CONCISE CLINICAL REVIEW

Tracheal Intubation in the Critically Ill

Where We Came from and Where We Should Go
Jarrod M. Mosier1,2, John C. Sakles1, J. Adam Law3, Calvin A. Brown III4, and Peter G. Brindley5
1
Department of Emergency Medicine and 2Division of Pulmonary, Allergy, Critical Care, and Sleep, Department of Medicine, University of
Arizona, Tucson, Arizona; 3Department of Anesthesiology and Department of Emergency Medicine, Dalhousie University, Halifax, Nova
Scotia, Canada; 4Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts;
and 5Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
ORCID IDs: 0000-0002-5371-0845 (J.M.M.); 0000-0001-7585-3591 (P.G.B.).

Abstract management. There are three actions that should be implemented

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
experience 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
to reduce the risk of danger: 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 on the basis of current evidence, guidelines, and
expert opinion.
Keywords: intubation; airway management; rapid-sequence
intubation; critically ill

Tracheal intubation in critically ill
patients is common and perilous. It is the
third most frequently performed procedure
in U.S. hospitals, increasing .50% in just
4 years (1). Tracheal intubation was
performed in more than 300,000 of
the approximately 2 million patients
admitted from U.S. emergency departments
to the ICU (2) and in 90% of ICU
admissions from a UK audit (3).
Unfortunately, this common procedure
carries complication rates of .40% in
some series (Table 1), an alarmingly
high percentage of patients suffer an
associated cardiac arrest (4, 5), and there
are numerous contributing factors
(Figure 1). How we intubate critically
ill patients is largely extrapolated from
operating room (OR) practice, although
many aspects have insufficient or no data,
and there are important differences
between elective and emergent tracheal
intubations, such as the risk of aspiration
versus desaturation or hypotension
and the risk of difficult laryngoscopy.
This narrative review describes the
historical evolution of emergency
airway management, explores the
current challenges, and offers
recommendations (Table 2 and Figure 2)
and important future research
considerations for airway management
in the critically ill.

( Received in original form August 21, 2019; accepted in final form January 2, 2020 )
Author Contributions: J.M.M. conceived and drafted the manuscript; all authors participated in literature review and revisions; J.M.M. and P.G.B. edited the
final manuscript; J.M.M., J.C.S., J.A.L., C.A.B., and P.G.B. participated in literature review and revisions; and J.M.M. takes responsibility for the final draft.
Correspondence and requests for reprints should be addressed to Jarrod M. Mosier, M.D., Division of Pulmonary, Allergy, Critical Care, and Sleep, Department
of Emergency Medicine and Department of Medicine, University of Arizona, 1501 North Campbell Avenue, AHSL 4165E, P.O. Box 245057, Tucson, AZ 85724-
5057. E-mail: jmosier@aemrc.arizona.edu.
CME will be available for this article at www.atsjournals.org.
Am J Respir Crit Care Med Vol 201, Iss 7, pp 775–788, Apr 1, 2020
Copyright © 2020 by the American Thoracic Society
Originally Published in Press as DOI: 10.1164/rccm.201908-1636CI on January 2, 2020
Internet address: www.atsjournals.org

Concise Clinical Review 775

 776
Table 1. Incidence of Complications in the Published Literature

Hypoxemia Esophageal Intubation Aspiration Cardiac Arrest

<2 >2 <2 >2 <2 >2 <2 >2
Attempts Attempts Hypotension Attempts Attempts Attempts Attempts Attempts Attempts
at at (Cardiovascular at at at at at at Severe Moderate
Intubation Intubation Collapse)* Intubation Intubation Intubation Intubation Intubation Intubation Complications† Complications‡

Mort, 2004 (137) 10.5 70 — 4.8 51 0.8 13 0.7 11 — —

(N = 2,833) 1.9x (severe) 28x (severe)
Jaber et al., 2006 (107) 26 (40 .2 attempts) 26 4.6 2 1.6 28 —
(N = 253)
Griesdale et al., 2008 19 9.6 7.4 5.9 — 25 39
(106) (N = 136)
Simpson et al., 2012 (3) 41 ,90% SpO2 33 — 2 1.5 — —
(N = 794) 21 ,80% SpO2
11 ,70% SpO2
Smischney et al., 2017 18 41 0.2 1.2 — — —
(109) (N = 420)
Perbet et al., 2015 (108) — 30 — — — — —
(N = 885)
Hypes et al., 2017 (74) 19 7.7 1.9 2.8 0.7 — —
(N = 905)
McKown et al., 2018 (77) 21.5 — — — — — —
(N = 426)
De Jong et al., 2018 (4) 22 29 — — 2.7 18 19
(N = 1,847)

