REVIEW

CURRENT
OPINION Airway management in the critically ill
Sheila Nainan Myatra

Purpose of review
To provide an evidence-based approach to improve first pass success in tracheal intubation while
maintaining patient safety in the critically ill.
Recent findings
Despite advances in the management of critically ill patients, tracheal intubation in these patients remains a
high-risk procedure associated with increased morbidity and mortality. Recent interventions to enhance patient
Downloaded from http://journals.lww.com/co-criticalcare by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 02/16/2022

safety and improve first pass success in tracheal intubation emphasize reducing repeated attempts at tracheal
intubation, oxygen desaturation and cardiovascular collapse during airway management by optimizing
patient physiology to mitigate risks and reduce complications. These include various strategies to improve
peri-intubation oxygenation like use of noninvasive ventilation, high flow nasal cannula oxygen and gentle
mask ventilation between induction of anesthesia and laryngoscopy; use of a videolaryngoscope and a
bougie; careful selection of drugs including neuromuscular blocking agent; improved strategies to avoid
haemodynamic collapse; rescue oxygenation strategies and human factor considerations.
Summary
Recognizing the challenges and using the appropriate interventions to improve first pass tracheal intubation
success, while maintaining patient safety are essential during tracheal intubation in critically ill patients. This
review will provide recommendations based on the current evidence, various guidelines and expert opinion in
the field. Further research will help us better understand the best strategies to improve patient outcomes.
Keywords
airway management in ICU, difficult airway, preoxygenation, rapid sequence intubation, tracheal intubation
in the critically ill

INTRODUCTION ICU, compared with 14% during anaesthesia [6].

Tracheal intubation is one of the most commonly Failure to use capnography, poor planning, poor
performed airway management procedures in criti- recognition of high-risk airways, lack of advanced
cally ill patients [1]. Critically ill patients have a airway skills and equipment, were major contrib-
‘physiologically difficult’ airway. The underlying uting factors. Three recent guidelines, by various
hypoxaemia, hypotension, metabolic acidosis and international societies, recommend an algorith-
other physiological derangements, increase the risk mic approach to manage the airway with a focus
of complications during tracheal intubation [2]. In on strategies to enhance patient safety during
contrast to airway management in the operating tracheal intubation in the critically ill [14–16].
room, the emergent nature of airway management, Recent reviews have also highlighted important
increased risk of aspiration, varying levels of opera- considerations to minimize complications in these
tor skills, limited access to advanced airway equip- patients [17– 20]. This review will provide an evi-
ment and complex intubating conditions, pose dence-based approach to maximizing patient
additional challenges during tracheal intubation safety and optimizing first pass success in tracheal
in these patients [3] (Table 1). These challenges
make tracheal intubation in the critically ill patients
Department of Anesthesiology, Critical Care and Pain, Tata Memorial
a high-risk procedure associated with an increased Hospital, Homi Bhabha National Institute, Mumbai, India
risk of complications between 22 and 54%. These Correspondence to Sheila Nainan Myatra, Department of Anesthesiol-
include hypoxaemia, hypotension, arrhythmias, ogy, Critical Care and Pain, Tata Memorial Hospital, Dr Ernest Borges
cardiac arrest and death [4–13]. Road, Parel, Mumbai, India. Tel: +91 9820156070;
The fourth UK National Audit Project report e-mail: [email protected]
showed that major airway-related complications Curr Opin Crit Care 2021, 27:37–45
lead to death or brain injury in 61% of the cases in DOI:10.1097/MCC.0000000000000791

1070-5295 Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved. www.co-criticalcare.com

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Respiratory system

INDICATIONS FOR TRACHEAL

KEY POINTS INTUBATION IN ICU
 Tracheal intubation is a high-risk procedure in critically The most common indications include the following:
ill patients.
(1) Facilitation of invasive mechanical ventilation
 Physiological optimization of the patient should be
performed to avoid complications. These include (inadequate oxygenation/ventilation, shock,
various peri-intubation oxygenation strategies and cardiac arrest, avoidance of hypercarbia, con-
haemodynamic support to reduce oxygen desaturation trolled hyperventilation, need for neuromuscu-
and cardiovascular collapse. lar paralysis, postoperative elective ventilation)
(2) Protection of the respiratory tract from aspira-
 Rapid sequence intubation, careful selection of
pharmacological agents, use of tools like tion of gastric contents
videolaryngoscopes and bougies may help improve first (3) Relief of upper airway obstruction
pass success in tracheal intubation and minimize (4) Tracheobronchial toileting
complications.
 Familiarity with rescue oxygenation strategies PLANNING AND PREPARATION FOR
is essential. TRACHEAL INTUBATION
 Human factor considerations, use of cognitive aids and
simulation-based training may help in better Clinical history and examination
preparation for safe and successful In addition to clinical history related to the present
airway management. illness and comorbidities, that related to airway
management including the time of last oral intake,
contraindications to use succinylcholine or other
drugs, drug allergies, history of sleep apnoea, pres-
intubation in critically ill patients. Tracheostomy ence of dentures, loose or missing teeth and previ-
and tracheal extubation will not be covered in ous history of a difficult tracheal intubation should
this review. be elicited from the patient or family. Examination

