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Observational Study
. 2026 Jan;52(1):31-41.
doi: 10.1007/s00134-025-08241-0. Epub 2026 Jan 15.

Dynamic driving pressure and clinical outcomes in mechanically ventilated patients with acute brain injury: a secondary analysis of the VENTIBRAIN study

Shaurya Taran  1   2 , Giuseppe Citerio  3   4 , Fabio S Taccone  5 , Emanuele Rezoagli  3   4 , Kuan Liu  6 , Victoria A McCredie  7   6 , John G Laffey  8   9 , Lorenzo Calabro  5 , Nicolo A Patroniti  10   11 , Francesca Graziano  4   12 , Paola Rebora  4   12 , Chiara Robba #  13   14 , Neill K J Adhikari #  7   6   15 ; VENTIBRAIN study group
Collaborators, Affiliations
Observational Study

Dynamic driving pressure and clinical outcomes in mechanically ventilated patients with acute brain injury: a secondary analysis of the VENTIBRAIN study

Shaurya Taran et al. Intensive Care Med. 2026 Jan.

Abstract

Purpose: To investigate the association between dynamic driving pressure (ΔPdyn) and mortality in mechanically ventilated patients with acute brain injury (ABI), and to evaluate whether neurological and pulmonary injury severity modify this relationship.

Methods: This prespecified secondary analysis of the VENTIBRAIN prospective study (NCT04459884) included mechanically ventilated adult patients with ABI (traumatic brain injury, subarachnoid hemorrhage, intracranial hemorrhage, or ischemic stroke). ΔPdyn was calculated daily over the first 14 days as peak inspiratory pressure minus positive end-expiratory pressure (PEEP). Bayesian joint models evaluated the time-varying association between ΔPdyn and mortality at ICU discharge, hospital discharge, and 6 months. Secondary analyses evaluated effect modification by baseline Glasgow Coma Scale (GCS), PaO₂/FiO₂, and ABI subtype.

Results: Among 1,555 patients (median age 59 years, 34.5% female), higher time-varying ΔPdyn was associated with increased ICU mortality (hazard ratio [HR], 1.057 per daily 1cmH2O; 95% credible interval, 1.037-1.078; posterior probability of HR > 1, 99.9%). Findings were consistent across all ABI subtypes and were similar for static ΔP (plateau pressure minus PEEP). The association was strongest in patients with severe ABI (GCS ≤ 8) and severe hypoxemia (PaO₂/FiO₂ ≤ 100). Results were robust across all outcome timepoints and multiple sensitivity analyses.

Conclusion: Higher time-varying ΔPdyn was associated with increased mortality in this cohort of patients with ABI. Neurological injury severity independently modified the harm from ΔPdyn with a magnitude comparable to severe hypoxemia. Measurement of ΔPdyn may aid risk stratification and ventilation strategies in ABI; future trials should evaluate the effect of reducing ΔPdyn in this population.

Keywords: Acute brain injury; Driving pressure; Lung protective ventilation; Ventilator-associated brain injury; Ventilator-induced lung injury.

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Conflict of interest statement

Declarations. Conflicts of interest: CR received fees for lectures from BD, not related to this work. GC reports fees as a Speakers' Bureau Member and Advisory Board Member from Integra and Neuroptics, all outside the submitted work. FST reports fees as an Advisory Board Member for Neuroptics, Nihon Khoden, and Eurosets. JGL reports consulting fees received from Cellenkos. CR is a Deputy Editor for Intensive Care Medicine. She has not taken part in the review or selection process of this article. All other authors declare that they have no relevant conflicts of interest. Ethics approval: The present analysis received ethics approval from Sunnybrook Health Sciences Centre (Project Identification Number: 6569; approval date: 09/Dec/2024).

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