Journal of Acute Care

Register      Login

VOLUME 2 , ISSUE 1 ( January-April, 2023 ) > List of Articles


Difficult Airway Management in Surgical Intensive Care Unit

Kolli S Chalam

Keywords : Airway, Critically ill patients, Intensive care units

Citation Information : Chalam KS. Difficult Airway Management in Surgical Intensive Care Unit. 2023; 2 (1):15-21.

DOI: 10.5005/jp-journals-10089-0066

License: CC BY-NC 4.0

Published Online: 23-08-2023

Copyright Statement:  Copyright © 2023; The Author(s).


A considerable number of patients in the surgical intensive care unit (ICU) require advanced airway management in terms of intubation or laryngeal mask airway (LMA) placements. It is not uncommon to come across difficult airways in ICU. A difficult airway cart with a fiberoptic bronchoscope and trained personnel are fundamental to the practice of surgical critical care. So, clinicians in ICU should be capable of carrying bronchoscopic intubation in sedated as well as awake patients. Anesthetizing techniques for awake fiberoptic bronchoscopic intubation (FOBI) such as airway blocks or topicalization and monitoring during the procedure are of considerable interest. It is equally important to keep the patient comfortable, maintaining spontaneous breathing and hemodynamic stability. Finally, combined techniques such as fiberoptic bronchoscope in combination with LMA or video laryngoscope (VL) do improve success rates of advanced airway management in surgical ICU (SICU).

