Being anesthesiologist, our primary responsibility is to secure airway during emergency as well as

elective situations inside as well as out of OT (1). Tracheal intubation is a crucial step in airway

management in intensive care unit, it may be associated with difficult intubation and its related

complications like hypoxia, cardiovascular collapse which could be life threatening. So, there is

always a need to prepare and have the protocols for airway management in critically ill

patients for their better safety and outcomes. Tracheal intubation in the ICU is a high-risk procedure,

Resulting in significant morbidity and mortality. Up to 40% of cases are associated with marked

hypoxemia or hypotension. The ICU patient is physiologically very different from the usual patient

who undergoes intubation in the operating room, and different intubation techniques should be

considered. The common operating room (OR) practice of sedation and neuromuscular blockade to

facilitate intubation may carry significant risk in the ICU patient with a marked oxygenation

abnormality, particularly when performed by the non-expert (2). Tracheal Intubation in intensive care

unit is affected by various factors operator, patient and environment related

factors.

Endotracheal Intubation Practice in ICU – Dr Rushikesh Kadam Page 27

Operator related factors includes level of experience and training. Patient related factors include

anatomically difficult airway and physiological factors that limit the duration of laryngoscopic attempts

such as hypoxemia and hemodynamic instability of critically ill patient. Other major concern being

inadequate fasting because of their acute presentation. 1 Hence, critically ill patient’s normal airway

becomes physiologically difficult due to rapid deterioration, urgency and decreased reserve.

Environmental factors include limited space, poor lightening, suboptimal bed characteristics and bed

space crowded with monitors that limit the proper positioning for assessment of patient airway. All

these above-mentioned factors can impair direct visualization of glottis using direct laryngoscopy

therefore making tracheal intubation difficult and increasing the rate of complications. Use of Video

laryngoscope as well as Neuromuscular blocking agents has been shown to ease intubation in

intensive care unit and emergency department.2

Preoperative Airway assessment definitely aids to identify difficult airway. This is more so in elective

inductions in OR. However, in ICU every airway can be considered as difficult airway due to the

various physiological factors associated with the critical patient. Critically ill patients could be septic

or with or without multiorgan dysfunction syndrome, with lung injury, with ionotropic

support. Therefore, inducing drugs play a very important role in maintaining the hemodynamics in

these patients during airway management, Type of inducing drugs and their doses need to be well

planned and titrated.2

Patients who are already desaturating they have very poor oxygen reserve and they do not tolerate

apneic time at all. Use of high flow nasal cannula [HFNC], NIV, nasal prongs in these patients can

prevent severe desaturation as well as increase the apnea safety time. Outcome of these patients

who received oxygen by these methods would be much better and safer for patients to decrease the

complication rates.

Availability of better suctions SALAD STRATERGY [suction assisted laryngoscopy and airway

decontamination] will also optimize better intubation techniques. (3)

Presence of more than two anesthetist is also required for facilitating a smoother intubation in the

ICU. Help is required during Sellick’s maneuver which is applied during RSI technique. Supervision

of trainee intubating critically ill patients is extremely vital for the patient’s outcome so

trainees’ supervision is mandatory.

So primarily this thesis has been proposed to know the PRACTICE of our own institute of tracheal

intubation, to learn and improvise on the methods and techniques of tracheal intubation for safer and

hemodynamically stable patients with minimal complication rates. This thesis will help in future to

make an intubation bundle for the next generations in order to prevent airway mishaps and have the

safest airway management in the ICU outside the OR.