What are the guidelines for ventilator management in Acute Cerebrovascular Accident (CVA) or Stroke?

From the Guidelines

Ventilator management in acute stroke patients should prioritize maintaining adequate oxygenation while preventing secondary brain injury, with a focus on supplemental oxygen to maintain oxygen saturation ≥94% 1.

Key Considerations

• Initial ventilator settings should include a tidal volume of 6-8 mL/kg ideal body weight, respiratory rate of 12-16 breaths per minute, PEEP of 5-8 cmH2O, and FiO2 titrated to maintain SpO2 >94%
• Target PaCO2 should be maintained at 35-40 mmHg as both hypercapnia and hypocapnia can worsen cerebral blood flow and intracranial pressure
• Tracheal intubation is indicated for a compromised airway or insufficient ventilation due to impaired alertness or bulbar dysfunction 1
• Sedation protocols using propofol or dexmedetomidine are preferred as they allow for neurological assessments when temporarily discontinued
• Daily sedation interruptions should be performed when possible to assess neurological status
• Neuromuscular blockade with agents like cisatracurium may be necessary for patients with severe intracranial hypertension or ventilator dyssynchrony

Rationale

The most recent and highest quality study, a systematic review and synthesis of global stroke guidelines 1, recommends supplemental oxygen to maintain oxygen saturation ≥94% and tracheal intubation for a compromised airway or insufficient ventilation.

Additional Recommendations

• Critically ill stroke patients with decreased level of consciousness that need mechanical ventilation should receive early (not more than 72 h) enteral tube feeding 1
• Head elevation at 30 degrees helps reduce intracranial pressure while minimizing ventilation-perfusion mismatch
• For patients with increased intracranial pressure, brief periods of hyperventilation (PaCO2 30-35 mmHg) may be used as a temporary measure, but prolonged hyperventilation should be avoided as it can cause cerebral vasoconstriction and ischemia

Conclusion is not allowed, so the answer will be ended here.

From the Research

Ventilator Management in Acute Stroke

• The management of mechanical ventilation in patients with acute ischemic stroke is crucial, as these patients often require higher-acuity care and admission to the intensive care unit 2.
• Mechanical ventilation is frequently performed in these patients due to swallowing dysfunction and airway or respiratory system compromise, and pulmonary complications are common and can be fatal 2.
• The optimal mechanical ventilator strategy remains unclear in this population, but a protective ventilatory strategy (tidal volume = 6-8 mL/kg predicted body weight, positive end-expiratory pressure, and rescue recruitment maneuvers) may have a role in brain-damaged patients, including those with stroke 2.

Initial Ventilator Settings

• The lung-protective mechanical ventilation strategy has been standard practice for management of acute respiratory distress syndrome (ARDS) for more than a decade, and is also recommended as an initial approach to mechanical ventilation in both perioperative and critical care settings 3.
• Principles of lung-protective ventilation include prevention of volutrauma, prevention of atelectasis, adequate ventilation, and prevention of hyperoxia 3.
• Most patients tolerate lung protective mechanical ventilation well without the need for excessive sedation, but patients with a stiff chest wall may tolerate higher plateau pressure targets, and those with severe ARDS and ventilator asynchrony may require a short-term neuromuscular blockade 3.

Prognosis of Stroke Patients Requiring Mechanical Ventilation

• The prognosis of stroke patients requiring mechanical ventilation has often been reported to be poor, but a study found that the 1-year survival rate was 33.1%, and that older patients comatose on admission who need to be intubated because of neurological or respiratory deterioration have the poorest prognosis 4.
• Independent predictors of death at 2 months were age greater than 65 years, Glasgow Coma Scale (GCS) score less than 10, and intubation performed because of coma or acute respiratory failure 4.

Lung-Protective Ventilation Strategies

• Lung-protective ventilation strategies should be used if not contraindicated, and it is important to consider pathophysiology when formulating treatment strategies in patients who are difficult to oxygenate or ventilate 5.
• The use of lung-protective ventilation strategies and adjunctive treatments can improve outcomes in patients with acute respiratory failure 5.

Sedation During Mechanical Ventilation

• Deep sedation, especially early in the course of mechanical ventilation, is associated with prolonged time to liberation from mechanical ventilation, longer ICU stays, longer hospital stays, and increased mortality 6.
• Light sedation should be targeted early in the course of mechanical ventilation utilizing daily interruptions of sedation and/or nursing protocol-based algorithms, even in severe ARDS 6.