Neuroprotective Ventilation in Traumatic Brain Injury (TBI)
Introduction
Neuroprotective ventilation in TBI aims to prevent secondary brain injury by maintaining adequate oxygen delivery to the injured brain while avoiding ventilator settings that worsen intracranial pressure (ICP) or cerebral perfusion. The clinician must balance lung‑protective ventilation (to reduce ventilator‑associated lung injury) with precise control of arterial carbon dioxide tension (PaCO2), because small changes in PaCO2 rapidly alter cerebral blood flow (CBF) and ICP.
Key arterial gas targets (UK guidance)
- PaO2: aim for PaO2
> 13 kPa in patients with head injury (NICE NG232). Avoid hypoxaemia - it is strongly linked to worse outcomes.
- PaCO2: target 4.5-5.0 kPa in intubated TBI patients (NICE NG232). Avoid routine prophylactic hyperventilation; short‑term hyperventilation is only for acute ICP crises and must be documented and monitored.
Note: Resuscitation Council UK post‑arrest guidance gives slightly different post‑ROSC targets (PaO2 ≈ 10-13 kPa; PaCO2 ≈ 4.7-6.0 kPa). When TBI and post‑arrest management overlap, prioritise the TBI targets unless other clinical priorities dictate otherwise (NICE NG232; Resuscitation Council UK).
Initial ventilator strategy (a defensible starting approach)
These represent commonly used starting parameters consistent with UK guidance; individualise to ABG, ICP/CPP and lung mechanics.
- Mode: controlled IPPV for sedated/paralysed patients.