When the Injured Brain Fights the Ventilator: Review Maps Neurogenic Breathing Asynchrony

Patients with acute brain injuries can develop breathing patterns that clash with mechanical ventilation, and a new review article in Neurocritical Care argues that this problem has been overlooked in neurocritical care practice. Written by Eelco F. Wijdicks and William M. LeTourneau, the review examines how neurogenic respiratory drive generated by an injured brain can prevent the ventilator from synchronizing with the patient, producing discordance that is rooted in the neurology of the patient rather than in the machine itself.

According to the authors, this asynchrony may be perceived by patients as distress. Beyond discomfort, a high respiratory drive could also lead to global lung stress and diaphragmatic myoinjury, and it may affect liberation from mechanical ventilation at a later point in the patient’s course. The review frames these consequences as potential risks tied to sustained mismatch between the patient’s drive and the ventilator’s delivery, rather than as established outcomes for every affected patient.

A central criticism in the article is that patient–ventilator synchrony concerns have rarely been prioritized in neurocritical care guidelines. The authors note that these problems are often inappropriately treated with escalating sedation, an approach that addresses the observable struggle without resolving the underlying neurogenic pattern that produced it.

The review is structured to move from the essentials of waveform interpretation toward more complex readings of asynchronies, using ventilator waveforms as the practical tool for recognizing what the injured brain is driving the respiratory system to do. Among the patterns analyzed, the authors identify high respiratory drive, double-triggering with breath-stacking, and reverse triggering as the most prevalent observations in mechanically ventilated patients with acute brain injury.

Importantly, the authors conclude that adjusting the ventilator can improve patient–ventilator interaction, and they lay out a number of options to remediate these synchrony concerns. By mapping the common themes of neurogenic asynchrony and grounding recognition in waveform analysis, the review aims to give neurocritical care teams alternatives to escalating sedation and a path toward safer ventilation for patients whose injured brains set the pace of their own breathing.

Subject of Research: Neurogenic patient–ventilator asynchrony in mechanically ventilated patients with acute brain injury

Article Title: Understanding Neurogenic Patient–Ventilator Discordance and its Management

Article References: Wijdicks, E. F., & LeTourneau, W. M. (2026). Understanding Neurogenic Patient–Ventilator Discordance and its Management. Neurocritical Care. https://doi.org/10.1007/s12028-026-02611-2

Image Credits: AI Generated

DOI: 10.1007/s12028-026-02611-2

Keywords: neurocritical care, mechanical ventilation, patient-ventilator asynchrony, respiratory drive, reverse triggering, double-triggering, breath-stacking, diaphragmatic myoinjury, waveform interpretation, sedation, brain injury, Understanding