Managing the cerebral complications of acute respiratory distress syndrome

Robba, C., Cho, SM. & Sekhon, M.S. Managing the cerebral complications of acute respiratory distress syndrome. Intensive Care Med (2024). https://doi.org/10.1007/s00134-024-07434-3

Abstract:

Acute Respiratory Distress Syndrome (ARDS) accounts for a significant portion of critical care admissions globally, with evolving ventilation strategies improving survival rates. However, these strategies often neglect the neurological sequelae that many survivors face. This paper discusses the cerebral complications associated with ARDS, including ischemic stroke, intracranial hemorrhage, and neurocognitive dysfunction, and explores management strategies that balance optimal lung function with the preservation of neurological integrity. The paper emphasizes the importance of early and individualized assessment of cerebral physiology to prevent or minimize brain injury in the context of ARDS management.

Keywords:

Acute Respiratory Distress Syndrome, ARDS, cerebral complications, ischemic stroke, intracranial pressure, lung protective ventilation, veno-venous ECMO, neurocognitive dysfunction

Introduction:

ARDS is a critical condition characterized by severe respiratory failure, leading to a high incidence of cerebral complications due to both the disease and its treatments. As ARDS treatments have evolved, there is an increasing need to understand and address the potential neurological impacts, as these can significantly affect long-term outcomes.

Pathophysiology:

The cerebral complications in ARDS can be attributed to several factors exacerbated by necessary medical interventions:

• Hypercapnia: Common in ARDS due to ventilatory management, leading to cerebral vasodilation and potentially increased intracranial pressure (ICP).
• Hypoxemia: Strategies to minimize oxygen toxicity can lead to significant reductions in arterial oxygen tension (PaO2), risking cerebral hypoxia and subsequent injury.
• Venous Return Impairment: Techniques like prone positioning can impede jugular venous return, elevating ICP and risking further cerebral injury.

Management Strategies:

Management of ARDS must consider the delicate balance between ensuring lung protection and preventing cerebral harm. This involves:

• Early Neurological Assessment: Prompt use of neuroimaging and non-invasive neuromonitoring to gauge the risk of neurological complications.
• Tailoring Ventilatory Strategies: Adjusting strategies like the use of neuromuscular blockade, permissive hypercapnia, and ECMO settings based on individual cerebral risk assessments.
• Non-invasive Neuromonitoring: Employing tools like transcranial Doppler and optic nerve sheath diameter ultrasonography to continuously assess cerebral status and guide treatment decisions.

Discussion:

The article discusses the complexities of managing ARDS patients who are at risk of significant cerebral complications. It highlights the need for a multidisciplinary approach to manage these patients, integrating pulmonary and neurological expertise to optimize both respiratory and neurological outcomes. The discussion also notes the lack of definitive guidelines for balancing these aspects and calls for more research into integrated management strategies.

Conclusion:

The management of ARDS requires not only the optimization of respiratory function but also the protection of cerebral integrity. Early and individualized assessment of cerebral physiology should be a standard part of ARDS management to mitigate the risk of long-term neurological damage. This approach promises to improve overall outcomes by reducing both pulmonary and neurological complications.

Watch this video on "Why monitor brain function in ARDS?" by Dr. Chiara Robba (ISICEM)

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Discussion Questions:

1. How can current ventilatory strategies be adjusted to minimize the risk of cerebral complications in ARDS patients?
2. What role does veno-venous ECMO play in balancing lung protection and cerebral perfusion?
3. How can non-invasive neuromonitoring be effectively integrated into daily clinical practice for ARDS patients to monitor and manage potential cerebral complications?

Javier Amador-Casta?eda, BHS, RRT, FCCM, PNAP

Interprofessional Critical Care Network (ICCN)

[email protected]

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