Table 1. Challenges associated with tracheal intubation in ICU

ICU environmental factors
Infrastructure Poor access to patient’s head end, lack of space around the patient, poor lighting
Equipment Adjunct airway devices such as a flexible bronchoscope, supraglottic airways devices, video laryngoscope,
capnography, equipment for an emergency cricothyroidotomy etc. may not be readily available in the ICU
Monitoring Patient monitors are usually placed at the head end of the bed and may not be visible to the airway operator
Timing An urgent tracheal intubation may be required at any time in the day or night
Personnel Availability of trained personnel for assistance in an emergency may be limited and variable
Patient factors
Airway assessment May be difficult or impossible, due to lack of time or the patient being uncooperative
Challenging anatomy Maxillofacial trauma, cervical spine injury, airway injuries, burns, retropharyngeal abscess, radiation etc.
Risk of aspiration Patient may not be fasted or having gastroparesis associated with critical illness
Preoxygenation Insufficient time for preoxygenation when progressive illness requires rapid tracheal intubation. Inefficient
preoxygenation caused by ventilation perfusion mismatch due to the underlying illness. Lack of physiological
reserves may lead to rapid oxygen desaturation allowing less safe apnoea time for tracheal intubation
Physiologically difficult Poor physiologic reserve due to critical illness
airway Presence of hypotension, hypoxaemia, metabolic acidosis, right ventricular failure, etc. may increase the risk
of complications during tracheal intubation
Patient may be uncooperative due to critical illness
Waking up the patient Unlike in the operating room, waking up the patient and postponing airway management is not possible, as
the critical illness mandates a definitive airway
Operator factors
Variability in training The airway operator may have limited airway training and poor airway management skills
and experience An inexperienced junior doctors may be performing tracheal intubation alone
Human factors The patient, ICU or operator-related factors, alone or in combination may produce a stressful situation for the
operator which may affect performance. For example, cognitive overload, fixation errors, tunnel vision,
poor communication which may lead to an increased chance of errors

38 www.co-criticalcare.com Volume 27  Number 1  February 2021

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

 Airway management in ICU Myatra

of the cardiorespiratory system and other systems Table 2. MACOCHA score

should be performed and relevant laboratory inves-
tigations and imaging reports reviewed. Factor Points

Factors related to patient

Airway assessment Mallampati score III or IV 5

Obstructive sleep apnoea syndrome 2
Airway assessment is often not feasible in critically
Reduced mobility of cervical spine 1
ill patients due to the emergent nature of the tra-
Limited mouth opening (<3 cm) 1
cheal intubation or because the patient may be
uncooperative. A recent systematic review and Factors related to pathology
meta-analysis of over 30 000 patients in the operat- Coma 1
ing room, comparing different clinical tests to pre- Severe hypoxaemia 1
dict difficult tracheal intubation, showed inability Factors related to operator
to bite the upper lip with the lower incisors, a short Nonanaesthesiologist 1
hyomental distance, retrognathia and the modified Total 12
Mallampati score to have a positive likelihood ratio
&
of 14, 6.4, 6 and 4.1, respectively [21 ]. The MACO- The score is from 0 to 12: 0 ¼ easy, 12 ¼ very difficult.
CHA score [22] for airway assessment in the critically
ill (Mallampati class, presence of obstructive sleep
Apnoea, Cervical spine mobility, mouth Opening, Team preparation
presence of Coma or Hypoxaemia, and presence of The presence of two airway operators, with at least
an Anesthesiologist), takes into consideration ana- one being experienced has shown to reduce com-
tomic, physiologic and operator characteristics, is plications during tracheal intubation [24]. There
simple to perform and may be more suitable for use should be clear communication among the team
in critically ill patients (Table 2). members about the airway concerns, airway plan,
backup plan and the roles and responsibilities of
the team members before proceeding for tracheal
Use of check lists intubation.
A cart with all of the necessary supplies to facilitate
tracheal intubation, rescue oxygenation and hae-
modynamic support is essential to avoid the need THE TRACHEAL INTUBATION PROCEDURE
for securing essential equipment at the last minute. Recognizing that the physiological derangements in
Checklists may help ensure that the necessary prep- the patient will increase the risk of complications
arations and precautions have been taken. The first during tracheal intubation, it is essential to pay
randomized trial investigating the use of a written special attention to optimize patient physiology
checklist prior to tracheal intubation in ICU com- and improve first pass tracheal intubation success.
pared with usual care found no difference in lowest Suggested strategies for the same have been outlined
oxygen saturation and lowest systolic blood pres- in Table 3.
sure from induction up to 2 min after tracheal
intubation between the groups [23]. However,
the checklist did not include interventions aiming Patient positioning
at physiological optimization [e.g. noninvasive There is still a debate about whether ‘sniffing’ or the
ventilation (NIV), fluid load, early use of vasopres- semi upright ‘ramped’ may be more appropriate to
sors], possibly explaining why the checklist did not make glottic visualization and tracheal intubation
influence the selected outcomes. Moreover, the easier compared with patient positioned completely
participating centres were experienced with the flat. Being upright improves preoxygenation, pre-
use of checklists for other ICU procedures. Thus, vents reduction in the functional residual capacity
a high penetrance of checklist items may have been and may reduce the risk of pulmonary aspiration. A
present in the control group [1,23]. Nevertheless, a recent multicentre trial showed that ramped position
preintubation checklist, which includes interven- was associated with increased tracheal intubation
tions to enhance oxygenation and haemodynamic difficulty compared with the sniffing position. How-
optimization, may be effective in less experienced ever, the ramped positioning may have been subop-
hands, as observed following the implementation timal in this trial and should be considered while
of the ICU intubation bundle aimed at reducing life interpreting the results [25]. A prospective observa-
threatening complications associated with tracheal tional study showed improved first attempt tracheal
intubation [24]. intubation success when ramping was compared

1070-5295 Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved. www.co-criticalcare.com 39

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Respiratory system

Table 3. Special considerations during tracheal intubation in critically ill patients

