Brain–lung interaction: A vicious cycle in neurocritically ill patients — A narrative review with a conceptual algorithm to guide neuroprotection

Abstract: How can we avoid secondary brain injury due to failed , delayed , or physiologically unfavorable ventilator liberation in neurosurgical patients outside of the operating room ? This question has exposed us to a dilemma between prolonged mechanical ventilation (MV)/weaning and the potential development of secondary neurological insults. In turn, one of the main dilemmas in neurocritical care units (NCCUs) is whether the neurological status of this vulnerable population might worsen as a result of prolonged MV. Accordingly, failed extubation attempts constitute one of the main risk factors that can significantly increase mortality and hospital length of stay. Given this: Should We Do Individualized Management during Extubation in Neurocritically Ill Patients? To address this question, a hypothesis-generating framework that led to the development of a Clinical Algorithm to Protect neurocritically ill patients under Mechanical Ventilation through Acute Brain Injury during extubation (CAPREVI), which synthesizes conceptually key neurological, hemodynamic, and respiratory parameters to mitigate secondary neurological insults during ventilator weaning and shorten MV duration. In addition, following the Scale for the Assessment of Narrative Review Articles (SANRA) checklist, we conducted a literature review of prospective studies (2000–2026) about weaning in neurocritically ill patients.