Definition of abbreviations: SBP = systolic blood pressure; SpO2 = oxygen saturation as measured by pulse oximetry.
Data presented as percentages.
*Jaber and colleagues (107) and Perbet and colleagues (108) define hypotension as SBP , 65 and/or ,90 mm Hg for .30 minutes despite fluids and/or vasopressors, and Simpson and
colleagues (3) define it as SBP , 90 mm Hg.
†
Jaber and colleagues (107) define severe complications as serious hypoxemia, severe collapse, cardiac arrest, or death; Griesdale and colleagues (106) define severe complications as
desaturation , 80%, SBP , 70, or cardiac arrest during or within 5 minutes of intubation; and DeJong and colleages (4) define severe complications as severe hypoxemia (O2
saturation , 80% or .10% change), severe collapse SBP , 65 mm Hg at least once, ,90 mm Hg lasting 30 minutes despite 500–1,000 ml of fluid loading (crystalloid solutions), or decrease
of SBP . 20% if ,65 mm Hg before intubation or requiring introduction or increasing doses by .30% of vasoactive support, cardiac arrest, and death.
‡
Jaber and colleagues (107) define moderate complications as difficult intubation, cardiac arrhythmia, esophageal intubation, aspiration, agitation, or dental injury; and DeJong and colleages
(4) define moderate complications as difficult intubation (more than two attempts), severe ventricular or supraventricular arrhythmia requiring intervention, esophageal intubation, agitation,
pulmonary aspiration, and dental injuries.
x
Mort (137): hypoxemia < 90%, severe hypoxemia < 70%; Jaber and colleagues (107): ,80%; Griesdale and colleagues (106): ,80%; Hypes and colleagues (74): .10% change; McKown
and colleagues (77): ,80% or .10% change; and De Jong and colleages (4): ,80% or .10% change.
CONCISE CLINICAL REVIEW

American Journal of Respiratory and Critical Care Medicine Volume 201 Number 7 | April 1 2020
CONCISE CLINICAL REVIEW

He

Pre
Patient-Related Materials Methods

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Appropriate equipment not

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of knowledge or lack of effort)

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(enough oxygen sources,

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regulators, ventilators, drugs) Airway

r
Human factors
management–
-task fixation Inexperienced operator or
Malfunctioning equipment related harm
-cognitive biases inexperienced help
-heightened arousal (bulb failure, camera
failure, contamination,
Lack of cohesive Lack of ongoing mask failure)
team/team training/skill degradation
training/lack of Tissue/airway structure Inadequate monitoring
Help delayed or
shared mental model injury (usually from (e.g., EtCO2)
unavailable
repeated attempts)
Terminology
inadequacies
(”difficult airway”)
Environment Manpower Equipment
Figure 1. This fishbone diagram demonstrates all the patient-, equipment-, and human factor–related variables that contribute to harm with airway
management in critically ill patients and the interconnection of these contributing factors that results in the high complication rates reported with tracheal
intubation. ETCO2 = end tidal carbon dioxide; PEEP = positive end-expiratory pressure.

History of Emergency Airway
Management
Aspiration has historically been the biggest
threat to morbidity and mortality, and this
remains the case today in the OR (6–12).
Preventing aspiration was a cornerstone in
the evolution of airway management, and
traditional practice was to intubate patients
“awake” to preserve airway reflexes. Yet, the
upper airway is richly innervated and
laryngoscopy causes intense stimulation,
increasing the potential for vomiting and
aspiration (6, 7, 13–15). Awake patients
thus required topical anesthesia of the
upper airway, and many patients benefited
from adjunctive sedative agents and
appropriate positioning to limit aspiration.
In patients at high risk of aspiration,
sedative agents were administered with a
neuromuscular blocking agent by “rapid-
sequence induction” of anesthesia to
facilitate laryngoscopy and minimize the
risk of vomiting (7–9).
For decades, patients were positioned
in the feet-down position to avoid passive
regurgitation of gastric contents (7, 12, 16).
This position worsened hypotension,
particularly when combined with
thiopental induction, and more likely led to
aspiration when patients did regurgitate (8,
17, 18). Therefore, opponents
recommended a head-down position,
which increased the risk of regurgitation
but decreased the likelihood that those
contents would aspirate into the lungs (8).
Others advocated a head-down left lateral
position and, ultimately, supine with the
head and neck extended (i.e., “sniffing”
position) combined with pressure on the
cricoid cartilage (Sellick’s maneuver) to
compress the hypopharynx (8, 17, 18).
Patients were preoxygenated for 2 to
3 minutes to avoid mask ventilation after
induction (8) over concerns that gastric
insufflation from mask ventilation would
increase the likelihood of regurgitation and
aspiration—a fear that persists. In 1970,
Stept and Safar published a 15-step
protocol for rapid-sequence induction and
intubation in patients at risk for aspiration
(9). The goal was to prevent aspiration by
avoiding mask ventilation, positioning to
mitigate passive regurgitation and the
hemodynamic effects of a feet-down
position, and limiting the time during
which the airway was unprotected by using
rapid induction. This protocol involved
placement, and then removal, of a
nasogastric tube to decompress the
stomach, preoxygenation for at least
2 minutes, and then positioning in the “V”
position (head up, feet up, bent at waist).
A small “precurarizing” dose of a
nondepolarizing neuromuscular blocking
agent was then given to prevent
regurgitation secondary to abdominal wall
fasciculations and increased intraabdominal
pressure caused by succinylcholine (9).
After precurarizing, thiopental and
succinylcholine were given in rapid
succession.
Although the seminal Stept and Safar
paper provided the impetus for emergency
airway management outside of the OR, the
protocol ignored oxygen saturation (9).
Hypoxemia with intubation was likely
underrecognized, because the first pulse
oximeter was not invented for another 4
years, was not commercially available for
another decade, and was not widely used
clinically for yet another two decades
(19–22). Emergency airway management
was born in the 1970s and 1980s and
involved direct laryngoscopy without
medications in comatose patients, “blind”
nasotracheal intubations in spontaneously
breathing patients, and cricothyrotomy in
patients with suspected cervical injuries