Intervention Suggestion

Airway assessment Consider using the MACOCHA score

Team preparation Presence of two operator (preferably at least one experienced in airway management)
Clear communication among the team members about the airway concerns, airway plan, backup plan
and the roles and responsibilities of the team members
Patient positioning Upright or ‘ramped’ position (keeping external auditory meatus levelled with the sternal notch)
improves preoxygenation by preventing reduction in the patient’s functional residual capacity and
may reduce risk of pulmonary aspiration of gastric contents
Preoxygenation and NIV should be the method of choice for preoxygenation in severely hypoxic patients
apneic oxygenation HFNO oxygen use has shown lesser intubation-related complications as compared with bag valve
mask in patients who are not severely hypoxemic
Apneic oxygenation may be used after optimal preoxygenation to prolong the time to desaturation
Gentle mask ventilation should be considered between induction and laryngoscopy, especially in
patients at high risk for desaturation
Rapid sequence intubation Should be the considered in all patients
Induction agents Prefer intravenous ketamine or etomidate unless contraindicated
Neuromuscular blocking agent Use intravenous rocuronium or succinylcholine unless contraindicated
Haemodynamics Use fluids or vasopressors in the peri-intubation period to maintain haemodynamics
Device selection A VL should be immediately available for use
VL improves glottic visualization as compared with a direct laryngoscopy, making it an important tool
for difficult airway management
Use of a bougie should be considered for initial tracheal intubation
A hyperangulated VL along with a rigid stylet should be preferred over a traditional geometry VL if
available, during an anticipated difficult airway
Confirmation of tracheal Use waveform capnography
tube placement
Rescue oxygenation Limit attempts at tracheal intubation to two
Use face mask ventilation or a supraglottic airway device to restore oxygenation
Perform emergency cricothyroidotomy if you cannot intubate and cannot ventilate the patient (surgical
tracheostomy may be considered if a trained surgeon is present)
Following a difficult tracheal Monitor the patient for complications, treat airway oedema
intubation Documentation and counselling
Team debriefing
Human factors Use a shared mental model for communication
Follow an algorithmic approach to tracheal intubation, to reduce cognitive load and improve the
recognition and management of failure
Advance training in both technical and nontechnical skills for airway management is essential

HFNO, high flow nasal oxygen; NIV, noninvasive ventilation; VL, videolaryngoscope.

with supine position and a large retrospective study face mask, standard or high flow nasal oxygen
showed that a combination of ramped and sniffing (HFNO), NIV mask or a combination of these devices.
positions significantly reduced complication rates In addition to oxygenation, HFNO generates postive
[26,27]. However, randomized clinical trials are lack- end-expiratory pressure (PEEP) [29]. NIV improves
ing. Recent guidelines have recommended a head-up oxygenation, PEEP delivery and ventilation by aug-
position, especially in patients at a high risk of aspi- menting minute ventilation with pressure-supported
ration or desaturation [14,15]. breaths and decreasing right ventricular preload and
left ventricular afterload [30].
&&
In the PROTRACH study [31 ], patients without
Preoxygenation and apnoeic oxygenation preexisting hypoxaemia (PaO2/FiO2 ratio
Hypoxia is a leading complication of tracheal intu- 200 mmHg) were randomized to HFNO (from
bation in the critically ill [1]. Different preoxygena- induction to tracheal intubation) or to oxygen by face
tion and apnoeic oxygenation strategies to increase mask for preoxygenation. Though HFNO failed to
the safe apnoea period (time interval before desatu- increase the lowest oxygen saturation during tracheal
ration after inducing apnoea) have been compared intubation, patients in the HFNO group experienced a
[28]. Oxygen delivery can be achieved using a simple lower incidence of tracheal intubation-related

40 www.co-criticalcare.com Volume 27  Number 1  February 2021

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

 Airway management in ICU Myatra

complications. The application of nasal cannula at meta-analyses which largely included observational
15 l/min did not increase the lowest oxygen saturation studies and a Cochrane analysis, both showed that a
during tracheal intubation attempts [32]. In the FLOR- single dose of etomidate was not associated with an
&&
ALI2 study [33 ] critically ill adults undergoing tra- increased mortality in patients with sepsis and criti-
cheal intubation were randomized to NIV or HFNO cally ill patients, respectively [39,40]. If etomidate is
(from induction to tracheal intubation). There was no used in patients with septic shock, corticosteroid
difference in the incidence of severe hypoxaemia. supplementation should be considered [41].
However, in the subgroup of patients with a P/F ratio
less than 200, a potential benefit for NIV was seen. Ketamine
OPTINIV, a proof of concept study [34], showed that Ketamine is popular as an induction agent of choice
adding HFNO for apnoeic oxygenation to NIV for unless contraindicated in critically ill patients, as it
preoxygenation was more effective in reducing the preserves the haemodynamics. No difference in
severity of desaturation during tracheal intubation, intubating conditions or serious adverse events
compared with NIV alone. However, more studies are was found in a trial of 655 critically ill patients
required to confirm this. randomized to either etomidate or ketamine during
From the available evidence, NIV seems to be rapid sequence intubation (RSI). However, there was
the method of choice for preoxygenation to increase a higher incidence of adrenal insufficiency in the
the oxygen reserve, especially in severely hypoxic etomidate group [42]. A study comparing the two
patients. HFNO use has shown lesser tracheal intu- agents in adult trauma patients, showed no differ-
bation-related complications as compared with bag ence in first-pass success rates, ICU-free days, venti-
valve mask preoxygenation in patients who are not lator-free days or mortality when used for RSI [43].
severely hypoxemic.

