High-frequency oscillatory ventilation in adults with traumatic brain injury and acute respiratory distress syndrome

Background:  This study observed adverse events of rescue treatment with high-frequency oscillatory ventilation (HFOV) in head-injured patients with acute respiratory distress syndrome (ARDS). Methods:  Data of five male patients with ARDS and traumatic brain injury, median age 28 years, who failed to respond to conventional pressure-controlled ventilation (PCV) were analyzed retrospectively during HFOV. Adjusted mean airway pressure at initiation of HFOV was set to 5 cm H2O above the last measured mean airway pressure during PCV. Frequency of pulmonary air leak, mucus obstruction, tracheal injury, and need of HFOV termination due to increased intracranial pressure, decreased cerebral perfusion pressure, or deterioration in PaCO2 were analyzed. Results:  During HFOV we found no complications. We recorded 390 datasets of intracranial pressure, cerebral perfusion pressure and PaCO2 simultaneously. Intracranial pressure increased (>25 mmHg) in 11 of 390 datasets, cerebral perfusion pressure was reduced ( 6.0 kPa) were observed in eight of 390 datasets after initiation of HFOV. All these alterations were responsive to treatment. PaO2/FIO2-ratio improved in four patients during HFOV. Conclusion:  High-frequency oscillatory ventilation appears to be a promising alternative rescue treatment in head-injured patients with ARDS if continuous monitoring of intracranial pressure, cerebral perfusion pressure and PaCO2 are provided, in particular during initiation of HFOV.