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.

[author title=”About the Author”]