Mechanical ventilation in neurocritical caresetting: a clinical approach

Abstract Neuropatients often require invasive mechanical ventilation. Ideal ventilator settings and respiratory targets in neuro patients are unclear. Current knowledge suggests maintaining protective tidal volumes of 6-8 ml/kg of predicted body weight in neuropatients. This approach may reduce the rate of pulmonary complications, although it cannot be easily applied in neuro setting due to the need for special care to minimize the risk of secondary brain damage. Additionally, the weaning process from mechanical ventilation is particularly challenging in these patients who cannot control the brain respiratory patterns and protect airways from aspiration. Indeed, extubation failure in neuropatients is very high, while tracheostomy is needed in one third of them. The aim of this manuscript is to review and describe the current management of invasive mechanical ventilation, weaning and tracheostomy for the main four sub-populations of neuropatients: traumatic brain injury, acute ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage.