Effect of positive end-expiratory pressure on optic nerve sheath diameter in mechanically ventilated traumatic brain injury patients

Document Type : Original papers

Authors

1 Emergency Medicine and Traumatology Department, Faculty of Medicine, Tanta University, Tanta, Egypt

2 Anesthesia and Surgical ICU Department, Faculty of Medicine, Kafrelsheih University, Kafrelsheih, Egypt

3 Ophthalmology Department, Faculty of Medicine, Ain Shams University, Ain Shams, Egypt

10.21608/jicem.2025.464970

Abstract

Background: In patients with traumatic brain injury (TBI), positive end-expiratory pressure (PEEP) can change intrathoracic pressure and cerebral hemodynamics, which in turn affects intracranial pressure (ICP). This research aimed to determine varying PEEP levels on optic nerve sheath diameter (ONSD), an indirect predictor of ICP, in mechanically ventilated (MV) TBI and non-TBI patients. Methods: This prospective observational study enrolled 60 MV patients (30 TBI, 30 non-TBI controls). ONSD was measured bilaterally at 5, 10, and 15 mmHg PEEP levels. Results: At 15 mmHg PEEP, ONSD was considerably more remarkable in the TBI group (5.68±0.27 mm) compared to controls (5.4±0.18 mm,  p<0.001). The median delta change in average ONSD between 15 mmHg and 5 mmHg was 0.55 mm (IQR: 0.31-0.65) in the TBI group and 0.27 mm (IQR: 0.20-0.35) in controls (p<0.001). TBI was an independent predictor of delta ONSD change. Conclusions: TBI patients exhibit a significantly greater increase in ONSD with higher PEEP levels than non-TBI controls, suggesting enhanced ONSD sensitivity to PEEP in individuals with brain injury. This highlights the need for careful PEEP titration to balance lung recruitment and ICP management in MV TBI patients.

