Brain protective ventilation in acute brain injury patients with use of fully automated ventilation (BRAVE): A cross-over clinical trial

Abstract

BACKGROUND Invasive ventilation can be challenging in acute brain injury (ABI) patients as partial pressure of carbon dioxide and oxygen need to be kept in precise optimal ranges while simultaneously applying lung-protective ventilation. Fully automated ventilation may be effective in achieving protective ventilation targets for brain and lung. OBJECTIVE(S) To compare automated ventilation to conventional ventilation for ABI patients. DESIGN Single-centre, observational, cross-over trial. SETTING Primary care hospital in Italy, recruiting in 2024. PATIENTS Twenty ABI patients receiving invasive mechanical ventilation. METHODS We performed 3infh of data collection during conventional ventilation followed by 3infh of data collection during automated ventilation. MAIN OUTCOME MEASURE The primary endpoint was the percentage of breaths in three predefined zones of ventilatory targets, defined as optimal, acceptable and critical. The zones were based on patient-specific ranges of four measures: end-tidal carbon dioxide (EtCO2), peripheral oxygen saturation (SpO2), tidal volume (VT), and maximum airway pressures (Pmax). RESULTS A total of 20 patients were included. With automated ventilation the proportion [range] of breaths within the optimal zone significantly increased from 2.7% [0.0 to 23.4] to 30.5% [0.9 to 66.3] (Pinf inf0.001). Automated ventilation markedly decreased the proportion of breaths in the critical zone, from 16.6% [1.9 to 41.3] to 2.1% [0.5 to 7.4] (Pinf inf0.001), while slightly reducing breaths in the acceptable zone from 58.1% [34.4 to 90.9] to 45.1% [25.4 to 90.8] (Pinf inf0.001). Optimal breaths increased for EtCO2, SpO2, and VT, but declined for Pmax with automation. The percentage of time spent in each ventilation zone mirrored the percentage of breaths in each zone. CONCLUSION Automated ventilation outperformed conventional ventilation in maintaining protective ventilation targets for brain and lung in ABI patients. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT06367816.