Effects of positive end-expiratory pressure on intracranial pressure and compliance in brain-injured patients

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✓ Hypoxic pulmonary disorders and head injuries associated with increased intracranial pressure (ICP) frequently co-exist. Positive end-expiratory pressure (PEEP) improves hypoxemia but has been reported to impede cerebral venous return, potentially causing a further increase in ICP. This study examined the effects of PEEP on ICP at different levels of brain compliance.

Continuous ICP recordings were obtained after insertion of Scott cannulas to the lateral ventricles of seven comatose patients. Brain compliance was assessed by calculation of the pressure volume index. Patients were maintained in a 30° head-up position. Maintenance of PEEP to levels of 40 cm H2O pressure for as long as 18 hours did not increase ICP in patients with either normal or low intracranial compliance, and did not increase ICP in the absence of pulmonary disease. Central venous pressure and pulmonary artery wedge pressure increased proportionately as PEEP was increased. No consistent changes were found in blood pressure recordings, nor were there any reductions in cardiac output found during the studies. Abrupt discontinuation of PEEP did not result in increased ICP except for a transient rise on two occasions when respiratory secretions became copious and the patients were inadequately ventilated. Improved oxygenation in two patients as a result of PEEP was concomitant with improved intracranial compliance and neurological status.

In patients with brain injuries, PEEP improves arterial oxygenation without increasing ICP as previously supposed. Consequently, PEEP is a valuable form of therapy for the comatose patient with pulmonary disorders such as pneumonia or pulmonary edema.

Article Information

Address reprint requests to: Elizabeth A. M. Frost, M.D., Department of Anesthesiology, Albert Einstein College of Medicine, Yeshiva University, 1300 Morris Park Avenue, Bronx, New York 10461.

© AANS, except where prohibited by US copyright law.

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    Intracranial pressure (ICP) recordings with changing positive end-expiratory pressure (PEEP). Effect of increasing levels of PEEP on ICP in seven patients with different brain compliance (pressure volume index).

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    Wave patterns with changing positive end-expiratory pressure (PEEP). Effect on intracranial pressure (ICP) wave patterns of incremental changes in airway pressure from zero end-expiratory pressure (ZEEP) to 40 cm H2O PEEP. PVI = pressure volume index.

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    Response of central venous pressure (CVP) to changing positive end-expiratory pressure (PEEP). Average increase in CVP with stepwise increase in PEEP in seven patients.

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    Pulmonary arterial wedge pressure (PAWP) versus increasing positive end-expiratory pressure (PEEP). Average increase in PAWP in two patients as end-expiratory pressure is increased from 0 to 25 cm H2O.

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