Table 2 Summary points for management of the physiologically difficult airway
From: Managing the Physiologically Difficult Airway in Critically Ill Adults
Risks and risk prediction |
Cardiovascular instability, hypoxemia, and cardiac arrest are the most common adverse events associated with tracheal intubation |
Risk factors for cardiovascular collapse include age, shock, hypoxemia, advanced critical illness, and propofol administration |
Hemodynamic optimization |
Etomidate and ketamine may impact hemodynamics less than propofol |
A crystalloid bolus prior to intubation has not been associated with improved hemodynamics, even in patients receiving positive pressure ventilation |
Given the frequency of cardiovascular instability, vasopressors should be readied as part of preparation for tracheal intubation |
Mitigating hypoxemia |
Standard pre-oxygenation strategies are inadequate to safely extend the apneic interval in patients with moderate to severe respiratory failure |
Non-invasive ventilation can be used with or without high flow nasal oxygen and is more effective than high flow nasal oxygen alone |
While historically avoided, bag-mask ventilation improves oxygenation during airway management and can be employed either preemptively or for rescue |
First pass success |
Multiple attempts at intubation increase the risk of adverse events |
Depending on the preferences and expertise of the intubating clinician, video laryngoscopy or direct laryngoscopy with adjuncts may improve first pass success |
Checklists improve adherence to complex, multi-step processes and may help prompt preparation for physiologic trespass |