Controversies in rapid sequence intubation

Induction of anaesthesia Critically ill patients may have gastroparesis associ-
Critically ill patients usually have reduced require- ated with critical illness or may not be fasted at the
ments for general anaesthesia [35]. Drugs used for time of tracheal intubation. Thus, conventionally, a
induction of anaesthesia can increase the risk of RSI which involves administration of rapid onset
both haemodynamic and respiratory complications. agents (induction agent and muscle relaxant), cri-
Hypoxaemia during induction may be exacerbated coid pressure and avoidance of ventilation between
by the loss of a respiratory compensation and is an induction and tracheal intubation, to limit gastric
important risk factor for hypoxaemia during tra- insufflation and therefore pulmonary aspiration,
cheal intubation [36]. Reducing the patient’s min- is practiced.
ute ventilation during induction, may blunt the
respiratory compensation for metabolic acidosis, Use of neuromuscular blockade or
worsening acidosis and shock. Ketamine and etomi- spontaneous ventilation
date should be preferred in critically ill patients due RSI in critically ill patients is associated with greater
to their positive haemodynamic profile. first attempt success and fewer tracheal intubation-
related complications [44–46] and should be con-
Propofol sidered in all patients. The use of neuromuscular
Propofol provides superior conditions for tracheal blocking agents has been shown to improve mask
intubation, even without the use of muscle relax- ventilation, improve intubating conditions abolish
ants. However, it may not be suitable in most criti- upper airway muscle tone including laryngospasm
cally ill patients who are in shock, hypovolaemic, and optimize chest wall compliance. However,
with cardiac comorbidities having limited physio- inducing apnoea in critically ill patients may result
logic reserve, as there can be a precipitous fall in in rapid desaturation (secondary to loss of func-
blood pressure and even bradycardia following its tional residual capacity, high metabolic rate, physi-
use. However, retrospective studies have shown pro- ological shunt and ventilation perfusion mismatch),
pofol use to be safe when various strategies to miti- emphasizing the importance of peri-intubation and
gate hypotension including fluid loading and rescue oxygenation. The fear of inability to mask
vasopressor agents have been tried [37,38]. ventilate after giving neuromuscular blockade has
led to reluctance in using these agents. However,
Etomidate recent guidelines recommend the use of these
There are reservations for the use of etomidate based agents even during a cannot intubate, cannot ven-
on concerns of adrenal suppression. However, a tilate emergency [14,15].

1070-5295 Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved. www.co-criticalcare.com 41

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Respiratory system

A study comparing succinylcholine to rocuro- Haemodynamic instability is an independent pre-

nium in critically ill patients, found no difference dictor of adverse outcomes including mortality
between the two agents with respect to oxygen [4,54]. The combination hypotension and desatura-
desaturation, or successful first pass tracheal intuba- tion makes cardiac arrest even more likely [4]. Fluid
tion [47,48]. Sugammadex may be used as an option loading and vasopressors are often used to prevent
for rapid reversal of rocuronium in an emergency and treat hypotension. Fluid loading prior to tra-
[48]. However, there is a limited data regarding its cheal intubation as part of a tracheal intubation
safety in critically ill patients. Succinylcholine bundle has shown to reduce life threatening com-
should be used with caution, as it may precipitate plications [24]. However, a recent trial showed no
life-threatening hyperkalaemia in at risk patients. benefit with a routine fluid bolus prior to tracheal
Awake tracheal intubation using a videolar- intubation, although patients were not stratified by
&
yngoscope or flexible bronchoscope has a high suc- risk [55 ]. Prophylactic use of vasopressors instead to
cess and safety in the operating room. However, this fluid loading to prevent hypotension during tra-
requires patient co-operation and clinician expertise cheal intubation may be an alternative and needs
and may not be feasible in critically ill patients who to be investigated.
are often unstable and uncooperative.

Use of cricoid pressure Device selection for tracheal intubation

The use of cricoid pressure remains controversial.
The Cochrane review concluded that more evidence Videolaryngoscope
is required [49]. A recent double-blind, randomized A meta-analysis comparing direct laryngoscopy
study showed noninferiority of sham versus cricoid with videolaryngoscopy for emergency tracheal
pressure in preventing aspiration in patients at a intubation outside the operating room, showed
&
high risk for aspiration [50 ]. Clinicians often have higher first pass tracheal intubation success rates
difficulty in identifying the cricoid ring. In addition, with a videolaryngoscope and fewer oesophageal
there is evidence that cricoid pressure may worsen intubations in the subgroup of ICU patients, though
the laryngeal view preventing successful tracheal not overall success rates. Of concern, the use of
intubation and even mask ventilation [51,52]. Nev- videolaryngoscopy was associated with more life-
ertheless, several society guidelines still recommend threatening complications including arterial hypo-
the use of cricoid pressure during RSI [14,15]. tension [56]. A recent meta-analysis comparing vid-
eolaryngoscopy with direct laryngoscopy, included
Mask ventilation during rapid sequence nine randomized controlled trials with over 2000
intubation critically ill patients. The use of a videolaryngoscope
Critically ill patients are at a high risk for hypoxae- did not improve first-pass success rate, even when
mia due to avoidance of ventilation between admin- evaluating the studies according experience of the
istration of neuromuscular blockade and tracheal operator [57]. Some studies included in these meta-
intubation during RSI. In the PREVENT study, 401 analyses have shown higher incidence of severe life-
critically ill patients were randomized to receive threatening complications with videolaryngoscope
mask ventilation or no ventilation between induc- use. An explanation given for these findings is fail-
tion of anesthesia and tracheal intubation [53 ].
&&
ure to abort tracheal intubation attempts when
Patients receiving ventilation experienced a lower there is a clear laryngeal view using videolaryngo-
incidence of severe hypoxaemia (oxygen saturation scope, leading to prolonged apnoea time and com-
<80%) without increasing the rate of pulmonary plications. There was heterogeneity in the studies
aspiration. Though this study was not powered for included and some were low quality studies. Never-
pulmonary aspiration, it provides some reassurance theless, though recent evidence does not support
for gentle mask ventilation to limit hypoxia during the routine use of videolaryngoscope for tracheal
RSI, especially in high-risk patients. intubation in ICU, videolaryngoscopy improves
glottic visualization as compared with direct laryn-
goscopy making it an important tool for difficult
Haemodynamic support during tracheal airway management in ICU [58]. A hyperangulated
intubation videolaryngoscope along with a rigid stylet should
Nearly half of the critically ill patients develop be preferred over a traditional geometry videolar-
hypotension following tracheal intubation. The yngoscope if available, in an anticipated difficult
use of induction agents for anaesthesia and airway. Future trials will better define the role of a
positive pressure ventilation contribute to this. videolaryngoscope in ICU and should use adverse

