Mechanical Ventilation Practices in Traumatic Brain Injury: A Systematic Review of Contemporary Evidence

Traumatic brain injury (TBI) frequently necessitates mechanical ventilation to maintain adequate gas exchange, protect the airway, and support cerebral physiology during the acute phase of critical illness. Although ventilatory management is an integral component of neurocritical care, the optimal approach remains uncertain because interventions aimed at pulmonary protection may influence intracranial dynamics and neurological outcomes. This systematic review aimed to critically evaluate contemporary evidence on mechanical ventilation practices in adults with TBI, with emphasis on ventilatory strategies, lung-protective ventilation, airway management, tracheostomy, weaning approaches, and clinically relevant outcomes. A systematic literature search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines using PubMed/MEDLINE, Scopus, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EBSCOhost, the Cochrane Central Register of Controlled Trials (CENTRAL), Google Scholar, and selected grey-literature sources for studies published from January 2000 through June 2026. Eligible studies included adult patients with TBI who were receiving mechanical ventilation and reported ventilation-related interventions or outcomes. Methodological quality and risk of bias were assessed using the Newcastle-Ottawa Scale, Joanna Briggs Institute Critical Appraisal Checklists, and the Cochrane Risk of Bias 2 tool, as appropriate for the study design. Owing to substantial clinical and methodological heterogeneity, findings were synthesized narratively. Eleven studies, comprising randomized controlled trials, prospective and retrospective cohort studies, and cross-sectional surveys, met the inclusion criteria. Considerable variation was observed in ventilatory management, particularly regarding tidal volume, positive end-expiratory pressure, carbon dioxide targets, airway management, and tracheostomy timing. The available evidence suggests that individualized ventilatory management may help balance pulmonary protection with preservation of cerebral physiology when guided by appropriate neurological and respiratory monitoring. Early tracheostomy may be associated with shorter durations of mechanical ventilation and intensive care unit stay in selected patients, although consistent benefits in mortality or long-term neurological recovery have not been established. Overall, the included studies demonstrated substantial variability in ventilatory practices and clinical outcomes across different settings and patient populations. Current evidence suggests that ventilation strategies in adults with TBI should be tailored to individual respiratory mechanics and cerebral physiological status rather than applied uniformly. However, substantial heterogeneity, limited TBI-specific comparative evidence, and variation in clinical practice limit the certainty of the available evidence. High-quality multicenter studies are needed to establish evidence-based ventilatory targets and determine their effects on patient-centered neurological and pulmonary outcomes.