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Am J Respir Crit Care Med. 2020 Jan 2. doi: 10.1164/rccm.201908-1636CI. [Epub ahead of print]

Tracheal Intubation in the Critically Ill: Where We Came From and Where We Should Go.

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University of Arizona, Emergency Medicine, Tucson, Arizona, United States;
University of Arizona, Department of Emergency Medicine, Tucson, Arizona, United States.
Dalhousie University, 3688, Anesthesia, Halifax, Nova Scotia, Canada.
Brigham and Women's Hospital, 1861, Emergency Medicine, Boston, Massachusetts, United States.
University of Alberta Faculty of Medicine and Dentistry, 12357, Edmonton, Canada.


Tracheal intubation is commonly performed in critically ill patients. Unfortunately, this procedure also carries a high risk of complications; half of critically ill patients with difficult airways experiencing life threatening complications. The high complication rates stem from difficulty with laryngoscopy and tube placement, consequences of physiologic derangement, and human factors including failure to recognize and reluctance to manage the failed airway. The last 10 years have seen a rapid expansion in devices available that help overcome anatomic difficulties with laryngoscopy and provide rescue oxygenation in the setting of failed attempts. Recent research in critically ill patients has highlighted other important considerations for critically ill patients and evaluated interventions to reduce the risks with repeated attempts, desaturation, and cardiovascular collapse during emergency airway management. There are three actions that should be implemented to reduce the risk of danger and include: 1. Preintubation assessment for potential difficulty (e.g. MACOCHA score), 2. Preparation and optimization of the patient and team for difficulty-including using a checklist, acquiring necessary equipment, maximizing preoxygenation, and hemodynamic optimization, and 3. Recognition and management of failure to restore oxygenation and reduce the risk of cardiopulmonary arrest. This review describes the history of emergency airway management and explores the challenges with modern emergency airway management in critically ill patients. We offer clinically relevant recommendations based on current evidence, guidelines, and expert opinion.


Airway management; Critically ill; Intubation; RSI


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