Stroke Mechanical ventilation

1. MECHANICAL VENTILATION
IN STROKE PATIENTS
WAHEED SHOUMAN
PROFESSOR
CHEST DISEASES
ZAGAZIG UNIVERSITY

2. 20% of ICU patients undergo
MV due to neurogical etiology
10% of stroke patients need
MV
Two thirds of them die during
hospitalization

3. •The outcome of MV-stroke patients is
poor with mortality rates of 57%-90%
•Survivors have poor functional
outcome
•Mortality was worst in brain stem
hemorrhage (78%) and least in
cerebellar hemorrhage (43%)

8. Factors affecting outcome in MV-stroke
patients:
GCS at time of initiation of MV (very
important)
Age
Presence or absence of brain stem reflexes
Reason of intubation and MV
Location of infarction (basilar artery
occlusion) (but brain stem is controversial)
High ICP
Apneic episodes
Type of stroke
Need for hemicraniotomy

12. Causes of intubation in
stroke patients
GCS ≤ 8
Airway compromise
Apnea
Hypoxemia despite of supplemental
oxygen
Controlled hyperventilation (obsolete)
Impaired swallowing and gag reflex
Inability to clear secretions
Seizures with drugs suppressing respiratory
drive

13. Controlled hyperventilation
Is to make Paco2 ≤ 25mmHg, this
cause alkalosis induced cerebral
vasoconstriction through cerebral
influx of HCO3
It loses its efficacy by 6-12 hours
Patients treated with controlled
hyperventilation have poorer
outcome

14. There is higher rates of intubation in
hemorrhagic stroke patients (~30%)
than ischemic stroke (~5%) i.e. 5-6 times
Absence of papillary reflex at time
of intubation carry poor prognosis in
both stroke types
Initiation of MV for primary
neurological cause has worse
prognosis

16. Causes of acute respiratory
failure in stroke patients:
1. Central drive depression
2. Neurogenic pulmonary edema
3. Seizures and their drug therapy
4. Sepsis and pneumonia
5. Pulmonary embolism

17. OLD TRADITIONAL STRATEGIES
DO NOT USE IT

18. Ventilatory strategy in stroke patients
are the same as any neurological lesion
taking in consideration the primary lung
status
Old higher tidal volumes are not
recommended and it is better to consider
SIMV-PSV or protective lung strategies in
these patients

19. PEEP higher than 10 cmH2O significantly
increase ICP
This effect is largely attributed to
increased intra-thoracic pressure and
impaired venous return
If PEEP is used , elevation of bed head 30-
40 degree will help to alleviate its effect on
ICP
I-E ratio does not affect ICP
Hyperoxia has no proven efficacy in
stroke patients

21. Tracheostomy in stroke patients:
Controversial
If GCS is 6-8 at day 4-5 of MV
If ETT is in place for 2 weeks and
proposed to be need for longer period
(whatever the cause)
Early tracheostomy has modest benefit
(within the 1st 10 days)

22. Liberation from MV in stroke patients:
No guidelines in this situation
General guidelines are applied in these
patients with emphasis that :
NIP > 20 cmH2O
VC ~ 15 ml per kg (ideal body weight)
Spontaneous breathing trial may
increase ICP