Mechanical Ventilation in Brain-injured Patients

A before/after study design will be used. The before period (control phase) will consisted of all consecutive patients with severe brain-injury who were admitted to the participating ICUs.

During the interphase, all physicians, residents, physiotherapists and nurses will receive a formal training for the processes and procedures related to the 2 point bundle: protective ventilation and systematic approach to extubation (according to recommendation for the use of tidal volume < 7 ml/kg and of a positive expiratory pressure = 6 to 8 cmH20 (centimeter of water) and extubation as soon as ventilatory weaning is associated with a glasgow coma scale equal or above 10 and cought).

The after period consisted of all consecutive severe brain-injured patients admitted to the participating ICUs after the formal training.

• Pass recommendations on ventilation factors and extubation (Other): * the use of tidal volume < 7 ml/kg and of a positive expiratory pressure = 6 to 8 cmH20 (centimeter of water) * extubation as soon as ventilatory weaning is associated with a glasgow coma scale equal or above 10 and cough

Primary outcomes

• Mechanical ventilatory free days [Day-90]: The number of ventilator-free days was defined as the number of days from day 1 to day 90 on which a patient breaths spontaneously and is alive

Secondary outcomes

• Mortality [day-90]
• In-ICU mortality [90 days]
• Duration of mechanical ventilation [90 days]
• ICU free days at day 90 [day 90]: The number of ICU free days was defined as the number of days from day 1 to on which a patient is alive and not hospitalized in ICU
• Acute respiratory distress syndrome / acute lung injury [day-90]
• Hospital acquired pneumonia [day-90]
• Blood gaz [day-5]: PaO2 (arterial pressure of oxygen) and PaCO2 (arterial pressure of dioxide of carbon)
• Intracranial pressure [day-5]
• Glasgow outcome scale [day-90]
• Extubation failure [day-90]
• Ventilatory setting [day-5]: Tidal volume and Positive end expiratory pressure

Sex: All, ages: 18 Years to any

Inclusion Criteria:

* Adult patients (traumatic brain-injured, subarachnoid hemorrhage, stroke or other)
* Brain injury (Glasgow Coma Scale ≤ 12 associated with at least one anomaly related to an acute process on head tomographic tomodensitometry
* mechanical ventilation for more than 24 hours

Exclusion Criteria:

* early decision to withdraw care (taken in the first 24 hours in ICU),
* death in the first 24 hours

• Results publication: Asehnoune K, Mrozek S, Perrigault PF, Seguin P, Dahyot-Fizelier C, Lasocki S, Pujol A, Martin M, Chabanne R, Muller L, Hanouz JL, Hammad E, Rozec B, Kerforne T, Ichai C, Cinotti R, Geeraerts T, Elaroussi D, Pelosi P, Jaber S, Dalichampt M, Feuillet F, Sebille V, Roquilly A; BI-VILI study group. A multi-faceted strategy to reduce ventilation-associated mortality in brain-injured patients. The BI-VILI project: a nationwide quality improvement project. Intensive Care Med. 2017 Jul;43(7):957-970. doi: 10.1007/s00134-017-4764-6. Epub 2017 Mar 18. PMID 28315940

• Karim Asehnoune, MD, PhD, Principal investigator, Nantes University Hospital