Neurocritical care patients are susceptible to a variety of pulmonary complications. Therefore the neurointensivist needs to be very familiar with the common pulmonary problems that are encountered in the neurointensive care unit (NICU). Almost all neurocritical care patients are at increased risk for nosocomial pneumonia and venous thromboembolic disease (VTE). Safe prevention remains the mainstay of therapy for VTE, but diagnosis and management of pulmonary embolism (PE) also need to be well understood.

Trauma patients who require neurocritical care may develop pulmonary contusion and acute lung injury (ALI). Many patients have neurologic problems that predispose them to aspiration of gastric contents putting them at increased risk for the development of acute respiratory distress syndrome (ARDS) in addition to aspiration pneumonia. Further, neurogenic pulmonary edema may occur in a variety of patients with neurocritical care problems, and the approach to these patients is similar to that of patients with ARDS. Management of patients with ALI/ARDS is particularly challenging in the NICU given the effects of hypercapnia on intracranial pressure (ICP) and more complex choices for sedation, analgesia, and neuromuscular blockade. In addition, patients with common obstructive lung diseases, such as asthma or chronic obstructive pulmonary disease (COPD), often have exacerbations of their condition due to trauma, intubation, pneumonia, aspiration, or medications.

The discussion that follows is intended to assist the neurointensivist in the treatment of patients with common pulmonary problems in the context of their major neurologic comorbidities.