Concise Clinical Review 777


Table 2. Suggestions for Airway Management in Critically Ill Patients
Topic Direction of Evidence and Comments
Positioning Studies comparing upright and supine positions are
conflicting. Observational studies show an improvement in
first-attempt success, but a recent pragmatic trial showed
increased difficulty. A large retrospective study showed
that combining upright positioning with sniffing position
improved success and reduced complications.
Upright positioning is recommended in the 2018 Difficult
Airway Society guidelines for intubation in critically ill
patients.
Data are lacking for gastric decompression and controversial We recommend that gastric decompression and Sellick’s
for cricoid pressure.
Gastric decompression and cricoid pressure are
recommended by the 2018 Difficult Airway Society
guidelines for intubation in critically ill patients.
RSI Studies show improved outcomes with RSI.
Preoxygenation Studies consistently show an improvement in FRC,
particularly in people with risks such as obesity, late-term
pregnancy, or ascites.
Flush rate oxygen has been shown to provide similar
end-expiratory oxygen concentrations as those achieved
with tight-fitting face masks.
Preoxygenation with noninvasive positive pressure ventilation In patients with airspace disease, atelectasis, and/or shunt,
has been shown to result in improved preoxygenation in
patients with hypoxemic respiratory failure, and it is
recommended by the 2018 Difficult Airway Society
guidelines for intubation in critically ill patients.
Apneic and rescue Data for apneic oxygenation are also conflicting. Preclinical Continuously replenishing alveolar oxygen during apnea in
oxygenation data show apneic oxygenation prolongs the time to
desaturation ,60%, and loses efficacy as the degree of
shunt increases. Observational studies and clinical trials
have been mixed, but a recent meta-analysis suggests
apneic oxygenation is associated with improved procedural
outcomes.
Recommended by the 2018 Difficult Airway Society
guidelines for intubation in critically ill patients.
Recommended by the 2018 Difficult Airway Society
guidelines for intubation in critically ill patients.
Recommended by the 2018 Difficult Airway Society
guidelines for intubation in critically ill patients. See text for
further information.
Recommended by the 2018 Difficult Airway Society
guidelines for intubation in critically ill patients.
778 American Journal of Respiratory and Critical Care Medicine Volume 201 Number 7 | April 1 2020
CONCISE CLINICAL REVIEW
Authors’ Suggestions
Patients intubated in the supine position should be positioned
such that the lower cervical spine is flexed, the upper
cervical spine is extended, and the ear is leveled with the
sternal notch (i.e., the sniffing position).
In patients at risk of reduced FRC (e.g., obese,
late-term pregnant, and/or ascites) or at high risk of
aspiration, we suggest that patients should be in
ramped position for both preoxygenation and
laryngoscopy.
maneuver should be performed in patients at high risk of
aspiration (bowel obstruction, upper gastrointestinal
bleeding, etc.). Bedside gastric ultrasound can help
quantify those with high gastric volumes.
RSI should be performed in patients where oral laryngoscopy
is planned.
Preoxygenation is generally limited by three factors: the size
of the FRC, the extent of denitrogenation of that FRC, and
the degree of shunt limiting the availability of that FRC.
We recommend that patients should be preoxygenated in the
upright position when possible to maximize the FRC,
regardless of which position is utilized for laryngoscopy.
Denitrogenation should be routinely performed with flush flow
oxygen.
denitrogenation should be augmented by preoxygenating
with noninvasive positive pressure ventilation to improve
the FRC and improve ventilation–perfusion mismatch.
In some patients with refractory hypoxemia, shunt physiology
prohibits an adequate safe apnea time, despite optimizing the
FRC and denitrogenation. These patients frequently desaturate
immediately on induction. A PaO2 after preoxygenation can be
useful in identifying these patients, where we suggest an awake
intubation approach while maintaining spontaneous breathing
should be strongly considered.
We recommend that mask ventilation should be considered
between induction and laryngoscopy in patients
undergoing RSI when the risk for aspiration is low.
the presence of an adequate FRC and the absence of
significant shunt physiology will, theoretically, prolong the
safe apnea time indefinitely—thus the success seen in the
operating room. Many critically ill patients, however, are
limited by the airspace disease and shunt.
We recommend that apneic oxygenation should be used after
optimal preoxygenation is performed, but it should be
recognized that the more severe the hypoxemia, the less
effective it is likely to be.
A second-generation supraglottic airway should be
immediately available for rescue oxygenation.
One should be prepared to immediately perform an emergent
cricothyrotomy in the event of a can’t intubate–can’t
oxygenate scenario that is not rescued by a
second-generation supraglottic airway device.
Waveform capnography should be used for all patients
requiring mask ventilation to confirm tube placement and to
monitor for accidental extubation.
In a can’t intubate–can’t oxygenate emergency, a
cricothyrotomy should be performed without delay.
Reversing rocuronium or waiting for spontaneous respirations
to resume will result in a critically hypoxemic patient who is
no longer optimized for intubation or mask ventilation.
(Continued )
CONCISE CLINICAL REVIEW

Table 2. (Continued )

