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

The Airway Practitioner and the Clinical Setting

Inability to establish a definitive airway may be the result of inexperience and/or lack of skill on the part of the practitioner.[53,54,55,56,57,58] Lack of skilled assistance is also an important factor in scenarios in which airway problems are reported.[59,60,61,62] Airway and ventilatory procedures in the prehospital setting and in-hospital but outside the operating room (OR) show a higher frequency of adverse events and a higher risk of mortality than similar events in an OR.[63,64,65,66,67] Inexperience, poor assistance, and an unfavorable environment may combine leading to a failure to optimize conditions. Common errors include poor patient positioning; failure to ensure appropriate assistance; faulty light source in laryngoscope/no alternative scope; failure to use a longer blade in appropriate patients; use of inappropriate tracheal tube (size or shape); and a lack of immediate availability of airway adjuncts.

In the critical care unit, all invasive airway maneuvers are potentially difficult.[68] Positioning is more difficult on an intensive care unit bed than an OR table. The airway may be edematous as a result of the presence of an endotracheal tube (ETT) or previous airway instrumentation. Neck immobility or the need to avoid movement in a potentially unstable cervical spine will add to the difficulty.[69,70,71] Halo fixation (without elective tracheostomy) carries a high risk (14%) for emergent/semi-emergent intubation and airway-associated mortality.[72] Poor gas exchange in intensive care unit patients may reduce the effectiveness of preoxygenation thus increasing the risk of significant hypoxia if there is delay in securing the airway.[73] Cardiovascular instability may produce hypotension, hypoperfusion, and misleading (or absent) oximetry readings, a further confounding factor for the attending staff.


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