LAUSR

Introduction: We present a case of a young male who sustained a traumatic brain injury complicated by acute severe respiratory distress syndrome. The coexisting pulmonary pathology severely impacted intracranial pressure management. We present a novel strategy of ARDS management, wherein ventilator and airway pressure management was guided by esophagealpressure manometry to mitigate the risk of elevated intracranial pressure. There is growing evidence that supports esophageal pressure guided ARDS management but no cases demonstrating use in patients with ARDS and intractable intracranial hypertension due to traumatic brain injury. Description: 19-year-old male sustained a traumatic brain injury following a fall. At our trauma center, an intracranial pressure monitor was placed to assist with intracranial pressure management. ICPs ranged between 20-25 mmHg prior to medical therapy. Intracranial pressures responded to these therapies and stabilized in the range of 15-20 mmHg. Hospital day 4, the patient developed ARDS after aspiration of gastric feeds with progressively worsening P/F ratios. Despite increasing the minute ventilation, PaCO2 continued to rise above 60 mm Hg with associated PaO2 < 70 mmHg. His ICPs were elevated in the range of 22-26 mm HG but continued to rise as the patient developed worsening hypoxemia and hypercapnia. In order to better manage his complex pulmonary status, we placed an esophageal balloon catheter. In order to achieve alveolar stability, the PEEP would need to be increased to 23 cm H20 to reach an end expiratory Ptp of 0. The PaO2 slowly increased to 114 mm Hg and the P/F ratio increased above 100 mmHg and continued to improve resulting in decreases in the elevated ICP Discussion: Growing evidence suggests the utility of using esophageal pressures to guide ARDS management. By using the esophageal pressure, we could better control his respiratory system leading to improved ICP. We were able to effectively use high PEEP to decrease elevated ICPs, despite the concerns of intrathoracic pressure from PEEP being transmitted to the intracranial vault. This case presents a good example of the importance of the respiratory systems effect on intracranial pressure management. It highlights a novel approach of esophageal-pressure-guided therapy to manage severe ARDs in TBI