![]() ![]() The intent has evolved to avoid desaturation more so than passive regurgitation and aspiration with mask ventilation. ![]() This practice developed prior to the invention of pulse oximetry, and it has been assimilated into airway management in all clinical settings. The idea was to have patients breathe 100% oxygen prior to induction to avoid gastric insufflation with mask ventilation. Preoxygenation was introduced at a time when the biggest risk from intubation was aspiration during induction for high-risk surgeries, such as bowel obstructions or cesarean sections. A (non-exhaustive) list of important articles as determined by the authors for establishing or verifying important concepts or changing practice are detailed in Table 2. ![]() Abstracts were reviewed for relevance, and references from each selected article were reviewed for pertinent articles. Studies on neonates or pediatric patients ≤ 18 years and non-English language reports were excluded. We conducted a Medline search using PubMed with the following search terms, from 2000–present: intubation, AND (sequentially): ((critically ill ) OR (critical illness ) OR (emergency ) OR (emergency services ) OR (preoxygenation ) OR (mask ventilation ) OR (rapid sequence intubation ) OR (awake intubation ) OR (hypotension ) OR (shock ) OR (shock ) OR (respiratory insufficiency ) OR (respiratory failure ) OR (sepsis ) OR (cricoid pressure ) OR (bougie ) OR (tracheal introducer ) OR (direct laryngoscopy ) OR (video laryngoscopy ) OR (endoscope ) OR (supraglottic airway ) OR (laryngeal mask airway ) OR (extraglottic airway ) OR (cricothyrotomy ) OR (front of neck access ) OR (critically ill ) AND ((intubation))) AND ((“1” : “3000”)). A summary of our recommendations can be found in Table 1. In this paper, we will review advances in airway management in the critically ill patient, focusing on physiologic optimization, preparation, and devices used to prevent and manage the difficult airway. Focusing on the most expedient laryngoscopy possible and attempting to rescue the decompensation after the intubation increases the risk in this high-risk population. It is starting to be recognized that focusing on airway strategies that take into account physiology and attempt to reduce the risk of rapid desaturation or cardiovascular collapse plays an important role in these patients. Yet, despite adoption and evolution of OR practices to the ED and ICU, the first guidelines specific for critically ill patients were not published until 2018, and recognition of deranged physiology that increases the risk of complications despite the presence or absence of procedural difficulty with laryngoscopy-i.e., the physiologically difficult airway-is only recently becoming more clear. In addition, supraglottic airway devices designed to facilitate operative cases without requiring an endotracheal tube have become invaluable reoxygenation tools in critically ill patients with missed attempts and desaturation. ![]() Preoxygenation to avoid the need for mask ventilation as well as to prevent aspiration evolved to avoid desaturation, the most common and dangerous complication outside of the OR, despite critically ill patients being mostly unfasted and at a high risk of aspiration. For example, rapid sequence induction and intubation, developed to prevent aspiration, was adopted to facilitate laryngoscopy and intubation success in the emergency department (ED) and then in the intensive care unit (ICU)-now singularly referred to as rapid sequence intubation (RSI). Intubation practices for treating acute critically ill patients outside of the operating room (OR) are largely based on OR techniques. Today, a new global pandemic is again forcing critical care medicine to struggle with whom to intubate with acute respiratory failure and how to best perform a procedure that carries a 2–4% cardiac arrest rate. Almost seven decades ago during a polio epidemic, modern critical care emerged when the Danish anesthesiologist Bjørn Ibsen saved lives by performing tracheostomies on polio patients with respiratory failure. Accessing what Leonardo da Vinci referred to as the arteria aspera has been a source of danger, marvel, and intense study for as long as physicians have cared for the ill. It is noted, for instance, in ancient Egyptian hieroglyphs, Hippocratic writings, a tale of Alexander the Great opening the trachea of an asphyxiating soldier, and reports of George Washington’s death from a peritonsillar abscess. Airway management has always been central to critical care. ![]()
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