Topic Direction of Evidence and Comments Authors’ Suggestions

Hemodynamics Observational studies have shown periintubation hypotension We recommend that patients should have hemodynamics
to be associated with an increased risk of cardiac arrest optimized to the degree possible before induction. This
and poor outcomes. Data on interventions to prevent includes fluid and vasopressor-based resuscitation where
hypotension are lacking, but a recent pragmatic trial appropriate and RV-specific management in the setting of
showed that a fluid bolus in all patients did not reduce the decompensated acute or chronic right ventricular failure.
rate of hypotension.
Laryngoscopy Recommended by the 2018 Difficult Airway Society A video laryngoscope should be immediately available in
guidelines for intubation in critically ill patients. See text for every ICU and ED.
further information.
Data on direct and video laryngoscopy are conflicting and We recommend that a traditional geometry video
controversial. See text for detailed explanation. laryngoscope should be considered as the routine
first-attempt device if no difficulty is predicted. A bougie
should be considered for every intubation as a replacement
for a malleable stylet when a traditional-geometry video
laryngoscope is used.
A hyperangulated video laryngoscope should be considered
if RSI is planned in the presence of difficult airway
predictors. When a hyperangulated video laryngoscope is
used, a rigid stylet should be used to help guide tube
placement (186).
Recommended by the 2018 Difficult Airway Society A flexible endoscope should be immediately available in every
guidelines for intubation in critically ill patients. ICU and ED.
Human factors Consistent with the 2018 Difficult Airway Society guidelines We recommend that training programs should develop robust
for intubation in critically ill patients. See text for further curricula to provide experience to trainees in the various
information. devices used for airway management, algorithms, team
training, and intubation as it relates to physiology rather
than just laryngoscopy.
Although data are lacking, the 2018 Difficult Airway Society We recommend that airway management in critically ill
guidelines for intubation in critically ill patients recommend patients should be performed using a shared mental model.
a shared mental model approach.
There are several algorithms and cognitive aids in existence, An algorithmic approach to intubations should be performed
with no data comparing them to suggest which one is to cognitively offload the team and improve the recognition
superior. and management of failure.
A checklist with interventions aimed at improving We recommend that a checklist should be considered to
preoxygenation and hemodynamics before intubation has promote a systematic approach to airway management
been shown to reduce complications (91), but a fairly using a shared mental model.
similar checklist failed to replicate those results in a recent
pragmatic trial.

Definition of abbreviations: ED = emergency department; RSI = rapid-sequence intubation; RV = right ventricle.

(23–27). Rapid-sequence intubation as we
currently use it entails the administration
of a sedative-hypnotic agent and a
neuromuscular blocking agent followed
by placement of an endotracheal tube,
in rapid succession. The goal with
rapid-sequence intubation is to rapidly
optimize conditions for intubation rather
than rapidly inducing anesthesia.
Consequently, we refer to RSI (rapid-
sequence intubation), not RSII (rapid-
sequence induction and intubation).
Rapid-sequence intubation outside
of the OR was first adopted, albeit
controversially, in the emergency
department in the 1990s (26–38). It was
not until the mid-2000s that rapid-
sequence intubation started gaining
support in the ICU (39–41). Pulse
oximetry is now ubiquitous, and the goals
of rapid-sequence intubation have
evolved to both prevent aspiration and
facilitate intubation before oxygen
desaturation.
Current Challenges with
Emergency Airway
Management
Positioning and Cricoid Pressure
Debate about patient positioning generally
involves the semi-upright “ramped”
position and the sniffing position.
Although being upright improves
preoxygenation (42–45), outcomes and
comparisons are variable. In a trial of
patients in the OR, ramped position
improved laryngoscopic grade of view
compared with the sniffing position (46).
Outside the OR, a recent trial in patients
intubated by fellows showed ramped
position was associated with increased
intubation difficulty compared with the
sniffing position (47). A prospective
observational study of patients intubated
by emergency department residents
showed improved first-attempt success
when ramping compared with supine (48),
and a large retrospective study of patients
intubated by an anesthesia service—
dedicated to outside-of-OR intubations—
showed that a combination of ramped plus
sniffing positions substantially reduced
complication rates, including desaturation
(49). Current guidelines recommend a
head-up position, especially in patients
at high risk of aspiration or desaturation
(50, 51).
Cricoid pressure remains controversial.
There are no outcome data regarding
the effectiveness of cricoid pressure in
preventing aspiration, and although a 2015

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 CONCISE CLINICAL REVIEW

Cochrane review concluded that more
evidence is needed (52), and a large 2019
clinical trial failed to show noninferiority
of sham versus cricoid pressure (53),
the application of cricoid pressure is
recommended by the 2018 Difficult
Airway Society guidelines on airway
management in the critically ill (50).
Cricoid manipulation is not without some
risk, as misapplied cricoid pressure can
distort the cricoid ring and worsen the
view of the glottis, impeding successful
tube passage and rescue mask ventilation
(54–56).
Rapid-Sequence Intubation
Rapid-sequence intubation is associated
with increased first-attempt success (41, 57),
fewer intubation-related complications
(40), and fewer laryngeal injuries (58).
Despite clear evidence supporting rapid-
sequence intubation and its role in
increasing first-attempt success, there is
lingering debate about whether to use a
neuromuscular blocking agent over fear of
an inability to mask ventilate. The fear is
that if intubation is not rapidly successful
then the paralyzed patient could precipitate
a “can’t intubate–can’t oxygenate”
emergency (59–62). This fear persists
despite evidence that neuromuscular
blocking agents either improve, or at worst
have no effect on, the ease of mask
ventilation (63–66). Contemporary
guidelines now recommend administering
a neuromuscular blocking agent (if not
already given) during a can’t intubate–can’t
oxygenate emergency (10, 11, 60, 62–64,
66–71).
The Difficult Airway: Physiology
Although the risk of aspiration remains,
more frequent and dangerous complications
of intubation in critically ill patients are
oxygen desaturation and cardiovascular
collapse. These risks exist on a spectrum,
and more aggressive preventive
interventions are required for those with
increasing risk (Figure 2). Prolonged or
multiple attempts at intubation increase
these risks, and it has become common
wisdom that intubation be limited to no
more than three attempts. However, in
critically ill patients, even the need for a
second attempt is associated with a marked
increase in desaturation and hypotension
(72, 73).
Intubation in critically ill patients is
dangerous not only because of potential
anatomic challenges with laryngoscopy but
also because both the patient and team
are functioning near their limits (73–75).
This highlights the need to concomitantly
master the “physiologically difficult
airway” (where patients are at risk of
cardiopulmonary collapse) and the

