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ORIGINAL ARTICLE • Crit. Care Sci. 37 • 2025 • https://doi.org/10.62675/2965-2774.20250062 linkcopy

Open-access VENTIlatory strategies for patients with severe traumatic brain injury in the LOw- and Middle-Income CountrieS. The VENTILOMICS survey

AuthorshipSCIMAGO INSTITUTIONS RANKINGS

    ABSTRACT

    Objective  To revisit the VENTIlatory Strategies for Patients with Severe Traumatic Brain Injury (VENTILO) survey, focusing on ventilatory management practices among healthcare professionals in low- and middle-income countries.

    Methodology  A cross-sectional on-line survey, VENTIlatory strategies for patients with severe traumatic brain injury in the LOw- and Middle-Income CountrieS (VENTILOMICS), was conducted using the original VENTILO survey questionnaire, developed following a review of literature on respiratory management in traumatic brain injury patients, captured demographics of participants, type of hospital/specialty and available neuromonitoring tools; protocols for mechanical ventilation and weaning, and respiratory management strategies. Descriptive statistics were computed for all study variables. We analyzed data based on the economic status of the low- and middle-income countries.

    Results  There were 204 respondents from 28 low- and middle-income countries. Our results indicate that 55 - 70% of respondents recommend tidal volumes of 6 - 8mL/kg for patients with high or medium partial pressure of arterial oxygen/inspired fraction of oxygen, while tidal volumes of 4 - 6mL/kg is preferred for those with low partial pressure of arterial oxygen/inspired fraction of oxygen ratios. For patients with intracranial hypertension, lower positive end-expiratory pressure levels were utilized.

    Conclusion  The findings suggest a consistent approach to lung-protective ventilation across low-and middle-income countries, with notable variations influenced by local resources and economic status. This study highlights the necessity for tailored research and guidelines to address the specific challenges faced in traumatic brain injury management within low-and middle-income countries.

    Brain injury, traumatic; Critical care; Respiration, artificial; Survey and questionnaires; Developing countries; Economic status; Internationality

    INTRODUCTION

    Traumatic brain injury (TBI) remains a leading global neurological problem causing significant socioeconomic and healthcare burden.1About 28 million people sustain a TBI each year, with 50 million currently living with it, causing over 7 million years of disability.2 This burden is even greater in low- and middle-income countries (LMICs), where limited resources and prevention measures, like helmet use, contribute to higher rates of TBI.3,4 Patients sustaining severe TBI often require artificial airways to protect airways and invasive mechanical ventilation (MV) to maintain oxygenation and carbon dioxide clearance.5 Subsequently, this may lead to respiratory complications, as head-injured patients with endotracheal tubes are particularly susceptible to the development of acute respiratory distress syndrome (ARDS).6

    Ventilatory management of patients sustaining TBI is challenging because many currently advocated ventilation strategies like lung-protective ventilation, which protects alveoli and may be adjusted to target a desired carbon dioxide clearance, and permissive hypercapnia can adversely affect the brain by causing cerebral vasodilation and increasing cerebral blood volume. Furthermore, there is a lack of sufficient literature on optimal ventilatory strategies and targets for ventilation in patients with TBI.7-10

    Aiming to explore respiratory management practices in TBI patients, the VENTIlatory Strategies for Patients with Severe Traumatic Brain Injury (VENTILO) investigators performed survey a few years ago.11 This survey, endorsed by the European Society of Intensive Care Medicine (ESICM), showed important differences in respiratory management practices in TBI patients. However, most of the respondents to this survey were from Europe. Representation from the LMICs was limited; Sudan, Brazil, India, and Ukraine were the main ones represented. Therefore, we decided to revisit this survey to assess ventilatory management practice in TBI patients in the LMICs.

    METHODS

    Study design and ethics approval

    This was a cross-sectional on-line survey. Ethical approval for this survey was obtained from Institute Ethics Committee (IEC), before the survey started.

