Ventilatory management of head injury patient. Is there any conflict?

Prevention of secondary brain injury, consequent to early or delayed post-traumatic insults to the brain, represents the major objective of intensive care treatment of traumatic brain injury (TBI) patients. The knowledge that respiratory dysfunction is the most common among extracranial complications of TBI, and that alterations in respiratory variables can interfere with cerebral hemodynamics and cerebral energy metabolism, prompt neurointensivists to better elucidate pathophysiological mechanisms responsible for acute lung injury (ALI) following TBI, and to identify the best approach to the treatment of respiratory failure occurring after traumatic brain injury. Ventilatory management of TBI patients, in the event of associated ALI, is burdened with serious clinical concerns. Optimal target of mechanical ventilation for TBI patients and optimal ventilatory strategy for the treatment of patients with ALI are, in fact, potentially in conflict, and difficult to combine. The article discuss the pathomechanisms responsible for the occurrence of respiratory dysfunction after head injury, addresses the potential conflict between opposite therapeutic strategies (brain-protective and lung-protective ventilation) and suggests a possible compromise between them in the neuro-intensive care practice.