42 www.co-criticalcare.com Volume 27  Number 1  February 2021

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

 Airway management in ICU Myatra

outcomes such as severe complications, rather than the following options should be considered: tra-
first pass tracheal intubation success rate alone as a cheal intubation through the SGA under broncho-
primary outcome [1,58]. scopic guidance by an airway expert or a surgical/
percutaneous tracheostomy should be performed,
Use of a bougie since critically ill patients need a definitive airway
A recent randomized trial compared the use of a for prolonged ventilation [14].
bougie with a tracheal tube and a stylet for tracheal If SGA insertion is unsuccessful and the best
intubation in the emergency department in patients attempt at mask ventilation, using an optimal tech-
with at least one difficult airway characteristic nique and neuromuscular blockade is also unsuc-
&&
[59 ]. There was significantly higher first-attempt cessful an emergency cricothyroidotomy should be
tracheal intubation success in the bougie group. immediately performed, even if the oxygen satura-
This was a single-centre study with operators tion is preserved [14–16].
experienced with the use of a bougie. Hence, the The optimal method for performing a cricothyr-
generalizability of these findings is uncertain. oidotomy is still debatable. A surgical or wide bore
Nevertheless, it seems reasonable to suggest that a cannula cricothyroidotomy (commercially available
bougie may be used to facilitate the initial tracheal kits) should be performed. Needle cricothyroidot-
intubation in those experienced with its use. omy requires the use of transtracheal jet ventilation,
which is usually not available in ICU.
Following an unanticipated difficult tracheal
Confirmation of tracheal tube position intubation, monitoring the patient for complica-
Use waveform capnography to confirm tracheal tions is essential. Watch for airway oedema and treat
intubation (5–6 consistent waveforms with no appropriately. Further examination of the airway by
decline) [14,15]. Failure to use capnography resulted a specialist may be required, especially when airway
in 17 deaths or brain damage in ICU in the NAP4 trauma has occurred. Documentation of the airway
report [6]. Oesophageal intubations and accidental difficulty along with counselling of the patient, if
tube displacements accounted for 82% of events feasible, or the family is essential [14].
leading to death or brain damage. This report
strongly recommends the use of capnography for
confirmation of tracheal intubation in all critically
POSTINTUBATION CARE
ill patients [6]. Following tracheal intubation initiate mechanical
ventilation if required, using appropriate sedation.
Document the exact marking of the tracheal tube at
RESCUE OXYGENATION the level of the incisor (or nose). The tracheal tube
If the patient desaturates during attempts at tracheal position should ideally be noted during each nurs-
intubation, the first step should be to perform mask ing shift to check for tube migration. Perform at
ventilation. Optimize mask ventilation with a two- chest radiograph after tracheal intubation to con-
handed technique, using an oropharyngeal airway. firm tracheal tube and nasogastric tube position.
If mask ventilation is inadequate insert a supraglot- Nasogastric tube feeding should only be started if
tic airway (SGA) device [14–16]. These devices are required after this confirmation. The tracheal cuff
designed to be inserted blindly to form a seal around pressure should be checked daily using a cuff pres-
the laryngeal inlet. A second-generation SGA device sure gauge and maintained between 20 and 30 cm of
should be preferred as it facilitates gastric decom- H2O at all times, to reduce the risk of pressure
pression and provides a better laryngeal seal [14,15]. necrosis, mucosal ischaemia and aspiration. Main-
Rescue ventilation using a SGA is often lifesav- tain tracheal tube patency by performing tracheal
&
ing in the critically ill and should be practiced [60 ]. suction as required, using a closed suction system.
Since it is not used for routine airway management
in ICU, critical care specialists may be unfamiliar or
untrained to use it. The NAP4 report concluded that HUMAN FACTORS IN AIRWAY
in patients who were rescued using an emergent MANAGEMENT
surgical airway, a SGA was not inserted in half of ‘Human factors’ refers to how individual, team,
the cases. Moreover, it was often successful when patient, environmental and institutional character-
inserted after performing a surgical cricothyrotomy, istics influence human behaviour which, in turn,
indicating that a cricothyroidotomy could have can affect both the clinician’s technical and non-
been avoided [6]. technical skills during the process of airway man-
Following SGA insertion, successful rescue ven- agement. Considering the complexities and
tilation and restoration of oxygen saturation, one of challenges involved during airway management in

1070-5295 Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved. www.co-criticalcare.com 43

