Academic Report on “Ventilation Practices in Acute Brain Injured Patients and Association with Outcomes: The Ventibrain Multicenter Observational Study”

Academic Background

Mechanical ventilation (MV) is a fundamental component of the intensive care unit (ICU) management of acute brain injury (ABI) patients. However, strong evidence on the best ventilatory strategies for ABI patients remains lacking. Previous studies have shown that lung-protective ventilation strategies (LPS) significantly improve clinical outcomes in ICU patients, but these studies often excluded ABI patients because LPS may adversely affect cerebral physiology—such as low tidal volume (TV) and high positive end-expiratory pressure (PEEP) potentially increasing intracranial pressure (ICP). Thus, ventilatory strategies for ABI patients remain controversial, and there is a lack of large-scale international research to evaluate current ventilation practices and their association with clinical outcomes.

This study aims to fill this gap by conducting an international, multicenter, prospective observational study to describe mechanical ventilation settings in ABI patients and their association with ICU and 6-month mortality and neurological outcomes. The study hypothesizes that LPS is widely applied in ABI patients and that these strategies are associated with clinical outcomes.

Source of the Paper

This paper was completed by Chiara Robba, Daniele Giardiello, and other researchers from 74 ICUs across 26 countries including Italy, France, Spain, and China. It was published in the journal Intensive Care Medicine in 2025. The study was supported by the European Society of Intensive Care Medicine (ESICM) and registered at ClinicalTrials.gov (NCT04459884).

Research Process

Study Design and Participants

This study is a prospective, multicenter, observational cohort study conducted from November 25, 2020, to October 15, 2023, involving 2,095 adult ABI patients from 74 ICUs across 26 countries. Patients included those with traumatic brain injury (TBI), intracranial hemorrhage (ICH), subarachnoid hemorrhage (SAH), and acute ischemic stroke (AIS), all requiring intubation and mechanical ventilation. Exclusion criteria included pregnant patients and those receiving only non-invasive ventilation.

Data Collection

The study recorded ventilator settings daily during the first week after admission and additionally on days 10 and 14. Data included ventilation mode, tidal volume (TV), TV/predicted body weight (PBW), plateau pressure (Pplat), driving pressure (DP), PEEP, respiratory rate (RR), and fraction of inspired oxygen (FiO2). Additionally, information on patients’ neurological status and complications (e.g., pneumonia, pneumothorax, ARDS) was collected.

Statistical Analysis

Continuous variables were expressed as medians and interquartile ranges, while categorical variables were expressed as absolute and relative frequencies. Linear mixed-effects models were used to assess heterogeneity in ventilator settings among different countries, and time-dependent Cox proportional hazards regression models were used to analyze the relationship between ventilator settings and ICU and 6-month mortality. Neurological outcomes were assessed using the Extended Glasgow Outcome Scale (GOSE), and their association with ventilator settings was analyzed using logistic regression models.

Main Results

Patient Characteristics

Among the 2,095 patients included, the median age was 58 years, and 66.1% were male. 40% of patients were admitted due to TBI, 27.1% due to ICH, 19.2% due to SAH, and 13.7% due to AIS. The median Glasgow Coma Scale (GCS) score was 7.

Ventilatory Parameters

At admission, the median TV was 480 ml, TV/PBW was 6.5 ml/kg, PEEP was 5 cmH2O, Pplat was 15 cmH2O, and DP was 9 cmH2O. LPS strategies were applied in 86.1% of patients. During the study period, the usage rate of LPS was 91.6%.

Differences Among Countries

Significant differences in ventilator settings were observed across different countries, particularly in mechanical power (MP) and DP, which showed higher variability, while TV/PBW and Pplat exhibited lower variability.

Association Between Ventilator Settings and Outcomes

The ICU mortality rate was 29.2%, and the 6-month mortality rate was 42%. Increases in Pplat, Ppeak, and DP were significantly associated with increased ICU and 6-month mortality, while higher TV/PBW was associated with lower mortality. PEEP, RR, and FiO2 showed a U-shaped relationship with mortality. The association between ventilator settings and neurological outcomes was unclear, with only FiO2 and DP showing a correlation with unfavorable neurological outcomes.

Study Conclusions

This study demonstrates that LPS is widely applied in ABI patients but with significant variability across different countries. Increases in Pplat, Ppeak, and DP were significantly associated with increased ICU and 6-month mortality, while higher TV/PBW was associated with lower mortality. The results emphasize the importance of individualized ventilatory strategies in ABI patients and provide important references for future randomized controlled trials.

Highlights of the Study

1. Large-Scale International Study: This study is the first international, multicenter, prospective observational study on ventilatory practices in ABI patients, providing global data on ventilation practices.
2. Application of Lung-Protective Ventilation: The study confirms that LPS is widely applied in ABI patients but with significant variability across different countries.
3. Association Between Ventilator Settings and Mortality: Increases in Pplat, Ppeak, and DP were significantly associated with increased ICU and 6-month mortality, providing a basis for individualized ventilatory strategies.
4. Exploration of Neurological Outcomes: No clear association was found between ventilator settings and neurological outcomes, suggesting the need for more refined tools for neurological assessment in future studies.

Research Value

This study provides important practical insights into mechanical ventilation strategies for ABI patients, emphasizing the necessity of implementing individualized ventilatory strategies in ICUs. The findings can serve as a reference for the development of clinical guidelines and the design of future randomized controlled trials, further optimizing treatment and prognosis for ABI patients.