This document discusses mechanical ventilation in stroke patients. It notes that 10% of stroke patients require mechanical ventilation, and two-thirds of those patients die during hospitalization. The outcome for mechanically ventilated stroke patients is generally poor, with mortality rates between 57-90%. Several factors can affect the outcome, including Glasgow Coma Scale at initiation of ventilation and the location and type of stroke. The causes and strategies for mechanical ventilation in stroke patients are discussed, along with considerations for ventilator settings and weaning from 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