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Respiratory system

the critically ill, human factor considerations various challenges during tracheal intubation in
become extremely relevant. Cognitive overload, loss these patients and using appropriate interventions
of situation awareness, fixations errors and poor to improve first pass success in tracheal intubation,
decision making are known to occur in such stressful while maintaining patient safety is essential. Further
situations [14,15]. According to the NAP4 report, research will help us better understand the best
human factors were contributed to at least 40% of strategies to improve patient outcomes.
instances of adverse outcomes. Inadequate training
and experience, nonadherence to guidelines and Acknowledgements
failure to plan for failure were identified among None.
the factors contributing to adverse outcomes [6].
Advance communication among the team members Financial support and sponsorship
of the airway plan and backup plan, including None.
assigning roles and responsibilities to the team
members can help overcome some of these prob- Conflicts of interest
lems. There is some evidence that the use of cogni-
There are no conflicts of interest.
tive aids, in simulation and real-life, may improve
technical performance and team communication in
crisis situations, however, further research is REFERENCES AND RECOMMENDED
required in this area [61]. The Vortex Approach READING
[62] is one such cognitive aid developed to support Papers of particular interest, published within the annual period of review, have
been highlighted as:
decision-making processes and aid clinicians during & of special interest
&& of outstanding interest
an airway crisis.
1. Russotto V, Myatra SN, Lafey JG. What’s new in airway management of the
critically ill. Intensive Care Med 2019; 45:1615–1618.
FUTURE RESEARCH 2. Mosier JM, Joshi R, Hypes C, et al. The physiologically difficult airway. West J
Emerg Med 2015; 16:1109–1117.
Future research is required to find optimum inter- 3. Divatia JV, Khan PU, Myatra SN. Tracheal intubation in the ICU: life saving or
life threatening? Indian J Anaesth 2011; 55:470–475.
ventions to mitigate the high incidence of cardio- 4. De Jong A, Rolle A, Molinari N, et al. Cardiac arrest and mortality related to
respiratory complications during tracheal intubation procedure in critically ill adult patients: a multicenter cohort study.
Crit Care Med 2018; 46:532–539.
intubation. The, interventions aimed at increasing 5. Simpson GD, Ross MJ, McKeown DW, Ray DC. Tracheal intubation in the
first-pass tracheal intubation success should be inte- critically ill: a multicentre national study of practice and complications. Br J
Anaesth 2012; 108:792–799.
grated with those aiming at optimizing physiology. 6. Cook TM, Woodall N, Harper J, et al. Major complications of airway manage-
Future trials should be aimed at better defining the ment in the UK: results of the Fourth National Audit Project of the Royal
College of Anaesthetists and the Difficult Airway Society. Part 2: Intensive
role of videolaryngoscopy in ICU, especially with care and emergency departments. Br J Anaesth 2011; 106:632–642.
respect to appropriate use of airway adjuncts, the 7. Martin LD, Mhyre JM, Shanks AM, et al. 3,423 Emergency tracheal intubations
at a university hospital: airway outcomes and complications. Anesthesiology
ideal glottis view required for a successful video- 2011; 114:42–48.
laryngoscope-assisted tracheal intubation, using 8. Mayo PH, Hegde A, Eisen LA, et al. A program to improve the quality of
emergency endotracheal intubation. J Intensive Care Med 2011;
adverse outcomes such as severe complications, 26:50–5612.
rather than first pass tracheal intubation success 9. Bowles TM, Freshwater-Turner DA, Janssen DJ, Peden CJ; RTIC Severn
Group. Out-of-theatre tracheal intubation: prospective multicentre study of
rate alone as a primary outcome. An ongoing large clinical practice and adverse events. Br J Anaesth 2011; 107:687–69213.
international observational study (INTUBE, 10. Griesdale DE, Bosma TL, Kurth T, et al. Complications of endotracheal
intubation in the critically ill. Intensive Care Med 2008; 34:1835–1842.
NCT03616054), will provide data on the current 11. Jaber S, Amraoui J, Lefrant JY, et al. Clinical practice and risk factors for
incidence of tracheal intubation-related complica- immediate complications of endotracheal intubation in the intensive care unit:
a prospective, multiple-center study. Crit Care Med 2006; 34:2355–2361.
tions and the practice of airway management in 12. Mort TC. Emergency tracheal intubation: complications associated with
critically ill patients worldwide. This snapshot of repeated laryngoscopic attempts. Anesth Analg 2004; 99:607–61310.
13. Schwartz DE, Matthay MA, Cohen NH. Death and other complications of
real-world practices may help develop strategies emergency airway management in critically ill adults. A prospective investiga-
aimed at physiological optimization and tracheal tion of 297 tracheal intubations. Anesthesiology 1995; 82:367–376.
14. Myatra SN, Ahmed SM, Kundra P, et al. Republication: all India difficult airway
intubation-related risk reduction. Point-of-care association 2016 guidelines for tracheal intubation in the intensive care unit.
ultrasound may help identify patients at risk of Indian J Crit Care Med. 2017; 21: 146–153.
15. Higgs A, McGrath BA, Goddard C, et al. Guidelines for the management of
pulmonary aspiration and should be studied further tracheal intubation in critically ill adults. Br J Anaesth 2018; 120:323–352.
in critically ill patients. 16. Quintard H, l’Her E, Pottecher J, et al. Intubation and extubation of the ICU
patient. Anaesth Crit Care Pain Med 2017; 36:327–341.
17. De Jong A, Casey JD, Myatra SN. Focus on noninvasive respiratory support
before and after mechanical ventilation in patients with acute respiratory
CONCLUSION failure. Intensive Care Med 2020; 46:1460–1463.
18. Mosier JM, Sakles JC, Law JA, et al. Tracheal intubation in the critically ill.
Tracheal intubation in critically ill patients remains Where we came from and where we should go. Am J Respir Crit Care Med
2020; 201:775–788.
a high-risk procedure. Critically ill patients have a 19. Sklar MC, Detsky ME. Emergent airway management of the critically ill patient:
physiologically difficult airway. Recognizing the current opinion in critical care. Curr Opin Crit Care 2019; 25:597–604.