Typical Patient is intubated for Typical Patient is intubated for

Typical Patient is intubated for
respiratory failure in the severe ARDS and refractory
airway protection without any
presence of recruitable disease hypoxemia. PaO2 does not increase
airspace disease.
and minimal–moderate shunt. despite optimal preoxygenation.

Recommendations: Recommendations: Recommendations:

Preoxygenation 1. Flush flow oxygen
2. Upright positioning
3. Apneic oxygenation
4. Mask ventilation between
induction and laryngoscopy
1. NIPPV preoxygenation
2. HFNO preoxygenation and
apenic oxygenation
2. Upright positioning
3. Apneic oxygenation
4. Mask ventilation between
induction and laryngoscopy
1. Maintain spontaneous respiration
2. HFNO
2. Upright positioning
3. Consider inhaled vasodilators to
improve ventilation:perfusion

Typical Patient is normotensive
with a normal or elevated
shock index.
Typical Patient is hypotensive
with elevated shock index.
Typical Patient is hypotensive with
an etiology likely to worsen with
intubation (e.g., pulmonary embolism,
ARDS with RV failure, decompensated
pulmonary hypertension).

Recommendations: Recommendations: Recommendations:

1. Fluid bolus if likely to be
Hemodynamics volume responsive
2. Push-dose or continuous
vasopressors immediately
available
1. Fluid resuscitation if likely
to be volume responsive
2. lnline continuous vasopressor
3. Consider point-of-care
ultrasound
4. Hemodynamically neutral
sedative agent (consider a
reduced dose)
1. Consider maintaining
spontaneous respiration
2. HFNO
2. Point-of-care ultrasound to evaluate
RV function
3. Vasopressors/fluids/inotropes based
on ultrasound findings
4. Slow transition to positive pressure,
maintain low mean airway pressure

Low High Refractory

Risk of Decompensation
Figure 2. Recommendations for reducing the risk of desaturation and cardiovascular collapse depending on preintubation risk. Future research is needed
to characterize patients’ risk on the basis of preintubation hemodynamics and gas exchange and evaluate the interventions within each risk category.
ARDS = acute respiratory distress syndrome; HFNO = high-flow nasal oxygen; NIPPV = noninvasive positive pressure ventilation; RV = right ventricle.