    Survey

    The original VENTILO survey,11 developed following a review of literature on respiratory management in TBI patients, captured participants’ demographics, type of hospital/specialty and available neuromonitoring tools; protocols for MV and weaning; and respiratory management strategies. In the present survey, named VENTIlatory strategies for patients with severe traumatic brain injury in the LOw- and Middle-Income CountrieS (VENTILOMICS), the questionnaire was revised and modified by two investigators, keeping in mind the context and resource-limited settings in the LMICs. Eight new questions were added to the original questionnaire as they felt relevant in the LMICs. Once the questionnaire was finalized, we performed a pilot survey testing among five of our experts in the writing group. This was performed to identify and fix issues prior to the survey being launched to a larger group.

    Respondents were asked about their area of practice (rural/urban). They were also enquired about the use of the prone position during MV in patients with TBI and what sedatives, analgesics, and muscle relaxants they used. They were also questioned about their preference for early versus late tracheostomy.

    Participants

    The participants of this international survey included all healthcare workers involved in the care of TBI patients across various LMICs. We allowed more than one response from different respondents in the same hospital, considering that different experts would have different management strategies, even in the same department. We did not exclude any respondents who completed the questionnaire.

    Survey distribution

    This survey was initially distributed to representatives (VENTILOMICS Investigators) from the different LMICs, who were considered experts (physicians and healthcare workers) in their field and involved in the daily care of TBI patients. These representatives have good clinical experience and academic interests and were also involved in research. Participants were recruited through emails sent by representatives from the various LMICs. The survey link was also shared on social media such as WhatsApp and Twitter. The survey was carried out over 3 months, from March 2024 to May 2024. Study data were collected and managed using Google Forms. The collected information was automatically entered into an Excel spreadsheet.

    Questionnaire

    An electronic survey composed of 38 items and 3 different clinical scenarios (partial pressure of arterial oxygen [PaO2]/inspired fraction of oxygen [FiO2] > 300, 150 - 300, and < 150) was used, revising and modifying the VENTILO survey.11We considered PaO2/FiO2 of > 300, between 150 - 300 and < 150 as high, medium and low PaO2/FiO2, respectively. Since these cutoffs differ from those used for severity classification, we did not categorize them as mild, moderate, or severe ARDS12 (Survey questionnaire - Supplementary Material).

    Data storage

    Data were collected and stored as spreadsheets in a secure Google database. Only one author had access to data to respect respondents’ confidentiality and anonymity.

    Statistical analysis

    Data from the questionnaire was stored as an Excel file (Microsoft Corp, Redmond, WA).

    Stata 18.0 (StataCorp LP, Texas, USA) was used for statistical analysis. Descriptive statistics were computed for all study variables. We analyzed data based on their economic status [low-income country (LIC), lower middle-income country (LoMIC), and upper middle-income country (UMIC)]. We also analyzed data based on the characteristics of intensive care unit (ICU), such as general or neurocritical care ICU (NICU). The results are presented as number (%). Differences in the groups were assessed using the Chi-squared test. Given the exploratory nature of this study, a priori sample size calculations and power analyses were not conducted. All p values were two-tailed, with values below 0.05 considered statistically significant.

    RESULTS

    Respondents

    The survey included 204 respondents from 28 LMICs (Figure 1S - Supplementary Material), with most respondents from India, Pakistan, and Nepal (Figure 1). The majority were intensivists, neuro-intensivists, or anesthesiologists working in general or specialized neuro-ICUs (Table 1). Most respondents (178/204 (87.3%) had not participated in the previous VENTILO survey. We did not exclude any response from the final analysis.

    thumbnail of Figure 1
    Figure 1
    Number of respondents from different low-and middle-income countries.

    LMICS - low-income and middle-income countries.


