Evaluation and management of the difficult airway

Even routine airway management requires specific skills that are best acquired in a controlled setting, before "trial by fire" in an emergency situation. Furthermore, recognition of a potential difficult airway and appropriate preparation prior to initiating airway intervention are critical steps in avoiding airway catastrophes in the intensive care or emergency setting. Familiarity with a difficult airway algorithm and various alternate techniques for endotracheal intubation is a mandatory requirement for all practitioners involved in airway management, and should be incorporated in critical care curricula. Critically ill patients, by nature, are at risk for complications during manipulation of the airway, and may have a higher incidence of adverse reactions to anesthesia-inducing drugs and muscle relaxants. In general, "less is more" in the intensive care unit, and techniques that preserve spontaneous ventilation during airway interventions are desirable, particularly in patients with anticipated difficult airways. All intubating sites should have a portable storage unit for equipment for managing difficult airways readily available. Correct ETT placement always should be verified by detection of exhaled CO2, and by chest radiography if prolonged intubation is planned.