Ventilatory Strategies in the Neurocritical Care

Most of the patients admitted to a neurocritical care unit due to subarachnoid hemorrhage, traumatic brain injury, and stroke require prolonged mechanical ventilation (MV) and have a higher risk of pulmonary complications such as acute respiratory distress syndrome (ARDS). The primary lesion could lead to impairments in consciousness, swallowing, airway protection, and tracheal clearance. Nonetheless, the iatrogenics could also damage the respiratory system, leading to difficulties for extubation and often requiring tracheostomy. Protective MV has been showing increasingly positive results, but whereas it is a viable option for these patients, it could also provoke an undesirable elevation in intracranial pressure (ICP). Increases in intrathoracic pressure and permissive hypercapnia could cause this ICP elevation, further worsening the clinical picture. When faced with the choice among different forms of MV or alveolar recruiting, wrong pathways could lead to carbon dioxide retention, cerebral vasodilation, and rises in the ICP. The recommended strategy for adequately ventilating those patients without causing secondary damage is to provide positive end-expiratory pressure and keeping the plateau under 30 cmH2O. Multimodal monitoring can improve management by providing individualized parameters.