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    Table 1
    Baseline characteristics of the respondents

    Recommendations for tidal volume

    For patients with high or medium PaO2/FiO2, the majority of respondents (approximately 55 - 70% respondents) suggested that the setting of tidal volume (VT) was between 6 - 8mL/kg predicted body weight (PBW). The most recommended setting for VT in patients with a low PaO2/FiO2 was 4 - 6mL/kg PWB (Table 2).

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    Table 2
    Ventilator settings and respiratory targets utilized in the three clinical settings

    Recommendations for patients without intracranial hypertension

    In patients with medium or low PaO2/FiO2, the frequently utilized upper positive end-expiratory pressure (PEEP) level was 15cmH2O [n = 75 (37%) and 99 (48.5%)], respectively; among those with high PaO2/FiO2, the upper PEEP level of 10cmH2O was the most utilized [n = 61 (30%)]. The respiratory targets most frequently employed, irrespective of the PaO2/FiO2, were partial pressure of arterial carbon dioxide (PaCO2) 36 - 40mmHg, PaO2 81 - 100mmHg, and oxygen saturation (SpO2) 92 - 94%.

    Recommendations for patients with intracranial hypertension

    While VT recommendations were similar to those in patients without intracranial hypertension (Table 2), our survey (43% respondents) suggested lower upper PEEP levels of up to 5cmH2O for patients with high PaO2/FiO2; 8 to 10cmH2O for patients with medium PaO2/FiO2, and 10cmH2O for patients with low PaO2/FiO2. The PaCO2 targets (30 - 35mmHg) were identical for all PaO2/FiO2, and PaO2 and SpO2 targets remained unchanged, that is, 81 to 100mmHg for PaO2 and 92 - 94% for SpO2, irrespective of the PaO2/FiO2.

    Comparison of the intensive care units

    Respondents from neuro-ICUs had better access to intracranial pressure (ICP) monitors (87%), near-infrared spectroscopy (NIRS) (46%), transcranial Doppler (TCD) (76%), continuous electroencephalogram (EEG) (48%) and automated pupillometer (39%) compared to those from general ICUs (Table 3). The use of automated ventilation modes (a type of MV in which the ventilator adjusts settings dynamically in response to the patient’s physiological parameters, aiming to optimize ventilation and reduce the need for manual adjustments by the clinician), protocols for MV and weaning, target driving and plateau pressures, thresholds for using prone position in respiratory failure, medications used during prone MV and tracheostomy plans were comparable in both, neuro-ICUs and general ICUs (Table 3).

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    Table 3
    Comparison between data from general and neurocritical care intensive care units

    Geoeconomic differences

    Most respondents from the LICs were anesthesiologists (93%), while those from the UMIC were intensivists (73%) (Table 4). Neurologic and neurosurgical patients were mostly managed in general ICUs. There was significant variation across the geoeconomic regions in the presence of ventilation protocols and their specific recommendations (65% and 71% in the LoMIC and UMIC, respectively, versus only 27% in the LICs). The presence of weaning protocols was not different, but recommendations for weaning were different. Compared to respondents from UMICs and LoMICs, respondents from LICs had limited or negligible access to ICP monitors, NIRS, TCD, intermittent electroencephalogram (iEEG), jugular venous oximetry (SjVO2), and point of care ultrasound (POCUS) (Table 4).

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    Table 4
    Comparison of data between various low - income and middle-income countries based on their economic status

    Rescue strategies

    In case of refractory respiratory failure, neuromuscular blocking agents (NMBAs) are the commonest rescue strategy, followed by prone positioning (80%) and recruitment maneuvers (62%) (Figure 2).

    thumbnail of Figure 2
    Figure 2
    Rescue strategies used in respiratory failure.

    CO2 - carbon dioxide; VV- ECMO – Venovenous extracorporeal membrane oxygenator


    DISCUSSION

    This international survey, conducted across various LMICs, provides important insight regarding the respiratory management of patients with TBI who have been admitted to the ICU.

    Ventilator settings and respiratory targets in traumatic brain injury

    The second hit theory of brain-lung crosstalk highlights the deleterious mechanical effect of ventilation on the injured brain.13 The VT close to 6 - 8mL/kg of PBW is strongly recommended in several trials and systematic reviews.12,14 The beneficial effects of lung protective ventilation (LPV) are observed in patients with and without ARDS, making it a general practice.15 The protective MV strategy for patients with concomitant acute brain injury and ARDS includes using low VT (4 - 8mL/kg of PBW) and low minute volume, avoiding permissive hypercapnia. In our study, most respondents also chose VT of 6 - 8mL/kg for patients with medium PaO2/FiO2. In our survey, 65.7% of respondents chose a lower VT of 4 - 6mL/kg in patients with a low PaO2/FiO2. This is slightly higher than the findings of the VENTILO survey, in which only 53% of respondents use VT 4 - 6mL/kg in patients with a PaO2/FiO2 < 150.11 In a recent trial, the effects of low VT with low PEEP (< 5cmH2O) and low VT with high PEEP (> 12cmH2O) on ICP and oxygenation were studied. The authors found that an increase in PEEP did not influence ICP.16 However, 15% of the attempted interventions in six patients were stopped because ICP increased to more than 22mmHg for 5 minutes. It is suggested that though LPV seems safe, its effect depends on baseline ICP, brain compensatory reserve, and mechanical power.16

    The ESICM Guidelines on MV in brain-injured patients strongly recommend maintaining a PaO2 of 80 - 120mmHg in all acute brain-injured patients, irrespective of the ICP.(8) Most respondents in our survey target a PaO2 of 81 - 100mmHg while managing patients with TBI, similar to the findings of the VENTILO Survey.11 In patients with brain hypoxia (PbtO2 levels < 20mmHg), it is recommended to increase the FiO2 to 0.6 in tier one; and to target PaO2 of 150mmHg and above in tier 2 - 3, respectively.17 However, in the LMICs, the availability of probes is a major limiting step (utilized only by 10.8% of our respondents). The availability of sophisticated monitors is an important reason patients are transferred to referral centers or those with sophisticated monitoring systems. The non-availability of monitoring could be the reason for using higher oxygen levels, which may induce hyperoxia-induced injury. Another important consideration is the limited availability of respiratory therapists in the LMICs.

    Most respondents in our survey target a PaCO2 of 36 - 40mmHg in daily clinical practice. However, in patients with intracranial hypertension, a slightly lower range (30 - 35mmHg) was preferred by the majority of responders, which is in contrast with the data of the VENTILO survey,11 in which a PaCO2 of 36 - 40mmHg was mainly chosen even in the presence of intracranial hypertension.

    In patients with intracranial hypertension with ARDS, we found that the majority of respondents agree that a PEEP of 10cmH2O can be applied to maintain oxygenation. Multimodal neuromonitoring (ICP and brain tissue oxygenation) can help individualize PEEP and maintain it below ICP based on cerebral and lung compliance.18,19

    Protocols and modes of mechanical ventilation

    In the VENTILO survey,11 a less frequent use of standardized protocol for MV and weaning, when comparing responses from the European versus non-European respondents, was reported. We found that protocols less frequently used in the LIC. However, nearly 70 - 80% of respondents in our survey utilize a standardized protocol for weaning. The utilization of automated ventilation modes was comparable across the various LMICs, ranging from 45 - 70%, almost similar to the VENTILO survey.

