• Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons. Guidelines for the management of severe traumatic brain injury. Hyperventilation. J Neurotrauma 2007;24(1):S87-S90. [26 references]

This is the current release of the guideline.

This guideline updates previous versions: Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care. Guidelines for the management of severe traumatic brain injury: cerebral perfusion pressure. New York (NY): Brain Trauma Foundation, Inc.; 2003 Mar 14. 14 p.

Brain Trauma Foundation, Inc, American Association of Neurological Surgeons. Part 1: guidelines for the management of severe traumatic brain injury. New York (NY): Brain Trauma Foundation, Inc.; 2000. 165 p.

The grades of evidence (I-III) and levels of recommendations (I-III) are defined at the end of the "Major Recommendations" field.

Level I

There are insufficient data to support a Level I recommendation for this topic.

Level II

Prophylactic hyperventilation (PaCO₂ of 25 mm Hg or less) is not recommended.

Level III

Hyperventilation is recommended as a temporizing measure for the reduction of elevated intracranial pressure (ICP).

Hyperventilation should be avoided during the first 24 hours after injury when cerebral blood flow (CBF) is often critically reduced.

If hyperventilation is used, jugular venous oxygen saturation (SjO₂) or brain tissue oxygen tension (PbrO₂) measurements are recommended to monitor oxygen delivery.

Summary

In the absence of trials that evaluate the direct effect of hyperventilation on patient outcomes, the guideline developers have constructed a causal pathway to link hyperventilation with intermediate endpoints known to be associated with outcome. Independent of hyperventilation, CBF can drop dangerously low in the first hours following severe TBI. The introduction of hyperventilation could further decrease CBF, contributing to the likelihood of ischemia. The relationship between hyperventilation and metabolism, as well as cerebral oxygen extraction, is less clear. The one study that evaluated patient outcomes strongly suggests that hyperventilation be avoided for certain patient subgroups.

Definitions:

Grades of Evidence

Class I - Good quality randomized controlled trial (RCT)

Class II - Moderate quality RCT, good quality cohort, or good quality case-control

Class III - Poor quality RCT; moderate or poor quality cohort; moderate or poor case-control; or case series, databases, or registries

Levels of Recommendation

Levels of recommendation are Level I, II, and III, derived from Class I, II, and III evidence, respectively.

Level I - Recommendations are based on the strongest evidence for effectiveness, and represent principles of patient management that reflect a high degree of clinical certainty.

Level II - Recommendations reflect a moderate degree of clinical certainty.

Level III - Recommendations for which the degree of clinical certainty is not established.

None provided

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

• Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons. Guidelines for the management of severe traumatic brain injury. Hyperventilation. J Neurotrauma 2007;24(1):S87-S90. [26 references]

Not applicable: The guideline was not adapted from another source.

2000 (revised 2007)

Brain Trauma Foundation - Disease Specific Society

Brain Trauma Foundation

Not stated

Primary Authors: Susan Carson, MPH, Oregon Health & Science University; Cynthia Davis-O'Reilly, BSc, Brain Trauma Foundation Center for Guidelines Management; Pamela Drexel, Brain Trauma Foundation; Rochelle Fu, PhD, Oregon Health & Science University; Susan Norris, MD, MPH, MSc, Oregon Evidence-based Practice Center; Michelle Pappas, BA, Brain Trauma Foundation Center for Guidelines Management; Kimberly Peterson, MS, Oregon Health & Science University; Adair Prall, MD, South Denver Neurosurgery; Patricia Raksin, MD, Cook County Hospital

Not stated

Congress of Neurological Surgeons - Professional Association

This is the current release of the guideline.

This guideline updates previous versions: Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care. Guidelines for the management of severe traumatic brain injury: cerebral perfusion pressure. New York (NY): Brain Trauma Foundation, Inc.; 2003 Mar 14. 14 p.

Brain Trauma Foundation, Inc, American Association of Neurological Surgeons. Part 1: guidelines for the management of severe traumatic brain injury. New York (NY): Brain Trauma Foundation, Inc.; 2000. 165 p.

None available

None available

This NGC summary was completed by ECRI Institute on August 15, 2007. The information was verified by the guideline developer on January 28, 2008.

This is a limited license granted to NGC, AHRQ and its agent only. It may not be assigned, sold, or otherwise transferred. BTF owns the copyright. For any other permission regarding the use of these guidelines, please contact the Brain Trauma Foundation.