780 American Journal of Respiratory and Critical Care Medicine Volume 201 Number 7 | April 1 2020
CONCISE CLINICAL REVIEW
“situationally difficult airway” (where the
team is inexperienced/stressed or the
location is challenging/unusual). Airway
management experts now accept that
emergency airway management is about
more than performing laryngoscopy;
it is about maintaining the patient’s
cardiopulmonary reserve, leveraging the
team’s potential, and mitigating chaos as we
transition the patient to positive pressure
ventilation.
Preventing Oxygen Desaturation
Preoxygenation has evolved from a
maneuver to avoid mask ventilation to
the paramount step for patient safety by
maintaining Hb saturation and prolonging
the apneic period (76). Predictors of
desaturation include 1) acute respiratory
failure, 2) inexperienced operators, and 3)
low starting oxygen saturation (77, 78). All
three are associated with higher ICU and
in-hospital mortality (78). Preoxygenation
requires denitrogenation of the FRC with
oxygen, such that there is an oxygen
reservoir available to draw on during
hypoventilation or apnea. Maneuvers that
increase the size of the FRC (e.g., upright
positioning) (42–45) or reduce room air
entrainment will improve the efficacy of
preoxygenation (79, 80). Renitrogenation
of the lungs occurs rapidly with
spontaneous respirations if the source for
preoxygenation is removed between
injection of rapid-sequence intubation
medications and the onset of apnea. Mask
ventilation in this period prevents this
renitrogenation, recruits alveoli when a
positive end-expiratory pressure valve is
used, and was recently shown to reduce
desaturation rates in critically ill patients at
low aspiration risk (81).
In critically ill patients, preoxygenation
becomes uncoupled from denitrogenation
(76). The FRC reduces in proportion to the
severity of the airspace disease (82, 83), and
associated shunt decreases the availability
to resaturate Hb (84). Attempting to
compensate for the shunt by increasing the
denitrogenation time may not only be
ineffective but also worsen the hypoxemia
in one out of four patients (85), likely
through absorption atelectasis. This is
potentially one of the reasons why 100%
oxygen via high-flow nasal insufflation is
associated with mixed results when used for
hypoxemic respiratory failure (86–88).
Noninvasive positive pressure for
preoxygenation in hypoxemic respiratory
Concise Clinical Review
failure shows the most promise for
improving safety (89, 90). Noninvasive
positive pressure reduced the rate of
hypoxemia in ICU intubations by 15% in
one study (91) and may be better than
high-flow nasal insufflation in patients with
a PaO2/FIO2 ratio , 200 (92). In patients
with refractory hypoxemia, an awake
approach, which maintains spontaneous
respiration, with high-flow nasal oxygen
may be the best option, as there is likely no
truly safe apnea time (Figure 2).
The addition of continuous oxygen into
the nasopharynx during apnea (termed
apneic oxygenation) may also extend the
safe apnea time. In a porcine model of acute
respiratory distress syndrome, the use of
apneic oxygenation maintained saturation
.60% in most animals for 10 minutes,
whereas without apneic oxygenation they
desaturated to ,60% in ,2 minutes (93).
The more severe the shunt, the faster the
desaturation (93), indicating that it may be
least effective in patients who need it most.
Results from clinical studies of apneic
oxygenation have been mixed, especially
in patients with hypoxemic respiratory
failure (88, 94–98). However, there are
methodological shortcomings. For example,
the preoxygenation method was not
standardized, nor was efficacy measured.
Moreover, intubation was often performed
rapidly, leaving only 1 to 2 minutes to
evaluate the intervention. This short
duration for laryngoscopy combined with
the very act of intubation does not permit
an optimal evaluation of the intervention at
maintaining oxygen saturation.
Rescue Oxygenation
The first rescue maneuver to perform when
faced with desaturation (,90% saturation)
is “best-technique” mask ventilation.
This should include, at minimum, an
oropharyngeal airway and two-handed
thenar grip of the mask. If mask ventilation
is still inadequate, then a supraglottic
airway can provide rescue oxygenation (99,
100). Supraglottic airways are designed to
be blindly placed in the oropharynx and
seal around the laryngeal opening. When a
supraglottic airway is placed in a can’t
intubate–can’t oxygenate emergency, it has
been successful at restoring oxygenation in
.60% of patients (101). The Fourth
National Audit of Practice (NAP4) report
concluded that in patients who would
almost certainly have died without an
emergent surgical airway, a supraglottic
airway was not attempted in half of the
cases. Moreover, it was often successful
when placed after the surgical airway,
indicating that it could have avoided the
need for a cricothyrotomy (102). Many
devices provide a conduit for intubation,
which can be used in patients with
predicted difficulty or as a rescue technique,
and second-generation devices also
facilitate gastric decompression.
When oxygenation cannot be restored
using a supraglottic airway, prompt
emergency cricothyrotomy is indicated
(50, 69, 103, 104). There is debate regarding
the optimal method for cricothyrotomy;
however, bougie-aided scalpel
cricothyrotomy is more rapid and
successful than a percutaneous technique
and is recommended by the Difficult
Airway Society guidelines (50, 102, 105).
Preventing Cardiovascular Collapse
Hypotension or cardiovascular collapse also
poses a serious threat, with between one-
quarter and one-half at risk (25–46%)
(3, 4, 106–109). Hemodynamic instability
is an independent predictor of death
after intubation (4, 5, 110–113), and
periintubation hypotension is associated
with longer ICU stays and increased in-
hospital mortality (4, 110, 111, 113–115).
Nearly half of ICU patients develop
postintubation hypotension as an effect of
the induction agents and transition to
positive pressure ventilation, which is
associated with twice the risk of a
composite endpoint of mortality, ICU
length of stay .14 days, mechanical
ventilation .7 days, and renal replacement
therapy (114, 116). Requiring vasopressors
within 60 minutes of intubation is also
associated with increased odds of in-
hospital death (3.84; 95% confidence
interval, 1.31–11.57). The combination
of desaturation and hypotension makes
cardiac arrest much more likely (4).
Intervention data are extremely limited,
and a recent trial showed no benefit with
a routine fluid bolus before intubation,
although patients were not stratified by risk
(117).
The Difficult Airway: Anatomy
Contemporary direct laryngoscopes have
either curved (e.g., Macintosh) or straight
(e.g, Miller) blades. The Macintosh blade is
designed to compress and displace the
tongue and elevate the epiglottis by engaging
the hyoepiglottic ligament. The Miller blade
781