    Rescue strategies utilized in refractory respiratory failure

    Refractory respiratory failure (PaO2/FiO2 < 150mmHg) remains a challenge in TBI patients where protocols of general ICU cannot always applied. The first strategy used by our respondents is the use of NMBAs, similar to the VENTILO survey.11 It has been suggested that if a short trial of NMBAs in ARDS patients with ventilator dyssynchrony shows improvement in PaO2, it may be continued, preferably for less than 48 hours.20 In this context, the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC) protocol suggests a short trial of NMBAs as tier two intervention in case of raised ICP.17

    Prone position causes alveolar recruitment, improves oxygenation, and reduces mortality in severe ARDS.21 We found that 79.4% of respondents would use the prone position in our survey compared to 63% in the VENTILO survey.11

    A recent systematic review studied the feasibility of prone positioning in brain-injured patients with severe ARDS.22 The authors found that 75% of the selected studies excluded patients with brain injuries and that the number of patients recorded from randomized controlled trials was too small to carry out a meta-analysis. The results, however, indicate an increase in ICP after 1 hour of prone position. The small number of patients included prevented the authors from making any recommendations.

    Our survey shows that about 62% of respondents would use recruitment maneuvers, comparable to the 69% reported in the VENTILO survey.11 The use of recruitment maneuvers can increase intrathoracic pressure and hamper cerebral venous return, thereby reducing cerebral perfusion pressure and causing deleterious effects in brain-injured patients (especially in the case of deranged cerebral autoregulation). If hemodynamic stability is maintained, it can be safely used if associated with improved oxygenation.18,23 However, it must be mentioned that the updated guidelines on the management of adult patients with ARDS recommend against the use of lung recruitment maneuvers.24

    The extracorporeal membrane oxygenation (ECMO) can potentially be a life-saving modality in hypoxemic patients with severe TBI. However, anticoagulation associated with the procedure can promote the progression of hemorrhagic lesions.24 The huge human and financial burden can be a limiting step in its widespread use in resource-limited countries. Notably, 41% of our respondents from LMICs utilize venovenous ECMO, almost comparable to 47% in the VENTILO survey.11 The high use of ECMO in our survey suggests a respondent bias as sophisticated equipment may not be available uniformly in the LMICs. These findings are, therefore, not generalizable.

    Strengths

    An important strength of our study is its international representation. There are experts and respondents from 28 LMICs in this study. No previous study has provided data from the LMICs based on their economic status. Our study gives valuable insight into the variations of practice across the LMICs. The variation between practitioners working in general and neuro-ICUs helps identify gaps due to limited resources. The difference in the economic status of the LMICs, resulting in variations in practice, is also identified in this study; this has never been addressed in any previous trial. Information collected in this study can help in planning future research in the LMICs.

    Limitations

    This study presents some limitations. Firstly, surveys have inherent drawbacks, such as inflexibility and validity. It is challenging to calculate survey response rates, mainly if they are circulated through social media groups and emails. Our respondents worked in either NICUs or general ICUs. This article discusses only the respiratory management of patients with TBI and not the patients’ other systemic or specific clinical conditions. We did not use the defined cut-off values for PaO2/FiO2 in ARDS as we wanted to remain close to the original survey because we used the same clinical scenarios as those in the VENTILO study.11 Another limitation can be a lack of proportionate representation from various nations/regions and within the nation (various set-ups within a nation). This would lead to a likely failure to elicit the exact scenarios in all the LMICs. A limitation of this study is that only a single participant represented some countries. There was also a low representation form LICs (15 of 204 respondents). This limits the ability to draw reliable conclusions about national clinical practices in those countries. Our respondents were physicians and nurses, so respondent bias cannot be ignored. Therefore, some of our findings may not be generalizable.

    CONCLUSION

    The international survey showed variation in ventilatory management of head-injured patients across different geographical regions. This study highlights the necessity for tailored research and guidelines to address the specific challenges faced in traumatic brain injury management within low-and middle-income countries, thereby advocating improved access to neuromonitoring and standardized protocols.

