Perioperative Ventilation in Neurosurgical Patients: Considerations and Challenges

The aim of this narrative review is to summarize critical considerations for perioperative airway management and mechanical ventilation in patients undergoing neurosurgical procedures.

Given the significant influence that ventilation has on intracranial pressure (ICP) and cerebral blood flow, ventilator settings need to be carefully managed. For example, high positive end-expiratory pressure (PEEP) can increase ICP, while hyperventilation can reduce it. Finding the optimal balance is the key. While evidence supporting lung-protective ventilation in neurosurgical patients is limited, preliminary data suggest that its use could be beneficial, similar to general surgical patients. This typically involves using lower tidal volumes and maintaining optimal oxygenation to prevent ventilator-associated lung injury. Airway management in neurosurgical patients must consider the risk of increased ICP during intubation and the potential for airway complications. Techniques like rapid sequence induction and the use of neuromuscular blockers may be employed to minimize these risks. The primary goal of ventilation in neurosurgical patients is to maintain adequate oxygenation and carbon dioxide removal while minimizing harm to the lungs and brain. However, there may be exceptions where specific ventilatory adjustments are needed, such as in cases of compromised gas exchange or elevated ICP.

Patients undergoing neurosurgical procedures often require invasive ventilation due to the complexities of the operation and the need to manage the airway. This creates unique challenges because ventilator settings must balance the need to protect both the lungs and the brain. Further research is needed to establish clear guidelines and optimize ventilatory care in this population.