Keywords

References

  1. Cove ME, Pinsky MR, Marini JJ. Are we ready to think differently about setting PEEP? Crit Care. 2022;26:222.
  2. Bala R, Kumar R, Sharma J. A study to evaluate effect of PEEP and end-tidal carbon dioxide on optic nerve sheath diameter. Indian J Anaesth. 2019;63:537-43.
  3. Boone MD, Jinadasa SP, Mueller A, Shaefi S, Kasper EM, Hanafy KA, et al. The effect of positive end-expiratory pressure on intracranial pressure and cerebral hemodynamics. Neurocrit Care. 2017;26:174-81.
  4. El Sayed MJ, Zaghrini E. Prehospital emergency ultrasound: a review of current clinical applications, challenges, and future implications. Emerg Med Int. 2013;2013:531674.
  5. Rajajee V, Vanaman M, Fletcher JJ, Jacobs TL. Optic nerve ultrasound for the detection of raised intracranial pressure. Neurocrit Care. 2011;15:506-15.
  6. Chen L-M, Wang L-J, Hu Y, Jiang X-H, Wang Y-Z, Xing Y-Q. Ultrasonic measurement of optic nerve sheath diameter: a non-invasive surrogate approach for dynamic, real-time evaluation of intracranial pressure. Br J Ophthalmol. 2019;103:437-41.
  7. Meiburger KM, Naldi A, Michielli N, Coppo L, Fassbender K, Molinari F, et al. Automatic optic nerve measurement: a new tool to standardize optic nerve assessment in ultrasound B-mode images. Ultrasound Med Biol. 2020;46:1533-44.
  8. Soldatos T, Karakitsos D, Chatzimichail K, Papathanasiou M, Gouliamos A, Karabinis A. Optic nerve sonography in the diagnostic evaluation of adult brain injury. Crit care. 2008;12:1-7.
  9. Blaivas M, Theodoro D, Sierzenski PR. Elevated intracranial pressure detected by bedside emergency ultrasonography of the optic nerve sheath. Acad Emerg Med. 2003;10:376-81.
  10. Chen H, Chen K, Xu J-Q, Zhang Y-R, Yu R-G, Zhou J-X. Intracranial pressure responsiveness to positive end-expiratory pressure is influenced by chest wall elastance: a physiological study in patients with aneurysmal subarachnoid hemorrhage. BMC Neurol. 2018;18:124.
  11. Chen H, Xu M, Yang Y-L, Chen K, Xu J-Q, Zhang Y-R, et al. Effects of increased positive end-expiratory pressure on intracranial pressure in acute respiratory distress syndrome: a protocol of a prospective physiological study. BMJ open. 2016;6:e012477.
  12. Chin J-H, Kim W-J, Lee J, Han YA, Lim J, Hwang J-H, et al. Effect of positive end-expiratory pressure on the sonographic optic nerve sheath diameter as a surrogate for intracranial pressure during robot-assisted laparoscopic prostatectomy: a randomized controlled trial. PLoS One. 2017;12:e0170369.
  13. Fernandez-Bustamante A, Sprung J, Parker RA, Bartels K, Weingarten TN, Kosour C, et al. Individualized PEEP to optimise respiratory mechanics during abdominal surgery: a pilot randomised controlled trial. Br J Anaesth. 2020;125:383-92.
  14. Liu X-M, Chang X-L, Sun J-Y, Hao W-W, An L-X. Effects of individualized positive end-expiratory pressure on intraoperative oxygenation in thoracic surgical patients: study protocol for a prospective randomized controlled trial. Trials. 2024;25:19.
  15. Rezoagli E, Bellani G. How I set up positive end-expiratory pressure: evidence-and physiology-based! Crit Care. 2019;23:412.
  16. Zunino G, Battaglini D, Godoy DA. Effects of positive end-expiratory pressure on intracranial pressure, cerebral perfusion pressure, and brain oxygenation in acute brain injury: Friend or foe? A scoping review. J Intensive Med. 2024;4:247-60.
  17. Kim DH, Jun J-S, Kim R. Ultrasonographic measurement of the optic nerve sheath diameter and its association with eyeball transverse diameter in 585 healthy volunteers. Sci Rep. 2017;7:15906.
  18. Gupta N, Singh VK, Jafa S. Correlation of positive end-expiratory and intracranial pressure using the ultrasonographic-guided measurement of optic nerve sheath diameter in traumatic brain injury patients. Neurol India. 2021;69:1670-4.
  19. Balakrishnan S, Naik S, Chakrabarti D, Konar S, Sriganesh K. Effect of respiratory physiological changes on optic nerve sheath diameter and cerebral oxygen saturation in patients with acute traumatic brain injury. J Neurosurg Anesthesiol. 2022;34:52-6.
  20. Fenerci A, Akcil EF, Tunali Y, Dilmen OK. Effect of different positive end expiratory pressure levels on optic nerve sheath diameter in patients with or without midline shift who are undergoing supratentorial craniotomy. Acta Neurochir. 2024;166:177.
  21. Ertl M, Knüppel C, Veitweber M, Wagner A, Pfister K, Wendl C, et al. Normal age-and sex-related values of the optic nerve sheath diameter and its dependency on position and positive end-expiratory pressure. Ultrasound Med Biol. 2020;46:3279-85.
  22. Klinzing S, Hilty MP, Bechtel-Grosch U, Schuepbach RA, Bühler P, Brandi G. Dynamic optic nerve sheath diameter changes upon moderate hyperventilation in patients with traumatic brain injury. J Crit Care. 2020;56:229-35.
  23. Suresh V, Ushakumari P, Aggarwal A, Kumar A, Kutty RK, Prabhakar RB, et al. Perioperative variation in optic nerve sheath diameter–A prospective observational study of traumatic brain injury patients undergoing decompressive craniectomy. Neurol India. 2022;70:1460-7.
The Egyptian Journal of Intensive Care and Emergency Medicine
Volume 5, Issue 2
June 2025
Pages 118-126

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