    ACKNOWLEDGMENTS

    List of collaborators

    Alejandro Hlavnicka, Álvaro del Portillo, Ana Maria Mazzola, Bernardo Dorfman, Carina Balasini, Carina Tolosa, Christian Casabella, Diego Perez, Ferioli Alejandro Martín, Gabriela Izzo, Giovanna Salinas, Jorgelina María Guyon Araujo, Juan Ignacio Mele, Leandro Tumino, Luciano Berloni, Maria Gabriela Rodríguez Alvarez, Natalia Fernandez and Pablo Centeno (Argentina); Fredy Sandi, Gabriela Andrea Rivero Guzmán, Luis Arturo Lavadenz Cuentas, Luis David Sanga, Marcela Carola Mérida Iporre and Víctor Alanis Mirones (Bolivia); Cássia Righy and Eduardo Leite Vieira Costa (Brazil); Eder Caceres, Heinznel Negrete Pérez, Jairo Figueroa, Juan Ciro, Ricardo Romero Figueroa and Sebastián Vásquez-García (Colombia); Edgar O Izquierdo (Equador); Aman Edao Bime, Amria Shamil Shafi, Ataklti Adhanom Woldearegay, Befekadu Ali, Habtamu Tilahun Aniley, Hewan Fesehatsion Teklehaimanot, Natnael Kinfe, Nura Kedir, Nura Nasser, Samuel Shisema, Taresa Dechasa Fite, Taye Tesfa and Yonathan Abebe Bulto (Ethiopia); Akhil Mohanan Sugatha, Ankur Luthra, Barkha Bindu, Basjinder Kaur, Chandini Kukanti, Deep Sengupta, Devachandran Jayakumar, Gunchan Paul, Inderpreet Singh Walia, Indranil Ghosh, Jaya Wanchoo, Kalavathy Swarna, Kallol Deb, Kanwalpreet Sodhi, Kiran L Kiro, Lawni Goswami, Madhuri Garg, Manoj Kumar Gatlawar, Monica S Tandon, Murali Thangaraj, Navneh Samagh, Neha Bhandari, Nikhilesh Jain, Nishant Shetty, Prajakta Sunil Lanjewar, Pratheema Ramachandran, Rajishth Mittal, Rekha Pradhan, Sampath, Sivaraj P, Sneha Pandit, Srinivas Samavedam, Uma Hariharan, Vasudha Singhal, Vinay Singhal and Yash Javeri (India); Ade Winata, Akhyar Nur Uhud, Dhania A. Santosa and Sinta Irina (Indonesia); Aigerim Eltaeva, Aset Zhulashev, Azamat, Bekzhan Serikovich, Maya Abdrakhmanova, Murat Daribayev, Nurlan, Pavel Ostanin, Vera Zhuzanova, Zaure Dauletova and Zhanbolat (Kazakhstan); Cerda García Paul Alejandro, Damián Gutiérrez Zárate, Fabricio Ortiz Larios, Francisco Javier Chavez Muro, Jocelyn Cruz Perez, José Iván Rodríguez de Molina Serrano, Julia Teresa Rochín Parra, Luis Alejandro Sanchez-Hurtado, Manuel José Rivera Chavez, María Teresa Mejia Martinez, Michell Estrella Montalvo Aguilar, Missael Espinoza, Sergio Moreno García and Sophia Selene Torres Valdez (Mexico); Nyi Nyi Swe Thein (Myanmar); Amit Shah, Anil Nepali, Anju Paudel, Ankit Rimal, Ashmita Paudel, Bal Chandra Karki, Bhumika Rimal, Bibek Shrestha, Bibhush Shrestha, BijayRaj Timalsina, Birendra Kumar Raut, Bishwo Ram Amatya, Bunu Maharjan, Diwas Bhandari, Grish Dhakal, Kabita Sitoula, Karuna Thapa, Manisha, Manoj Tripathee, Prastuti Panta, Rupesh Gami, Sabin Bhandari, Smita Banskota, Sunil Pathak and Utsav Lal Pradhan (Nepal); Misbahu Haruna Ahmad (Nigeria); Ahmad Naseer; Ahsun W Khan, Asma Yaqoob, Asra Abdul Malik, Atqua Sultan, Awais Durrani, Faisal Iqbal, Hadiqa Tul Batool, Mirza Shahzad Baig, Muhammad Hayat, Muhammad Ilyas, Muhammad Nasir Khoso, Muhammad Shabeer Khan, Muhammad Sheharyar Ashraf, Mujahid Ul Islam, Mustafa Ali, Muzamil Mehmood, Nasib Ullah, Naveed Latif, Rabia Noreen, Ranna, Saad Bin Nafis, Sadia Ali, Sidra Javed, Sohail Ali, Talha Masood and Vardah Wasim (Pakistan); Jessica Andrea Figueredo Sanabria and Noelia Rivas (Paraguay); Abel Arroyo-Sanchez, Hellen Gonzales, Juan Luis Pinedo Portilla, Víctor Antonio Ramirez Palomino and Zilane Vasquez Ortiz de Orue (Peru); Ravi K Weerakoon (Sri Lanka); Ece Uysal, Hidayet Safak Cine, Mehmet Emre Yildrim, Pelin Kuzucu, Sinem Keskin Kayalar, Tarık Akman and Yesim Serife Bayraktar (Turkey); Ciro Antonio Angulo Lacruz, Jacobo Mora and Rafael Davila (Venezuela).

