"This article was first published in the Fall 2022 issue of Critical Connections.

Tracheal intubation (TI) is one of the most common airway management procedures in critically ill patients and is associated with a high risk of complications, most noticeably hemodynamic compromise leading to cardiovascular collapse. The INTUBE study reported periintubation adverse events in 45.2% of patients, including cardiovascular instability in 42.6%, severe hypoxemia in 9.3%, and cardiac arrest in 3.1%. These patients have what is referred to as a “physiologically difficult airway,” wherein the patients’ physiologic perturbations predispose them to a high risk of cardiovascular collapse with TI and conversion to positive pressure ventilation. This baseline physiologic risk is often exaggerated with multiple attempts at TI. Anatomic and logistical challenges with airway management are also common in these patients. Meticulous preparation, teamwork, and optimization of the patient’s physiology before the procedure are important to prevent complications. Reducing repeated attempts at TI, improving periintubation oxygenation, and hemodynamic optimization before the procedure are some steps that can reduce morbidity and mortality.

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