The Difficult Airway in Adult Critical Care

Gavin G. Lavery, MD, FCARSCI, MB, BCh, BAO; Brian V. McCloskey, MB, BCh, FRCA, FFARCSI, MRCP


Crit Care Med. 2008;36(7):2163-2173. 

In This Article

Abstract and Introduction

Introduction: The difficult airway is a common problem in adult critical care patients. However, the challenge is not just the establishment of a safe airway, but also maintaining that safety over days, weeks, or longer.
Aims: This review considers the management of the difficult airway in the adult critical care environment. Central themes are the recognition of the potentially difficult airway and the necessary preparation for (and management of) difficult intubation and extubation. Problems associated with tracheostomy tubes and tube displacement are also discussed.
Results: All patients in critical care should initially be viewed as having a potentially difficult airway. They also have less physiological reserve than patients undergoing airway interventions in association with elective surgery. Making the critical care environment as conducive to difficult airway management as the operating room requires planning and teamwork. Extubation of the difficult airway should always be viewed as a potentially difficult reintubation. Tube displacement or obstruction should be strongly suspected in situations of new-onset difficult ventilation.
Conclusions: Critical care physicians are presented with a significant number of difficult airway problems both during the insertion and removal of the airway. Critical care physicians need to be familiar with the difficult airway algorithms and have skill with relevant airway adjuncts.

The difficult airway has been defined as the clinical situation in which a conventionally trained anesthetist experiences difficulty with mask ventilation of the upper airway, tracheal intubation, or both.[1] It has been a commonly documented cause of adverse events, including airway injury, hypoxic brain injury, and death in anesthesia.[2,3,4,5,6,7,8] In the critical care unit, up to 20% of all critical incident reports are airway-related.[9,10,11] For the critical care physician, the challenge is to establish a safe airway, to secure the (long-term) airway, and to manage any potential airway displacement and achieve safe extubation.


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