B80-1-18 Integrated Brain-lung Monitoring Guides Prone Ventilation in Intracranial Hypertension With Massive Atelectasis

Abstract Background In mechanically ventilated patients, extensive atelectasis reduces functional lung volume, increases cyclic strain, and predisposes to ventilator-induced injury. Recruitment maneuvers and prone positioning improve oxygenation by reopening collapsed alveoli, but in neurocritical patients with intracranial hypertension (ICH), these strategies may jeopardize cerebral perfusion. Integrated brain-lung monitoring is essential to safely balance aggressive pulmonary recruitment and cerebral protection. Case Presentation A 38-year-old man with a large intracerebral hemorrhage and an external ventricular drain developed refractory hypoxemia (PaO2/FiO2 = 142 on FiO2 0.45) despite optimized ventilation and neuromuscular blockade. Chest CT revealed 50% posterior opacities consistent with massive atelectasis, with no pleural effusion on ultrasound. Given the coexistence of ICH, any recruitment maneuver required close neuromonitoring. Intervention A multimodal ventilatory-neuromonitoring strategy was applied. Alveolar opening pressure (AOP) guided positive end-expiratory pressure (PEEP) optimization. The patient was proned with a 30° head-up tilt to enhance dorsal aeration and venous drainage. A stepwise pressure-control recruitment maneuver increased PEEP by 2 cm H2O every 30 s up to 28 cm H2O (plateau ≈ 43 cm H2O), sustained for 2 min, and then titrated down to identify optimal compliance. Continuous intracranial pressure (ICP) and serial transcranial Doppler (TCD) monitoring ensured stable cerebral hemodynamics. Posterior lung ultrasound score (LUS) was used to quantify aeration before and after the maneuver. Results Oxygenation and mechanics improved significantly without ICP compromise. PaO2/FiO2 rose from 142 to 230 mmHg, static compliance increased from 32 to 42 mL/cm H2O, and driving pressure decreased from 16 to 12 cm H2O. ICP remained stable, and cerebral perfusion pressure and TCD pulsatility indices were preserved. Post-prone LUS showed marked improvement in dependent regions, confirming successful recruitment. After returning supine, gas exchange and compliance remained favorable with lower FiO2 requirements. Discussion and Conclusion This case demonstrates that synchronized neuromonitoring and respiratory mechanics assessment can enable safe and effective prone ventilation in neurocritical patients. Continuous ICP and TCD monitoring, combined with AOP- and LUS-guided recruitment, allowed real-time optimization of lung aeration while maintaining cerebral homeostasis. A head-elevated prone position and adequate sedation prevented venous congestion, enabling aggressive yet safe recruitment. Integrated brain-lung monitoring represents a physiologically driven approach for dual organ management, improving oxygenation and mechanics without compromising intracranial dynamics. This model may be generalized to similar patients with concurrent pulmonary and cerebral injury. This abstract is funded by: N/A