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  • The choice between noninvasive ventilation versus ventilation via translaryngeal tracheal intubation is an increasingly critical branch point in the management of patients with respiratory failure.

  • Shock, a failed trial of extubation, inability to protect and maintain one’s own airway, need for larger minute ventilations or larger transpulmonary pressures, and transport of an unstable patient all remain indications for tracheal intubation.

  • Assessment and adequate preparation of the patient prior to intubation are crucial to ensuring successful and safe intubation.

  • For patients with respiratory failure, translaryngeal intubation can be performed awake with topical anesthesia or after induction of anesthesia. General anesthesia and paralysis can be associated with substantial risks in critically ill, hemodynamically unstable patients.

  • The appropriate timing of tracheostomy remains poorly defined. Tracheostomy insertions are often performed at the bedside to minimize the hazards associated with transporting a critically ill patient to an operating room.


Tracheal intubation remains one of the most common and important procedures performed in the ICU. When done well, tracheal intubation can be a lifesaving procedure. At times, however, it may initiate a cascade of events that can lead directly or indirectly to trauma, severe complications, and death. The widespread adoption of noninvasive ventilation1 and high-flow nasal cannula2 in the management of patients with respiratory failure has led to an increase in severity of respiratory distress in those who require intubation in the ICU. It is imperative that those who manage the airways in these patients have a high degree of knowledge, skill, and comfort in managing patients with little physiologic reserve. In addition, it is imperative that ICU physicians have knowledge and understanding of the indications for tracheal intubation, the assessment of the patient for tracheal intubation, the devices and techniques available for tracheal intubation, and the consequences and complications of tracheal intubation.3


The upper airway comprises air-conducting passages that begin at the mouth or nose and end at the mainstem carina. The thoracic inlet divides the upper airway into the intrathoracic and extrathoracic airways. The extrathoracic airways are further divided into the nasopharynx, oropharynx, hypopharynx, larynx, and extrathoracic trachea. Air inspired through the nose passes through the nasal cavities and enters the nasopharynx after exiting the nose by way of the posterior nares. Airflow proceeds inferiorly through the nasopharynx, passes posterior to the soft palate, and enters the oropharynx. Closure of the soft palate allows inspiration of air through the mouth. Air passes inferiorly through the oropharynx to the hypopharynx, which begins just superior to the hyoid bone, and passes the epiglottis, thereby entering the larynx.4

The larynx is constructed of a cartilaginous skeleton consisting of the thyroid, cricoid, and arytenoid cartilages. This skeleton surrounds the vocal cords, the movements of which are controlled by the intrinsic muscles of the larynx, with their innervation ...

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