44 www.co-criticalcare.com Volume 27  Number 1  February 2021

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

 Airway management in ICU Myatra

20. Scott JA, Heard SO, Zayaruzny M, Walz JM. Airway management in critical 41. Jung B, Clavieras N, Nougaret S, et al. Effects of etomidate on complications
illness: an update. Chest 2020; 157:877–887. related to intubation and on mortality in septic shock patients treated with
21. Detsky ME, Jivraj N, Adhikari NK, et al. Will this patient be difficult to intubate? hydrocortisone: a propensity score analysis. Crit Care 2012; 16:R224.
& The rational clinical examination systematic review. JAMA 2019; 42. Jabre P, Combes X, Lapostolle F, et al. Etomidate versus ketamine for rapid
321:493–503. sequence intubation in acutely ill patients: a multicentre randomised con-
Study identifies risk factors and physical findings that predict difficult intubation. trolled trial. Lancet 2009; 374:293–300.
Best predictors were inability to bite the upper lip with the lower incisors, a short 43. Upchurch CP, Grijalva CG, Russ S, et al. Comparison of etomidate and
hyomental distance, retrognathia and the modified Mallampati score. An abnormal ketamine for induction during rapid sequence intubation of adult trauma
upper lip bite test raised the probability of difficult intubation from 10% to greater patients. Ann Emerg Med 2017; 69:24–33.e22.
than 60%. 44. Mosier JM, Sakles JC, Stolz U, et al. Neuromuscular blockade improves first-
22. De Jong A, Molinari N, Terzi N, et al. Early identification of patients at risk for attempt success for intubation in the intensive care unit. A propensity matched
difficult intubation in the intensive care unit: development and validation of the analysis. Ann Am Thorac Soc 2015; 12:734–741.
MACOCHA score in a multicenter cohort study. Am J Respir Crit Care Med 45. Okubo M, Gibo K, Hagiwara Y, et al. The effectiveness of rapid sequence
2013; 187:832–839. intubation (RSI) versus non-RSI in emergency department: an analysis of
23. Janz DR, Semler MW, Jofe AM, et al. A multicenter randomized trial of a multicenter prospective observational study. Int J Emerg Med 2017; 10:1.
checklist for endotracheal intubation of critically ill adults. Chest 2018; 46. Wilcox SR, Bittner EA, Elmer J, et al. Neuromuscular blocking agent admin-
153:816–824. istration for emergent tracheal intubation is associated with decreased
24. Jaber S, Jung B, Corne P, et al. An intervention to decrease complications prevalence of procedure-related complications. Crit Care Med 2012;
related to endotracheal intubation in the intensive care unit: a prospective, 40:1808–1813.
multiple-center study. Intensive Care Med 2010; 36:248–255. 47. Laurin EG, Sakles JC, Panacek EA, et al. A comparison of succinylcholine and
25. Semler MW, Janz DR, Russell DW, et al. A multicenter, randomized trial of rocuronium for rapid-sequence intubation of emergency department patients.
ramped position vs sniffing position during endotracheal intubation of critically Acad Emerg Med 2000; 7:1362–1369.
ill adults. Chest 2017; 152:712–722. 48. Hristovska AM, Duch P, Allingstrup M, Afshari A. Efficacy and safety of
26. Turner JS, Ellender TJ, Okonkwo ER, et al. Feasibility of upright patient sugammadex versus neostigmine in reversing neuromuscular blockade in
positioning and intubation success rates at two academic EDs. Am J Emerg adults. Cochrane Database Syst Rev 2017; 8:CD012763.
Med 2017; 35:986–992. 49. Algie CM, Mahar RK, Tan HB, et al. Effectiveness and risks of cricoid pressure
27. Khandelwal N, Khorsand S, Mitchell SH, Joffe AM. Head-elevated patient during rapid sequence induction for endotracheal intubation. Cochrane
positioning decreases complications of emergent tracheal intubation in the Database Syst Rev 2015; CD011656.
ward and intensive care unit. Anesth Analg 2016; 122:1101–1107. 50. Birenbaum A, Hajage D, Roche S, et al. Group II. Effect of cricoid pressure
28. Russotto V, Cortegiani A, Raineri SM, et al. Respiratory support techniques to & compared with a sham procedure in the rapid sequence induction of
avoid desaturation in critically ill patients requiring endotracheal intubation: a anesthesia: the IRIS Randomized Clinical Trial. JAMA Surg 2019; 154:9–17.
systematic review and meta-analysis. J Crit Care 2017; 41:98–106. In a large trial in patients undergoing anaesthesia rapid sequence intubation failed
29. Goligher EC, Slutsky AS. Not just oxygen? Mechanisms of benefit from high- to demonstrate the non inferiority of the sham procedure in preventing pulmonary
flow nasal cannula in hypoxemic respiratory failure. Am J Respir Crit Care Med aspiration.
2017; 195:1128–1131. 51. Allman KG. The effect of cricoid pressure application on airway patency. J Clin
30. Kallet RH, Diaz JV. The physiologic effects of noninvasive ventilation. Respir Anesth 1995; 7:197–199.
Care 2009; 54:102–115. 52. Haslam N, Parker L, Duggan JE. Effect of cricoid pressure on the view at
31. Guitton C, Ehrmann S, Volteau C, et al. Nasal high-flow preoxygenation for laryngoscopy. Anaesthesia 2005; 60:41–47.
&& endotracheal intubation in the critically ill patient: a randomized clinical trial. 53. Casey JD, Janz DR, Russell DW, et al. Bag-mask ventilation during tracheal
