Managing ARDS in patients with traumatic brain injury

Article

Author: Carlo Tan, RRT

Date of first publication: 08.07.2025

The authors' point? Managing ARDS and TBI requires a careful, individualized balance of lung-protective ventilation and control of intracranial pressure.

Clinical question

How can clinicians balance lung-protective ventilation strategies with intracranial pressure management in patients with both acute respiratory distress syndrome (ARDS) and traumatic brain injury (TBI), given the conflicting physiological needs of the injured lung and brain?

Clinical background

ARDS is associated with high morbidity and mortality, partly due to ventilator-induced lung injury (VILI). Lung-protective ventilation strategies, such as low tidal volumes (VT), higher positive end-expiratory pressure (PEEP), and permissive hypercapnia, have improved outcomes in ARDS patients.
However, these strategies may worsen intercranial pressure (ICP) and cerebral perfusion in TBI patients, leading to concerns about their safety in this population.
Current guidelines for ARDS management and TBI treatment follow stepwise approaches, but their implementation in patients with both conditions remains challenging.
To date, most ARDS trials have excluded patients with brain injury, resulting in a lack of high-level evidence to guide ventilation strategies in this group.
A multidisciplinary, individualized approach is necessary to optimize lung protection and cerebral perfusion, while adapting treatment strategies based on the patient's condition.

Design and setting

The study is a narrative review examining the management of ARDS in patients with TBI. It discusses the conflicting treatment strategies for these two conditions, highlights the lack of consensus on optimal management, and emphasizes the need for a multidisciplinary, individualized approach (Robba C, Camporota L, Citerio G. Acute respiratory distress syndrome complicating traumatic brain injury. Can opposite strategies converge?. Intensive Care Med. 2023;49(5):583-586. doi:10.1007/s00134-023-07043-61). The article proposes a pragmatic, stepwise method for balancing lung protection with intracranial pressure control, stressing the importance of neuromonitoring in guiding treatment decisions.

Discussion

Managing ARDS and concomitant TBI requires balancing lung-protective ventilation with ICP control. The Seattle consensus categorizes 18 interventions into four escalating tiers based on severity. Tier 0 includes basic care, while Tiers 1–3 progressively introduce more intensive strategies for ARDS and ICP management. This structured approach helps maintain ICP below 22 mmHg, while optimizing oxygenation and ventilation.

Condition: TBI

Tier	Intervention / Strategy
Tier 0	Maintain homeostasis (normothermia, analgesia, sedation) Intubation Mechanical ventilation (normoxia, normocapnia)
Tier 1 - Increased ICP	Cerebral perfusion pressure (CPP) of 60–70 mmHg PaCO2 to 35–38 mmHg Deeper analgesia and sedation to lower ICP Osmotic therapy Anti-seizure prophylaxis
Tier 2 - Persistently increased ICP	PaCO2 to 32–35 mmHg Neuromuscular blockade Higher mean arterial pressure to increase CPP can be adopted
Tier 3 - Refractory intracranial hypertension	Barbiturates Hypothermia Decompressive craniectomy

Condition: Combined TBI and ARDS

ARDS type	Intervention / Strategy
No ARDS	Basic respiratory support: VT: 6–8 ml/PBW PEEP: 5 cmH2O RR: 16–22 bpm
Mild ARDS (PaO2/FiO2 200–300 mmHg)	Tidal volumes titrated keeping driving pressure < 14–15 cmH2O Respiratory rate can be adapted if hypercapnia is not controlled
Moderate to severe ARDS (PaO2/FiO2 < 200 mmHg)	Prone positioning with close ICP monitoring ECMO if ICP is uncontrolled Consider decompressive craniectomy, barbiturates, hypothermia earlier if needed to achieve lung-protective ventilation
Severe ARDS (PaO2/FiO2 < 100 mmHg)	ECMO (especially in patients with low risk of cerebral bleeding) Prone positioning with multimodal neuromonitoring

Be aware!

When managing TBI patients with ARDS, climbing one step of the ARDS treatment staircase can lead to worsening ICP, and vice versa.

Conclusion

In the case of a worsened cerebral and/or respiratory condition, physicians should be ready to adapt the guidelines to clinical needs, and more advanced treatment tiers for ARDS and TBI staircase should be discussed. The review emphasizes the importance of individualized care, taking into account the specific characteristics of each patient's TBI and ARDS.

How can Hamilton Medical technology help?

What do these findings mean in terms of Hamilton Medical technology? Hamilton ventilators offer advanced monitoring and ventilation modes that can facilitate the management of these complex patients. The key features are outlined below.


Advanced ventilation modes	Modes like ASV (Adaptive Support Ventilation) or INTELLiVENT-ASV can help optimize lung mechanics and gas exchange, while maintaining cerebral protection by means of tight CO2 control. INTELLiVENT-ASV incorporates a TBI protocol that allows for manual PEEP setting, strict PetCO2 control, and targeting higher SaO2 values as initial settings.
Integrated monitoring	Monitoring tools for respiratory mechanics (driving pressure, plateau pressure) can help guide ventilation settings and assess their impact on ICP and CPP when monitored together with hemodynamics.
Individualized settings	Hamilton ventilators allow for precise titration of ventilation parameters, enabling clinicians to tailor the settings to the individual patient's needs.

Additional abbreviations

RR: Respiratory rate
PaCO2: Partial pressure of carbon dioxide in the arterial blood
FiO2: Fraction of inspired oxygen
etCO2: End-tidal carbon dioxide
SaO2: Saturation of oxygen in the arterial blood

Footnotes

References

1. Robba C, Camporota L, Citerio G. Acute respiratory distress syndrome complicating traumatic brain injury. Can opposite strategies converge?. Intensive Care Med. 2023;49(5):583-586. doi:10.1007/s00134-023-07043-6

Acute respiratory distress syndrome complicating traumatic brain injury. Can opposite strategies converge?

Robba C, Camporota L, Citerio G. Acute respiratory distress syndrome complicating traumatic brain injury. Can opposite strategies converge?. Intensive Care Med. 2023;49(5):583-586. doi:10.1007/s00134-023-07043-6

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