  1. Russotto V, Myatra SN, Laffey JG, et al. Intubation practices and adverse peri-intubation events in critically ill patients from 29 countries. JAMA 2021;325(12):1164–1172. DOI: 10.1001/jama.2021.1727
  2. Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists Practice Guidelines for management of the difficult airway. Anesthesiology 2022;136(1):31–81. DOI: 10.1097/ALN.0000000000004002
  3. Law JA, Duggan LV, Asselin M, et al. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway. Can J Anaesth 2021;68(9):1405–1436. DOI: 10.1007/s12630-021-02008-z
  4. De Jong A, Molinari N, Terzi N, et al. AzuRéa Network for the Frida-Réa study group. Early identification of patients at risk for difficult intubation in the intensive care unit: development and validation of the MACOCHA score in a multicenter cohort study. Am J Respir Crit Care Med 2013;187(8):832–839. DOI: 10.1164/rccm.201210-1851OC
  5. Shallik N, Karmakar A. Is it time for high flow nasal oxygen to be included in the difficult airway algorithm. 2018;121(2):511–512. DOI: 10.1016/j.bja.2018.05.052
  6. McNarry AF, Patel A. The evolution of airway management - new concepts and conflicts with traditional practice. Br J Anaesth 2017;119(suppl_1):i154–i166. DOI: 10.1093/bja/aex385
  7. Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth 2015;115(6):827–848. DOI: 10.1093/bja/aev371
  8. Wong DT, Yee AJ, Leong SM, et al. The effectiveness of apneic oxygenation during tracheal intubation in various clinical settings: a narrative review. Can J Anaesth 2017;64(4):416–427. DOI: 10.1007/s12630-016-0802-z
  9. Corl KA, Dado C, Agarwal A, et al. A modified Montpellier protocol for intubating intensive care unit patients is associated with an increase in first-pass intubation success and fewer complications. J Crit Care 2018;44:191–195. DOI: 10.1016/j.jcrc.2017.11.014
  10. Ghosh S, Salhotra R, Arora G, et al. Implementation of a revised Montpellier bundle on the outcome of intubation in critically ill patients: a quality improvement project. Indian J Crit Care Med 2022;26(10):1106–1114. DOI: 10.5005/jp-journals-10071-24332
  11. Leslie D, Stacey M. Awake intubation. Contin Educ Anaesth Crit Care Pain 2015;15(2):64–67. DOI: 10.1093/bjaceaccp/mku015
  12. Ahmed A, Azim A. Difficult tracheal intubation in critically ill. J Intensive Care 2018;6;49. DOI: 10.1186/s40560-018-0318-4
  13. Cabrini L, Baiardo R, Ball L, et al. Awake fiberoptic intubation protocols in the operating room for anticipated difficult airway: a systematic review and meta-analysis of randomized controlled trials. Anesth Analg 2019;128(5):971–980. DOI: 10.1213/ANE.0000000000004087
  14. Collins SR, Blank RS. Fiberoptic intubation: an overview and update. Respir Care 2014;59(6):865–880. DOI: 10.4187/respcare.03012
  15. Gnaneswaran HH, Jain G, Agarwal A, et al. Optimal level of bispectral index for conscious sedation in awake fiberoptic nasotracheal intubation. J Oral Biol Craniofac Res 2020;10(3):299–303. DOI: 10.1016/j.jobcr.2020.06.004
  16. Wang S, Hu C, Zhang T, et al. Comparison of cricothyroid membrane puncture anesthesia and topical anesthesia for awake fiberoptic intubation: a double-blinded randomized controlled trial. Front Med (Lausanne) 2021;8:2109. DOI: 10.3389/fmed.2021.743009
  17. Matchett G, Gasanova I, Riccio CA, et al. Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial. Intensive Care Med 2022;48:78–91. DOI: 10.1007/s00134-021-06577-x
  18. Tran DT, Newton EK, Mount VA, et al. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev 2015;2015(10):CD002788. DOI: 10.1002/14651858.CD002788
  19. Groth CM, Acquisto NM, Khadem T. Current practices and safety of medication use during rapid sequence intubation. J Crit Care 2018;45:65–70. DOI: 10.1016/j.jcrc.2018.01.017
  20. Dalia AA, Raines DE. Etomidate and adrenocortical suppression: should we take the concerns to heart? J Cardiothorac Vasc Anesth 2021;35(4):1086–1088. DOI: 10.1053/j.jvca.2021.01.034
  21. Monet C, De Jong A, Jaber S. Intubation in the ICU. Anaesth Crit Care Pain Med 2021;40(4):100916. DOI: 10.1016/j.accpm.2021.100916
  22. Berkow LC, Schwartz JM, Kan K, et al. Use of the laryngeal mask airway-aintree intubating catheter-fiberoptic bronchoscope technique for difficult intubation. J Clin Anesth 2011;23(7):534–539. DOI: 10.1016/j.jclinane.2011.02.005
  23. Janz DR, Casey JD, Semler MW, et al. Effect of a fluid bolus on cardiovascular collapse among critically ill adults undergoing tracheal intubation (PrePARE): a randomised controlled trial. Lancet Respir Med 2019;7(12):1039–1047. DOI: 10.1016/S2213-2600(19)30246-2
  24. Ara T, Mori G, Adachi E, et al. [Combined use of the GlideScope and fiberoptic bronchoscope for tracheal intubation in a patient with difficult airway]. Masui 2014;63(6):647–649. PMID: 26442413.
  25. Kim S, Song J, Bae JH. Difficult airway management with fiberoptic bronchoscopy combined with video laryngoscope in a patient with ludwig angina. J Korean Dent Soc Anesthesiol 2013;13(4):189–193. DOI: 10.17245/jkdsa.2013.13.4.189
  26. Sreevathsa S, Nathan PL, John B, et al. Comparison of fibreoptic-guided intubation through ILMA versus intubation through LMA-CTrach. Anaesthesia 2008;63(7):734–737. DOI: 10.1111/j.1365-2044.2008.05481
  27. Mallampati SR. Clinical sign to predict difficult tracheal intubation (hypothesis). Can Anaesth Soc J 1983;30(3 Pt 1):316–317. DOI: 10.1007/BF03013818
  28. Samsoon GL, Young JR. Difficult tracheal intubation: a retrospective study. Anaesthesia 1987;42(5):487–490. DOI: 10.1111/j.1365-2044.1987.tb04039.x
  29. Ezri T, Warters RD, Szmuk P, et al. The incidence of class “zero” airway and the impact of Mallampati score, age, sex, and body mass index on prediction of laryngoscopy grade. Anesth Analg 2001;93(4):1073–1075. DOI: 10.1097/00000539-200110000-00055
  30. Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984;39(11):1105–1111. PMID: 6507827. DOI: 10.1111/j.1365-2044.1984.tb089
  31. Chalam KS, Gupta J. Comparison of intubating laryngeal mask airway and fiberoptic bronchoscopy for endotracheal intubation in patients undergoing cervical discectomy. J Anaesthesiol Clin Pharmacol 2016;32(4):515–518. DOI: 10.4103/0970-9185.194765
  32. Xue FS, Cheng Y, Li RP. Awake intubation with video laryngoscope and fiberoptic bronchoscope in difficult airway patients. Anesthesiology 2013;118(2):462–463. DOI: 10.1097/ALN.0b013e31827bd357
  33. Chalam KS. A comparative study of intravenous dexmedetomidineversus propofolbased sedation for awake fiberoptic intubation along with airway blocks in cervical discectomy patients. J Anesth 2015;1(1):21–27. DOI: 10.4103/2394-6954.149716
  34. Roth D, Pace NL, Lee A, et al. Airway physical examination tests for detection of difficult airway management in apparently normal adult patients. Cochrane Database Syst Rev 2018;5(5):CD008874. DOI: 10.1002/14651858.CD008874
  35. François B, Bellissant E, Gissot V, et al. 12-h pretreatment with methylprednisolone versus placebo for prevention of postextubation laryngeal oedema: a randomised double-blind trial. Lancet 2007;369(9567):1083–1089. DOI: 10.1016/S0140-6736(07)60526-1
  36. Difficult Airway Society Extubation Guidelines Group;Popat M, Mitchell V, et al. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia 2012;67(3):318–340. DOI: 10.1111/j.1365-2044.2012.07075.x
  37. Divatia JV, Khan PU, Myatra SN. Tracheal intubation in the ICU: life saving or life threatening? Indian J Anaesth 2011;55(5):470–475. DOI: 10.4103/0019-5049.89872
  38. Scott JA, Heard SO, Zayaruzny M, et al. Airway management in critical illness: an update. Chest 2020;157(4):877–887. DOI: 10.1016/j.chest.2019.10.026
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.