is designed to displace the tongue and
directly lift the epiglottis. Both blades have
been in use since the 1940s (118, 119).
Because both of these blade designs require
displacing the upper airway soft tissues,
any anatomic variant that limits tissue
displacement into the submental space can
impair laryngoscopy and increase the
difficulty of tracheal intubation. Multiple
attempts cause edema or hemorrhage of the
airway structures and can precipitate an
airway obstruction. This highlights the
importance of difficult airway prediction—
namely undertaking a careful methodical
approach—and real-time recognition of the
failed airway to mitigate hypoxic insult. The
difficult airway is deadly and dramatically
increases the risk of complications. ICU
patients with difficult airways have
significantly more life-threatening
complications than patients with
nondifficult intubations (51% vs. 36%;
P , 0.001) (120).
The prevalence of the difficult airway is
reported to be 1% to 2% of all intubations in
the OR (51, 121), and 11% to 50% outside
of the OR (106, 107, 121–123). Our ability
to definitively identify patients at risk of
difficult direct laryngoscopy is imperfect
(124–127), and assessments for potential
difficulty are often not performed. A recent
analysis of the Anesthesia Closed Claims
Project demonstrated that 76% of cases had
at least one predictor of difficult intubation,
and 41% had at least two (128). Therefore,
teams should assume that all intubations
could be difficult and should prepare and
proceed accordingly. In conscious and
cooperative patients, inability to bite the
upper lip with the lower incisors is the
single best predictor of difficulty with
laryngoscopy (124). In emergency or
unconscious patients, anthropomorphic
features that will limit the ability to open
the airway (interincisor distance and/or
large tongue), displace the tongue into
the submental space (large tongue,
short mandible, short thyrohyoid and
hyomental distances), and align the
visual axes (cervical mobility) should be
examined.
Most of these prediction models focus
on the anatomic features that make
visualization of the glottic inlet difficult but
are difficult to perform in high-acuity
uncooperative patients (129, 130). This is
because they exclude important patient,
operator-related, and environmental
factors. The MACOCHA score was recently
782 American Journal of Respiratory and Critical Care Medicine Volume 201 Number 7 | April 1 2020
developed for use in the ICU and considers
patient-related factors pertaining to
anatomy and physiology and operator-
related factors (120). This score
unfortunately does not predict first-attempt
success, nor has it been validated for video
laryngoscopy; however, a score of 3 or
lower excludes a difficult airway with near
certainty (120). Difficulty with mask
ventilation is also difficult to predict
(131–134), which, for some, has
perpetuated the fear of neuromuscular
blocking agents.
Historically, tracheal intubation success
was associated with an individual’s skill
using a direct laryngoscope. This spurred
debate over who should perform
intubations—and how intubations should
be performed—outside of the OR (135,
136). In 2004, Mort outlined complications
with multiple attempts at out-of-OR
intubations (137). Patients with difficult
airways requiring more than two attempts
are much more likely to arrest. Thus, it
became the goal to avoid the difficult
airway by intubating in fewer than three
attempts and reinforced practice patterns
such as routinely using a Macintosh blade
with video laryngoscopy backup, because it
was assumed the third attempt, not the
second, increased risk. However, as
subsequent studies have indicated, the
second attempt is associated with the
majority of the risk (73, 74). Intubation in
the critically ill is technically more complex
than elective operative cases, regardless of
who performs the procedure. This is
exemplified by a 2018 study that showed
patients who were reintubated in the ICU
within 30 days of an elective surgery by the
same group of anesthesiologists who had
previously intubated them in the OR had
worse glottic visualization, 8% lower first-
attempt success, 7% increase in moderate or
difficult intubation, and a 31% increase in
complications (138). They also reported a
16% incidence of moderate or difficult
intubation, consistent with previous
literature in this high-risk population (106,
107, 121–123).
Several new and cost-effective video
laryngoscopes and flexible endoscopes are
readily available to overcome anatomic
difficulty. Video laryngoscopes are designed
to improve glottic visualization, using both
traditional or Macintosh-like geometry
(e.g., C-MAC [Karl Storz Endoscopy],
GlideScope Direct [Verathon], and
McGrath Mac [Medtronic]) and
CONCISE CLINICAL REVIEW
hyperangulated geometry configurations
(e.g., C-MAC D-Blade, GlideScope
LoPro, McGrath X blade). With direct
laryngoscopy, difficulty is encountered
because the device cannot adequately
displace the upper airway structures to
achieve a view of the glottic opening.
With video laryngoscopy, especially
hyperangulated blades, a view of the airway
is almost always obtained; any difficulty
usually relates to navigating the
endotracheal tube to and beyond the larynx.
Data concerning which anatomic features
are associated with difficult video
laryngoscopy are limited. In the OR setting,
difficulty with hyperangulated video
laryngoscopy was more likely with a supine
sniffing head and neck position and limited
mouth opening (139). In the ICU, first-
attempt failure with video laryngoscopy
(primarily a Macintosh geometry) was
associated with blood in the airway, airway
edema, cervical immobility, and obesity
(140). When either direct or traditional
geometry video laryngoscopy is used,
routine use of a bougie can further increase
first-attempt success (141). It is commonly
taught that video laryngoscopy is not
effective in the presence of blood or vomit,
but recent evidence shows the contrary
(142, 143). Soil in the airway reduces the
first-attempt success of video laryngoscopy,
and also direct laryngoscopy, because it
obscures the view regardless of how it is
visualized.
Interpreting research results comparing
video laryngoscopy and direct laryngoscopy
is complex. Observational data show an
association with improved first-attempt
success, fewer esophageal intubations, fewer
difficult airways, and reduced complication
rates with video laryngoscopy compared
with direct laryngoscopy (72, 144–150).
Results from trials comparing video
laryngoscopy and direct laryngoscopy do
not always mirror observational studies.
Several trials show no benefit with video
laryngoscopy (151–156), and one shows an
association with increased complications
(154). However, almost all of these trials
excluded patients with a predicted or
