Acute Airway Management and Ventilation in the Neurocritical Care Unit

The depressant effects of an acute neurologic illness on airway, respiratory, and cardiovascular function can result in imminent peril to the patient and require expertise and judgment. However, airway management differs in that it also requires a range of manual skills. The emergence of new technology, principally video laryngoscopy, has improved intubation safety in the neurocritical care unit and has enhanced the skill set of intensivists. Recognizing a patient’s need for intubation, determining its urgency, and predicting its difficulty remain the critical first steps in airway management. Patients with evolving neurological injury and signs of airway compromise and respiratory insufficiency are vulnerable to acute deterioration for which intubation is often life-saving. Familiarity with intubating techniques and commonly used pharmacological agents for intubation and their hemodynamic and neurophysiologic effects is essential for maintenance of oxygenation and cardiovascular stability, management of intracranial pressure, avoidance of aspiration, and protection of the cervical spine. Overall level of respiratory support and choice of ventilator mode and settings should be chosen with both the patient’s respiratory physiology and neuropathology in mind. In this chapter we address the unique challenges of airway management in neurocritically ill patients, including general principles for the use of mechanical ventilation and a description of frequently employed ventilatory modes in this patient population.