![]() ![]() Focusing on the most expedient laryngoscopy possible and attempting to rescue the decompensation after the intubation increases the risk in this high-risk population. It is starting to be recognized that focusing on airway strategies that take into account physiology and attempt to reduce the risk of rapid desaturation or cardiovascular collapse plays an important role in these patients. Yet, despite adoption and evolution of OR practices to the ED and ICU, the first guidelines specific for critically ill patients were not published until 2018, and recognition of deranged physiology that increases the risk of complications despite the presence or absence of procedural difficulty with laryngoscopy-i.e., the physiologically difficult airway-is only recently becoming more clear. In addition, supraglottic airway devices designed to facilitate operative cases without requiring an endotracheal tube have become invaluable reoxygenation tools in critically ill patients with missed attempts and desaturation. Preoxygenation to avoid the need for mask ventilation as well as to prevent aspiration evolved to avoid desaturation, the most common and dangerous complication outside of the OR, despite critically ill patients being mostly unfasted and at a high risk of aspiration. For example, rapid sequence induction and intubation, developed to prevent aspiration, was adopted to facilitate laryngoscopy and intubation success in the emergency department (ED) and then in the intensive care unit (ICU)-now singularly referred to as rapid sequence intubation (RSI). ![]() Intubation practices for treating acute critically ill patients outside of the operating room (OR) are largely based on OR techniques. Today, a new global pandemic is again forcing critical care medicine to struggle with whom to intubate with acute respiratory failure and how to best perform a procedure that carries a 2–4% cardiac arrest rate. Almost seven decades ago during a polio epidemic, modern critical care emerged when the Danish anesthesiologist Bjørn Ibsen saved lives by performing tracheostomies on polio patients with respiratory failure. Accessing what Leonardo da Vinci referred to as the arteria aspera has been a source of danger, marvel, and intense study for as long as physicians have cared for the ill. It is noted, for instance, in ancient Egyptian hieroglyphs, Hippocratic writings, a tale of Alexander the Great opening the trachea of an asphyxiating soldier, and reports of George Washington’s death from a peritonsillar abscess. Airway management has always been central to critical care. ![]()
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