Intensive Care Med 2019; 45:447–458. && intubation of critically ill adults. N Engl J Med 2019; 380:811–821.
Preoxygenation with standard bag-valve mask oxygenation compared with high Patients receiving bag-mask ventilation had higher oxygen saturations and a lower
flow nasal oxygen did not improve the lowest oxygen saturation during intubation in incidence of severe hypoxaemia than those receiving no ventilation critically ill
the nonseverely hypoxemic patients, but there was a reduction in intubation-related adults undergoing tracheal intubation.
adverse events. 54. Kim WY, Kwak MK, Ko BS, et al. Factors associated with the occurrence of
32. Semler MW, Janz DR, Lentz RJ, et al., FELLOW Investigators; Pragmatic cardiac arrest after emergency tracheal intubation in the emergency depart-
Critical Care Research Group. Randomized trial of apneic oxygenation during ment. PLoS One 2014; 9:e112779.
endotracheal intubation of the critically ill. Am J Respir Crit Care Med 2016; 55. Janz DR, Casey JD, Semler MW, et al. Effect of a fluid bolus on cardiovascular
193:273–280. & collapse among critically ill adults undergoing tracheal intubation (PrePARE):
33. Frat J-P, Ricard J-D, Quenot J-P, et al. Noninvasive ventilation versus high-flow a randomised controlled trial. Lancet Respir Med 2019; 7:1039–1047.
&& nasal cannula oxygen therapy with apnoeic oxygenation for preoxygenation Administration of an intravenous fluid bolus compared with no fluid bolus, did not
before intubation of patients with acute hypoxaemic respiratory failure: a reduce the overall incidence of cardiovascular collapse during tracheal intubation
randomised, multicentre, open-label trial. Lancet Respir Med 2019; in critically ill adults.
7:303–312. 56. Arulkumaran N, Lowe J, Ions R, et al. Videolaryngoscopy versus direct
Preoxygenation with noninvasive ventilation (NIV) or high-flow oxygen therapy in laryngoscopy for emergency orotracheal intubation outside the operating
patients with acute hypoxaemic respiratory failure did not change the risk of severe room: a systematic review and meta-analysis. Br J Anaesth 2018;
hypoxaemia. However, in the subgroup of patients with a P/F ratio less than 200, a 120:712–724.
potential benefit for NIV was seen. 57. Cabrini L, Landoni G, Baiardo Redaelli M, et al. Tracheal intubation in critically
34. Jaber S, Monnin M, Girard M, et al. Apnoeic oxygenation via high-flow nasal ill patients: a comprehensive systematic review of randomized trials. Crit Care
cannula oxygen combined with noninvasive ventilation preoxygenation for 2018; 22:6.
intubation in hypoxaemic patients in the intensive care unit: the single-centre, 58. Jaber S, De Jong A, Pelosi P, et al. Videolaryngoscopy in critically ill patients.
blinded, randomised controlled OPTINIV trial. Intensive Care Med 2016; Crit Care 2019; 23:221–227.
42:1877–1887. 59. Driver BE, Prekker ME, Klein LR, et al. Effect of use of a bougie vs endo-
35. Allaouchiche B, Duflo F, Debon R, et al. Influence of sepsis on minimum && tracheal tube and stylet on first-attempt intubation success among patients
alveolar concentration of desflurane in a porcine model. Br J Anaesth 2001; with difficult airways undergoing emergency intubation: a randomized clinical
87:280–283. trial. JAMA 2018; 319:2179–2189.
36. McKown AC, Casey JD, Russell DW, et al. Risk factors for and prediction of Use of a bougie compared with an endotracheal tube and stylet resulted in
hypoxemia during tracheal intubation of critically ill adults. Ann Am Thorac Soc significantly higher first-attempt intubation success among patients undergoing
2018; 15:1320–1327. emergency endotracheal intubation in this emergency department.
37. Koenig SJ, Lakticova V, Narasimhan M, et al. Safety of propofol as an induction 60. Thomsen JLD, Norskov AK, Rosenstock CV. Supraglottic airway devices in
agent for urgent endotracheal intubation in the medical intensive care unit. J & difficult airway management: a retrospective cohort study of 658,104 general
Intensive Care Med 2015; 30:499–504. anaesthetics registered in the Danish Anaesthesia Database. Anaesthesia
38. Zettervall SL, Sirajuddin S, Akst S, et al. Use of propofol as an induction agent 2019; 74:151–157.
in the acutely injured patient. Eur J Trauma Emerg Surg 2015; 41:405–411. Supraglottic airway devices are not widely used in the management of the difficult
39. Gu WJ, Wang F, Tang L, Liu JC. Single-dose etomidate does not increase airway despite strong recommendations for use in various difficult airway manage-
mortality in patients with sepsis: a systematic review and meta-analysis of ment guidelines.
randomized controlled trials and observational studies. Chest 2015; 61. Marshall S. The use of cognitive aids during emergencies in anesthesia: a
147:335–346. review of the literature. Anesth Analg 2013; 117:1162–1171.
40. Bruder EA, Ball IM, Ridi S, et al. Single induction dose of etomidate versus 62. Chrimes N. The Vortex: a universal ‘high-acuity implementation tool’ for
other induction agents for endotracheal intubation in critically ill patients. emergency airway management. Br J Anaesth 2016; 117(Suppl 1):
Cochrane Database Syst Rev 2015; 1:CD010225. i20–i27.

1070-5295 Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved. www.co-criticalcare.com 45

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.