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Background  Secondary lung injury is the most common non-neurological complication after traumatic brain injury (TBI). Lung-protective ventilation (LPV) has been proven to improve perioperative oxygenation and lung compliance in some critical patients. This study aimed to investigate whether intraoperative LPV could improve respiratory function and prevent postoperative complications in emergency TBI patients.    Methods  Ninety TBI patients were randomly allocated to three groups (1:1:1): Group A, conventional mechanical ventilation [tidal volume (VT) 10 mL/kg only]; Group B, small VT (8 mL/kg) + positive end-expiratory pressure (PEEP) (5 cmH 2 O); and Group C, small VT (8 mL/kg) + PEEP (5 cmH 2 O) + recruitment maneuvers (RMs). The primary outcome was the incidence of total postoperative pulmonary complications; Secondary outcomes were intraoperative respiratory mechanics parameters and serum levels of brain injury markers, and the incidence of each postoperative pulmonary and neurological complication.    Results  Seventy-nine patients completed the final analysis. The intraoperative PaO 2  and dynamic pulmonary compliance of Groups B and C were higher than those of Group A ( P  = 0.028;  P  = 0.005), while their airway peak pressure and plateau pressure were lower than those of group A ( P  = 0.004;  P  = 0.005). Compared to Group A, Groups B and C had decreased 30-day postoperative incidences of total pulmonary complications, hypoxemia, pulmonary infection, and atelectasis (84.0 % vs. 57.1 % vs. 53.8 %,  P  = 0.047; 52.0 % vs. 14.3 % vs. 19.2 %,  P  = 0.005; 84.0 % vs. 50.0 % vs. 42.3 %,  P  = 0.006; 24.0 % vs. 3.6 % vs. 0.0 %,  P  = 0.004). Moreover, intraoperative hypotension was more frequent in Group C than in Groups A and B ( P  = 0.007). At the end of surgery, the serum levels of glial fibrillary acidic protein and ubiquitin carboxyl-terminal hydrolase isozyme L1 in Group B were lower than those in Groups A and C ( P  = 0.002;  P  < 0.001). The postoperative incidences of neurological complications among the three groups were comparable.    Conclusions  Continuous intraoperative administration of small VT + PEEP is beneficial to TBI patients. Additional RMs can be performed with caution to prevent disturbances in the stability of cerebral hemodynamics.    Trial registration  Chinese Clinical Trial Registry (ChiCTR2000038314), retrospectively registered on September 17, 2020.

Effects of intraoperative lung-protective ventilation on clinical outcomes in patients with traumatic brain injury: a randomized controlled trial