HYPERVENT-CHECK: A Checklist for Therapeutic Hyperventilation in Neurocritical Care

Introduction

In the past 30 years, changing evidence has led professional societies to update their position regarding therapeutic hyperventilation (HV). The Brain Trauma Foundation 2017 guidelines[1] discourage prophylactic HV (PaCO₂ < 30 mm Hg) in the initial 24 hours following severe traumatic brain injury due to the risk of worsening cerebral ischemia and eliminating any neuroprotective effect. Instead, they endorse restricted HV as a temporary “rescue” intervention in the context of acute, life-threatening intracranial hypertension—ideally only until definitive therapies (e.g., osmotherapy, decompressive surgery) can be established.[1] Likewise, the American Association of Neurological Surgeons and the Neurocritical Care Society have endorsed these recommendations, noting that extended hypocapnia can be detrimental by impairing microcirculatory perfusion and autoregulatory function.[2] Despite the presence of these concordant statements, clinical practice remains heterogeneous.

Publication History

Article published online:
13 June 2025

• References

• 1 Carney N, Totten AM, O'Reilly C. et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery 2017; 80 (01) 6-15
• 2 The Brain Trauma Foundation. The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care. Hyperventilation. J Neurotrauma 2000; 17 (6–7): 513-520
• 3 Godoy DA, Badenes R, Robba C, Murillo Cabezas F. Hyperventilation in severe traumatic brain injury has something changed in the last decade or uncertainty continues? A brief review. Front Neurol 2021; 12: 573237
• 4 Gouvea Bogossian E, Peluso L, Creteur J, Taccone FS. Hyperventilation in adult TBI patients: how to approach it?. Front Neurol 2021; 11: 580859
• 5 Stocchetti N, Maas AI, Chieregato A, van der Plas AA. Hyperventilation in head injury: a review. Chest 2005; 127 (05) 1812-1827
• 6 Zhang Z, Guo Q, Wang E. Hyperventilation in neurological patients: from physiology to outcome evidence. Curr Opin Anaesthesiol 2019; 32 (05) 568-573
• 7 Muizelaar JP, Marmarou A, Ward JD. et al. Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial. J Neurosurg 1991; 75 (05) 731-739
• 8 Clark D, Joannides A, Adeleye AO. et al; Global Neurotrauma Outcomes Study collaborative. Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study. Lancet Neurol 2022; 21 (05) 438-449
• 9 Badjatia N, Carney N, Crocco TJ. et al. Guidelines for prehospital management of traumatic brain injury 2nd edition. Prehosp Emerg Care 2008; 12 (Suppl. 01) S1-52