historically difficult intubation (151–153,
155). Lascarrou and colleagues randomized
371 patients without excluding predicted or
historically difficult intubations and found
not only no difference in success but also an
increase in severe complications with
McGrath Mac video laryngoscopy (154).
However, this study prohibited using a
CONCISE CLINICAL REVIEW
styleted endotracheal tube, and the majority
of intubations were performed by trainees
with little experience with the device or
airway management in general. Excluding
patients with a predicted or historically
difficult intubation may exclude those who
might benefit from video laryngoscopy.
Thus, enrolled patients may have been
relatively easy to intubate with either device
or unnecessarily more difficult navigating
the tube around the corner in the case of
hyperangulated video laryngoscopes. This
creates an artificial equivalence, but to
design the definitive clinical trial would be
ethically dubious and pragmatically
unfeasible.
The learning curve for direct
laryngoscopy is relatively flat, as
demonstrated by OR studies suggesting that
approximately 50 elective laryngoscopies are
required to achieve an overall (not first
attempt) success rate of 90%, and many
practitioners will require assistance well
beyond 50 intubations (157–159). The
learning curve for video laryngoscopy
appears steeper, with competency typically
achieved sooner than with direct
laryngoscopy (160–165), notwithstanding
one study that concluded, for those with
previous laryngoscopy experience,
GlideScope-facilitated expertise (as defined
by 90% probability of optimal
performance) still required 76 attempts
(166).
Although intubation is common in the
emergency department and ICU, it is
unlikely any trainee will receive enough
exposure to achieve 90% first-attempt
success with each of the standard
techniques: direct laryngoscopy and
traditional and hyperangulated video
laryngoscopy. Therefore, there is a strong
argument for focusing training on video
laryngoscopy, routinely using a traditional-
geometry blade as the first device and
hyperangulated blade when difficulty is
anticipated. This is because of the finite
procedural volume during training
(167–169), in practice (170), and because
there are learning curves for each device.
Clinical trials may not unequivocally
support video laryngoscopy for all first
attempts involving a rigid laryngoscope,
yet we prefer to routinely use video
laryngoscopy, as it has been shown to
improve the grade of view (144, 171),
reduce difficult intubations (144, 172),
Concise Clinical Review
reduce airway trauma (171, 173), aid
faster skill acquisition (particularly with
experienced operators [173] and novices
[172]), and improve successful intubations
in patients with difficult airways (171),
which, as we have described above, are
difficult to predict and harmful when
encountered. Direct laryngoscopy attempts
can be optimized by augmentation
maneuvers such as external laryngeal
manipulation, patient repositioning, and
bougie use, and direct laryngoscopy
proponents have suggested that augmented
direct laryngoscopy has not been compared
with video laryngoscopy. In a recent
large observational study of emergency
department patients, a direct comparison of
video laryngoscopy (both hyperangulated
and standard geometry) to augmented
direct laryngoscopy showed a strong
association between video laryngoscopy
and first-attempt success compared with
augmented direct laryngoscopy, further
supporting our opinion that video
laryngoscopy should be the principle
intubating device (174). In addition,
because the images can be seen on a screen
by others, video laryngoscopy has the
added benefit of a facilitating a shared
mental model to promote better airway
teamwork.
Future Research Directions
Preliminary studies on point-of-care
ultrasound show promise as a rapid
noninvasive method for detecting patients at
risk of aspiration, and studies are needed in
critically ill patients (175–178). Urgent
research is needed to evaluate reducing the
risk of cardiopulmonary decompensation.
Combining noninvasive positive pressure
with high-flow nasal oxygen in a proof-of-
concept study shows significant promise for
patients with severe hypoxemia, but more
studies are needed (179). Studies are also
needed in hypoxemic respiratory failure to
characterize who can be safely intubated
using rapid-sequence intubation, who
should be intubated awake/spontaneously
breathing, and where modifications to
rapid-sequence intubation, such as “rapid-
sequence airway” (180–182) or “delayed-
sequence intubation” (183) might help.
Rapid-sequence airway refers to giving
sedation, paralysis, and then placing a
supraglottic airway. Delayed-sequence
intubation involves dissociative doses of
ketamine followed by preoxygenation,
neuromuscular blocking agent, apneic
oxygenation, and intubation in those who
cannot tolerate traditional preoxygenation,
usually because of agitation.
We also need urgent research on how
to mitigate cardiovascular collapse and
characterize who may respond to various
resuscitation strategies, such as volume
resuscitation with crystalloid, colloid, or
hypertonic boluses; vasoactive infusions;
and attention to right ventricular failure.
Learning-curve data are limited to
hyperangulated video laryngoscopy, and
studies are needed for traditional geometry
blades.
Key Messages
Tracheal intubation in critically ill patients
is common, often perilous, and complex.
Accordingly, these patients should be treated
as high risk and in need of physiologic
optimization and preparation to reduce
danger (184, 185). Many questions remain,
but improving the safety of tracheal
intubation involves 1) developing a strategy
on the basis of anatomic and physiologic
assessment; 2) preparing for difficulty by
assembling a skilled team that trains
often, ensuring the required equipment
is immediately available, and optimizing
preoxygenation and hemodynamics;
and 3) recognizing and managing
failed intubations and rapidly restoring
oxygenation. Finally, data on different
interventions with airway management in
critically ill patients are often conflicting.
Some recent data suggest that the practice
we propose in our suggestions may not be as
helpful overall as we have experienced, as
indicated by the negative results of some
recent pragmatic trials. For these reasons, we
have offered our suggestions on the balance
of evidence across journals from diverse
specialties that practice airway management
in critically ill patients (anesthesia, critical
care medicine, and emergency medicine)
and provide the interested reader with an
extensive reference list to review the balance
of evidence on their own. n
Author disclosures are available with the text
of this article at www.atsjournals.org.
783

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