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Concepts of ventilator-induced lung injury have revolutionized our approach to the ventilatory management of patients with acute lung injury and acute respiratory distress syndrome over the past 10 years. The extension of these principles to patients with brain injuries is challenging, as many of them are out of keeping with usual brain-protective management.Many patients with acute lung injury or acute respiratory distress syndrome and an acute brain injury may in fact be managed safely within the confines of a lung-protective strategy. Elevated levels of positive end-expiratory pressure in head-injured patients with acute lung injury or acute respiratory distress syndrome also appear to be safe, particularly when the level is set below that of the intracranial pressure, when patients have a low respiratory system compliance, or when positive end-expiratory pressure results in significant lung volume recruitment. Several novel therapies to minimize ventilator-induced lung injury are currently in the early stages of investigation in neurosurgical patients.In many patients with brain injuries and acute lung injury the goals of lung protection can be achieved without threatening cerebral perfusion. In patients with more refractory raised intracranial pressure the optimal balance between brain and lung is not well established. Further research is needed on lung-protective strategies in this vulnerable population.