sonography in neurocritical care patients. Intensive Care Med 2008;34:2062-7.  Back to cited text no. 73
Stiefel MF, Spiotta A, Gracias VH, Garuffe AM, Guillamondegui O, Maloney-Wilensky E, et al. Reduced mortality rate in patients with severe traumatic brain injury treated with brain tissue oxygen monitoring. J Neurosurg 2005;103:805-11.  Back to cited text no. 74
Bardt TF, Unterberg AW, Härtl R, Kiening KL, Schneider GH, Lanksch WR. Monitoring of brain tissue PO2 in traumatic brain injury: Effect of cerebral hypoxia on outcome. Acta Neurochir Suppl 1998;71:153-6.  Back to cited text no. 75
Dings J, Meixensberger J, Jäger A, Roosen K. Clinical experience with 118 brain tissue oxygen partial pressure catheter probes. Neurosurgery 1998;43:1082-95.  Back to cited text no. 76
van Santbrink H, van den Brink WA, Steyerberg EW, Carmona Suazo JA, Avezaat CJ, Maas AI. Brain tissue oxygen response in severe traumatic brain injury. Acta Neurochir (Wien) 2003;145:429-38.  Back to cited text no. 77
Vivien B, Di Maria S, Ouattara A, Langeron O, Coriat P, Riou B. Overestimation of bispectral index in sedated intensive care unit patients revealed by administration of muscle relaxant. Anesthesiology 2003;99:9-17.  Back to cited text no. 78
Schneider G, Gelb AW, Schmeller B, Tschakert R, Kochs E. Detection of awareness in surgical patients with EEG-based indicis — Bispectral index and patient state index. Br J Anaesth 2003;91:329-35.  Back to cited text no. 79
Rishi MA, Kashyap R, Wilson G, Schenck L, Hocker S. Association of extubation failure and functional outcomes in patients with acute neurologic illness. Neurocrit Care 2015. [Epub ahead of print].  Back to cited text no. 80
Epstein SK, Ciubotaru RL. Independent effects of etiology of failure and time to reintubation on outcome for patients failing extubation. Am J Respir Crit Care Med 1998;158:489-93.  Back to cited text no. 81
Epstein SK, Ciubotaru RL, Wong JB. Effect of failed extubation on the outcome of mechanical ventilation. Chest 1997;112:186-92.  Back to cited text no. 82
Coplin WM, Pierson DJ, Cooley KD, Newell DW, Rubenfeld GD. Implications of extubation delay in brain-injured patients meeting standard weaning criteria. Am J Respir Crit Care Med 2000;161:1530-6.  Back to cited text no. 83
Koutsoukou A, Perraki H, Raftopoulou A, Koulouris N, Sotiropoulou C, Kotanidou A, et al. Respiratory mechanics in brain-injured patients. Intensive Care Med 2006;32:1947-54.  Back to cited text no. 84
Ko R, Ramos L, Chalela JA. Conventional weaning parameters do not predict extubation failure in neurocritical care patients. Neurocrit Care 2009;10:269-73.  Back to cited text no. 85
Cook D, Meade M, Guyatt G, Butler R, Aldawood A, Epstein S. Trials of miscellaneous interventions to wean from mechanical ventilation. Chest 2001;120(Suppl):438-44S.  Back to cited text no. 86
MacIntyre NR, Cook DJ, Ely EW Jr, Epstein SK, Fink JB, Heffner JE, et al. American College of Chest Physicians; American Association for Respiratory Care; American College of Critical Care Medicine. Evidence-based guidelines for weaning and discontinuing ventilatory support: A collective task force facilitated by the American College of Chest Physicians, the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest 2001;120(Suppl):375-95S.  Back to cited text no. 87
Namen AM, Ely EW, Tatter SB, Case LD, Lucia MA, Smith A, et al. Predictors of successful extubation in neurosurgical patients. Am J Respir Crit Care Med 2001;163:658-64.  Back to cited text no. 88
Gehlbach BK, Kress JP. Sedation in the intensive care unit. Curr Opin Crit Care 2002;8:290-8.  Back to cited text no. 89
Esteban A, Alia I, Tobin MJ, Gil A, Gordo F, Vallverdú I, et al. Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation: Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med 1999;159:512-8.  Back to cited text no. 90
Vallverdu I, Calaf N, Subirana M, Net A, Benito S, Mancebo J. Clinical characteristics, respiratory functional parameters, and outcome of a two-hour T-piece trial in patients weaning from mechanical ventilation. Am J Respir Crit Care Med 1998;158:1855-62.  Back to cited text no. 91
Liu Y, Wei LQ, Li GQ, Lv FY, Wang H, Zhang YH, et al. A decision-tree model for predicting extubation outcome in elderly patients after a successful spontaneous breathing trial. Anesth Analg 2010;111:1211-8.  Back to cited text no. 92
Khamiees M, Raju P, DeGirolamo A, Amoateng-Adjepong Y, Manthus CA. Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial. Chest 2001;120:1262-70.  Back to cited text no. 93
Ochoa ME, Marín Mdel C, Frutos-Vivar F, Gordo F, Latour-Pérez J, Calvo E, et al. Cuff-leak test for the diagnosis of upper airway obstruction in adults: A systematic review and meta-analysis. Intensive Care Med 2009;35:1171-9.  Back to cited text no. 94
Roberts RJ, Welch SM, Devlin JW. Corticosteroids for prevention of postextubation laryngeal edema in adults. Ann Pharmacother 2008;42:686-91.  Back to cited text no. 95
Seneviratne J, Mandraker J, Wijdicks EF, Rabinstein AA. Predictors of extubation failure in myasthenic crisis. Arch Neurol 2008;65:929-33.  Back to cited text no. 96
Nguyen TN, Badjatia N, Malhotra A, Gibbons FK, Qureshi MM, Greenberg SA. Factors predicting extubation success in patients with Guillain-Barré syndrome. Neurocrit Care 2006;5:230-4.  Back to cited text no. 97
Wu JY, Kuo PH, Fan PC, Wu HD, Shih FY, Yang PC. The role of non-invasive ventilation and factors predicting extubation outcome in myasthenic crisis. Neurocrit Care 2009;10:35-42.  Back to cited text no. 98


  [Figure 1]

  [Table 1], [Table 2], [Table 3]

This article has been cited by
1 First American College of Surgeons National Surgical Quality Improvement Program Report from a Low-Middle-Income Country: A 1-Year Outcome Analysis of Neurosurgical Cases
Mustafa Mushtaq Hussain, Farida Bibi, Shafqat Shah, Rida Mitha, Muhammad Shahzad Shamim, Afsheen Ziauddin, Hasnain Zafar
World Neurosurgery. 2021; 155: e156
[Pubmed] | [DOI]


Print this article  Email this article
Online since 20th March '04
Published by Wolters Kluwer - Medknow