Mechanical ventilation in acute brain injured patients: balancing brain, lung, and diaphragm protection

Purpose of review Mechanical ventilation in acute brain injury (ABI) requires simultaneous protection of the brain, lungs, and diaphragm. Recent studies have questioned whether conventional lung-protective settings are optimal in this population. This review summarizes emerging evidence and evolving strategies to personalize MV across the phases of ABI – from controlled ventilation to extubation and tracheostomy. Recent findings The PROLABI randomized trial and the VENTIBRAIN study indicate that excessively low tidal volumes or high positive end-expiratory pressure may worsen outcomes in isolated ABI, highlighting the need for “protective windows” for ventilation. Dynamic indices such as driving pressure and mechanical power predict prognosis even in nonacute respiratory distress syndrome (ARDS) ABI. Novel approaches – including automated ventilation, respiratory drive monitoring, and individualized CO 2 and O 2 targets – are reshaping mechanical ventilation in ABI. Extubation failure remains frequent (~20%), largely due to impaired airway protection rather than gas-exchange parameters. Summary Optimal mechanical ventilation in ABI demands individualized strategies balancing brain–lung–diaphragm interactions. Incorporating multimodal neuromonitoring, objective airway, drive assessment, and early rehabilitation may enhance patient safety, reduce secondary brain and pulmonary injury, and support timely liberation from mechanical ventilation.