Managing the mechanical ventilator in critical illness is far from formulaic. Criteria of intubation are rarely contemplated when a patient is struggling to maintain a patent airway. Once the airway is secured, adjustments in ventilator settings and modes are continuously made, and there is a fair amount of trial and error. Weaning from the ventilator is not standardized (and probably never will be), and protocols (if there are any) are based on consultant preferences and mostly experience. The consensus statement of the European Society of Intensive Care Medicine on mechanical ventilation (MV) in acute brain injury has clearly shown that evidence for certain approaches was either insufficient or lacking and that a substantial amount of research is needed to demonstrate the feasibility, safety, and efficacy of different management approaches in this category of patients.

This chapter reviews considerations in each intervention during the patient’s clinical trajectory of ventilation in the neurosciences ICU. The reader will find that early intubation and mechanical ventilation are initiated because patients cannot protect their airways or have insufficient respiratory drive to maintain oxygenation and normocarbia.