    REFERENCES

    • 1 Maas AI, Menon DK, Manley GT, Abrams M, Åkerlund C, Andelic N, et al.; InTBIR Participants and Investigators. Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol. 2022;21(11):1004-60. Erratum in: Lancet Neurol. 2022 Oct 7.
    • 2 Guan B, Anderson DB, Chen L, Feng S, Zhou H. Global, regional and national burden of traumatic brain injury and spinal cord injury, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. BMJ Open. 2023;13(10):e075049.
    • 3 Prust ML, Mbonde A, Rubinos C, Shrestha GS, Komolafe M, Saylor D, et al. Providing neurocritical care in resource-limited settings: challenges and opportunities. Neurocrit Care. 2022;37(2):583-92.
    • 4 Shrestha GS, Nepal G, Prabhakar H, Prust ML. Cost-effectiveness of neurocritical care in settings with limited resources. Lancet Glob Health. 2023;11(9):e1343.
    • 5 Borsellino B, Schultz MJ, Gama de Abreu M, Robba C, Bilotta F. Mechanical ventilation in neurocritical care patients: a systematic literature review. Expert Rev Respir Med. 2016;10(10):1123-32.
    • 6 Pelosi P, Ferguson ND, Frutos-Vivar F, Anzueto A, Putensen C, Raymondos K, et al.; Ventila Study Group. Management and outcome of mechanically ventilated neurologic patients. Crit Care Med. 2011;39(6):1482-92.
    • 7 Asehnoune K, Rooze P, Robba C, Bouras M, Mascia L, Cinotti R, et al. Mechanical ventilation in patients with acute brain injury: a systematic review with meta-analysis. Crit Care. 2023;27(1):221.
    • 8 Robba C, Poole D, McNett M, Asehnoune K, Bösel J, Bruder N, et al. Mechanical ventilation in patients with acute brain injury: recommendations of the European Society of Intensive Care Medicine consensus. Intensive Care Med. 2020;46(12):2397-410.
    • 9 Matin N, Sarhadi K, Crooks CP, Lele AV, Srinivasan V, Johnson NJ, et al. Brain-lung crosstalk: management of concomitant severe acute brain injury and acute respiratory distress syndrome. Curr Treat Options Neurol. 2022;24(9):383-408.
    • 10 Battaglini D, Siwicka Gieroba D, Brunetti I, Patroniti N, Bonatti G, Rocco PR, et al. Mechanical ventilation in neurocritical care setting: a clinical approach. Best Pract Res Clin Anaesthesiol. 2021;35(2):207-20.
    • 11 Picetti E, Pelosi P, Taccone FS, Citerio G, Mancebo J, Robba C; on the behalf of the ESICM NIC/ARF sections. VENTILatOry strategies in patients with severe traumatic brain injury: the VENTILO Survey of the European Society of Intensive Care Medicine (ESICM). Crit Care. 2020;24(1):158.
    • 12 Fan E, Del Sorbo L, Goligher EC, Hodgson CL, Munshi L, Walkey AJ, et al.; American Thoracic Society, European Society of Intensive Care Medicine, and Society of Critical Care Medicine. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2017;195(9):125363. Erratum in Am J Respir Crit Care Med. 2017;195(11):1540.
    • 13 Mascia L. Acute lung injury in patients with severe brain injury: a double hit model. Neurocrit Care. 2009;11(3):417-26.
