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. 2025 Aug 25.
doi: 10.1097/EJA.0000000000002253. Online ahead of print.

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

Robin L Goossen  1 , Sibilla Gavinelli, Simone Dragoni, David M P van Meenen, Frederique Paulus, Marcus J S Schultz, Lorenzo Ball, Nicolo' Antonino Patroniti, Chiara Robba
Affiliations

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

Robin L Goossen et al. Eur J Anaesthesiol. .

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.

Objectives: 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 3 h of data collection during conventional ventilation followed by 3 h 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] (P < 0.001). 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] (P < 0.001), while slightly reducing breaths in the acceptable zone from 58.1% [34.4 to 90.9] to 45.1% [25.4 to 90.8] (P < 0.001). 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.

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References

    1. Maas AI, Marmarou A, Murray GD, et al. Prognosis and clinical trial design in traumatic brain injury: the IMPACT study. J Neurotrauma 2007; 24:232–238.
    1. Robba C, Battaglini D, Abbas A, et al. Clinical practice and effect of carbon dioxide on outcomes in mechanically ventilated acute brain-injured patients: a secondary analysis of the ENIO study. Intensive Care Med 2024; 50:234–246.
    1. Robba C, Battaglini D, Cinotti R, et al. Individualized thresholds of hypoxemia and hyperoxemia and their effect on outcome in acute brain injured patients: a secondary analysis of the ENIO Study. Neurocrit Care 2024; 40:515–528.
    1. Robba C, Poole D, McNett M, et al. Mechanical ventilation in patients with acute brain injury: recommendations of the European Society of Intensive Care Medicine consensus. Intensive Care Med 2020; 46:2397–2410.
    1. Carney N, Totten AM, O’Reilly C, et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery 2017; 80:6–15.

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