Bad brain, good lungs… Right?

A 60 y/o male with a history of HTN, CAD, and polysubstance abuse presents to the ED with acute altered mental status followed by a generalized seizure.  He is intubated for airway protection, and his vital signs are as follows:

T: 38.5      P: 120-130   BP:  [210 – 240] / [120 – 140]     Vent: AC  16 / 700 / 5 / 40%  SpO2:100%

He is admitted to the NeuroICU and being managed in conjunction with the neurosurgeons in house.  After 4 days, the patient’s chest X-ray shows bilateral pulmonary infiltrates and he develops an increased O2 requirement.  His P/F ratio is 150 and is diagnosed with ARDS.  What happened?

This month in Critical Care Medicine, there was a great retrospective study on the incidence of acute respiratory distress syndrome (ARDS) in patients presenting with spontaneous intracerebral hemorrhage over a 10-year period.  After reviewing 1,665 patients, the authors found that:

  • The development of ARDS occurred in approximately 27% of patients with spontaneous ICH (similar to previous literature).
  • The incidence ARDS after spontaneous ICH was similar to other “high-risk” conditions such as sepsis, trauma, & aspiration.
  • Modifiable risk factors include: high tidal volume ventilation, higher total fluid balance, & transfusion of PRBCs/FFP.

It’s of particular importance to note that high tidal volume ventilation (>8cc/kg) was the single greatest modifiable factor for the development of ARDS.

Bottom line:  Try and use lung-protective ventilation strategies (6-8cc/kg ideal body weight) and avoid excessive volume resuscitation whenever possible.  Even in cases of isolated intracerebral hemorrhage – where the patient’s lungs may appear to be completely normal – traditional tidal volume settings may cause excessive barotrauma that can lead to the development of ARDS.

  1. Elmer J, Hou P, Wilcox SR, et al.  Acute respiratory distress syndrome after spontaneous intracerebral hemorrhage. Crit Care Med; 2013 Aug; 41(8): 1992-2001.
About the Author

John Greenwood

Creator of the PressorDex & . Resuscitationist, Heart & Vascular ICU Intensivist. Focus in mechanical circulatory support & medical education #FOAMcc #FOAMed Twitter: @johngreenwoodmd Email:

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