    • 14 Berardino A, Anania P, Battaglini D. Crosstalk between brain and the lungs. In: Mahajan C, Kapoor I, Prabhakar H, editors. Brain and Organ Communication - Effect of crosstalk on neurophysiology. San Diego: Elsevier Inc.; 2025. p. 81-96.
    • 15 Serpa Neto A, Cardoso SO, Manetta JA, Pereira VG, Espósito DC, Pasqualucci MO, et al. Association between use of lung-protective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta-analysis. JAMA. 2012;308(16):1651-9.
    • 16 Beqiri E, Smielewski P, Guérin C, Czosnyka M, Robba C, Bjertnæs L, et al. Neurological and respiratory effects of lung protective ventilation in acute brain injury patients without lung injury: brain vent, a single centre randomized interventional study. Crit Care. 2023;27(1):115.
    • 17 Chesnut R, Aguilera S, Buki A, Bulger E, Citerio G, Cooper DJ, et al. A management algorithm for adult patients with both brain oxygen and intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC). Intensive Care Med. 2020;46(5):919-29.
    • 18 Lachi A, Robba C, Pelosi P. Brain-Lung Cross Talk: From pathophysiology to Clinical Applications. In: Prabhakar H, Mahajan C, eds. Physiology in Clinical Neurosciences - Brain and Spinal Cord Crosstalks. Singapore: Springer Nature Singapore; 2020. pp 85-103.
    • 19 Riforgiato C, Battaglini D, Robba C, Pelosi P. Mechanical ventilation - PEEP. In: Prabhakar H, editor. Essentials of Evidence Based Practice of Neuroanesthesia and Neurocritical Care. San Diego: Elsevier Inc.; 2021. pp. 33-42.
    • 20 Rathi V, Ish P, Malhotra N. Muscle relaxants in ARDS - The final verdict with the updated evidence. Lung India. 2024;41(2):81-3.
    • 21 Guérin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, et al.; PROSEVA Study Group. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159-68.
    • 22 Elmaleh Y, Yavchitz A, Léguillier T, Squara PA, Palpacuer C, Grégoire C. Feasibility of prone positioning for brain-injured patients with severe acute respiratory distress syndrome: a systematic review and pilot study (ProBrain). Anesthesiology. 2024;140(3):495-512.
    • 23 Della Torre V, Badenes R, Corradi F, Racca F, Lavinio A, Matta B, et al. Acute respiratory distress syndrome in traumatic brain injury: how do we manage it? J Thorac Dis. 2017;9(12):5368-81.
    • 24 Qadir N, Sahetya S, Munshi L, Summers C, Abrams D, Beitler J, et al. An update on management of adult patients with acute respiratory distress syndrome: an Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2024;209(1):24-36.

    Edited by

    • Responsible editor:
      Viviane Cordeiro Veiga

    Publication Dates

    • Publication in this collection
      15 Aug 2025
    • Date of issue
      2025

    History

    • Received
      15 Feb 2025
    • Accepted
      24 Apr 2025
    Creative Common - by 4.0
    This is an open access article under the CC BY license (https://creativecommons.org/licenses/by/4.0/).
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