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The article reviews the evidence for and against early intubation for brain-injured patients.Although theoretical advantages to early intubation include airway protection, improved oxygenation, and control of ventilation, recent clinical data document an association between early intubation and mortality. This likely reflects some degree of selection bias when considering intubation without the use of neuromuscular blocking agents. Paramedic use of these drugs, however, has also been associated with higher mortality. Subgroup analysis from the San Diego Paramedic Rapid Sequence Intubation Trial and outcome data following air medical intubation suggest that suboptimal performance of intubation and subsequent ventilation may play an important role in determining the procedure's potential benefit or harm. In addition, refining patient selection criteria for early intubation may result in better outcomes.Available evidence is inconclusive regarding the role for early intubation following acute brain injury. Suboptimal performance of intubation and subsequent ventilation may offset potential benefits of the procedure. In addition, studies to better define the patient population benefiting from early intubation will help avoid exposing other patients to a potentially dangerous procedure.