Review Article

The Physiologically Difficult Airway

Bhavya Vakil, Nishanth Baliga1, Sheila Nainan Myatra1
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Department of Anaesthesia, Bai Jerbai Wadia Hospital for Children, 1Department of Anaesthesia, Critical Care and Pain, Tata Memorial
Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India

Abstract
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The physiologically difficult airway is defined as one in which severe physiologic derangements place patients at increased
risk of cardiovascular collapse and death during tracheal intubation and transition to positive pressure ventilation. Patients
with a physiologically difficult airway can be divided into those who are critically ill and those who are not. The critically
ill patient with a physiologically difficult airway may present with hypoxaemia, hypotension, right ventricular failure,
metabolic acidosis and neurologic injury. Noncritically ill patients with a physiologically difficult airway are patients who
are obese, paediatric, pregnant or at risk of aspiration during tracheal intubation (after a meal, with gastroesophageal reflux
disease, intestinal obstruction, etc). Recognition of this high‑risk group of patients is essential to implement measures to
avoid complications during tracheal intubation. Unlike the anatomically difficult airway, where placing the endotracheal
tube safely within the trachea is the primary goal, in patients with a physiologically difficult airway, prevention of adverse
events is equally important during airway management. Strategies to prevent complications associated with physiologically
difficult airway include measures to improve the chance of first‑pass success, effective peri‑intubation oxygenation and
measures to avoid hypotension and haemodynamic collapse.

Keywords: Airway in the obese, airway management in intensive care unit, airway management in the critically ill,
difficult airway, obstetric airway, paediatric airway

Introduction peri‑intubation oxygenation devices such as high flow

nasal oxygen (HFNO), tools for emergency invasive
The term ‘difficult airway’ has been defined
by the American Society of Anesthesiologists airway access, availability of guidelines and increased
taskforce as the clinical situation in which a training, securing the anatomically difficult airway
conventionally trained anaesthetist experiences has become relatively less challenging than in earlier
problems with mask ventilation or tracheal intubation times.
or both.[1] Conventionally, the concept of difficult
airway management has always focussed on anatomic Address for correspondence: Prof. Sheila Nainan Myatra,
factors which make mask ventilation, laryngoscopy Department of Anesthesiology, Critical Care and Pain, Tata
Memorial Hospital, Dr. Ernest Borges Road, Parel, Mumbai,
or tracheal intubation difficult. Lot of attention has
Maharashtra, India.
been paid to the anticipation of not being able to E‑mail: sheila150@hotmail.com
secure a definitive airway. Several scoring systems
have been formulated for the prediction of a difficult This is an open access journal, and articles are distributed under the
airway. However, with the availability of devices terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike
such as videolaryngoscopes, flexible bronchoscopes, 4.0 License, which allows others to remix, tweak, and build upon the
work non‑commercially, as long as appropriate credit is given and the
Access this article online new creations are licensed under the identical terms.
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Website:
www.arwy.org
How to cite this article: Vakil B, Baliga N, Myatra SN. The
physiologically difficult airway. Airway 2021;4:4-12.
DOI:
10.4103/arwy.arwy_10_21 Received: 12 March 2021 Revised: 20 March 2021
Accepted: 21 March 2021 Published: 29 April 2021

4 © 2021 Airway | Published by Wolters Kluwer - Medknow

 Vakil, et al.: Physiologically difficult airway

Physiologic derangements or poor physiologic reserve, Critically Ill Patients

particularly seen in critically ill patients, tends to
increase the risk of complications during tracheal Hypoxaemia
intubation. Although other groups of patients may not Patients with preexisting hypoxaemia are at
be critically ill, their physiological alterations compared increased risk of cardiopulmonary complications
to a healthy adult patient places them at an increased such as desaturation, hypoxic brain injury, cardiac
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risk of complications during tracheal intubation. dysrhythmias and cardiac arrest during intubation.[6]
These include obese, paediatric and pregnant patients. In patients with hypoxaemic respiratory failure, there
This type of difficulty faced by the physician while is inability to maintain adequate arterial oxygenation.
securing the airway is termed as a physiologically The common causes of acute hypoxaemic respiratory
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difficult airway. The physiologically difficult airway failure are pneumonia, pulmonary oedema, acute
can be defined as one in which physiologic alterations respiratory distress syndrome (ARDS), asthma, etc.,
place the patient at an increased risk for cardiovascular The mechanism of hypoxia in these cases is due to
collapse and death during tracheal intubation and a shunt and ventilation‑perfusion (V/Q) mismatch.
transition to positive pressure ventilation.[2] In a normal healthy mechanically ventilated patient
under anaesthesia, there is the mismatch of V/Q;
Tracheal intubation in critically ill patients is
however, this mismatch can be easily overcome by
associated with increased complications when
recruiting the lungs and increasing the fractional
compared to the operating room (OR) for anaesthesia.
inspired concentration of oxygen (FIO2). In critically
According to the Fourth National Audit Project
ill patients, there is a significant shunt where alveoli
Report, complications related to the airway leading
in the affected area are unable to participate in gas
to death or brain injury was seen in 61% of cases in
exchange. In these cases, increasing the FIO2 would
the intensive care unit (ICU) compared to 14% during
not help as the oxygen delivered is not able to reach
anaesthesia. One of the important factors leading to
the capillaries. Hence, these patients are at an increased
increased complications were the emergent need for
risk of cardiopulmonary complications due to increased
securing the airway.[3] A cohort study done in the
emergency department found that 1 in 25 patients who risk of rapid desaturation during attempts at tracheal
underwent emergency intubations suffered a cardiac intubation. In these patients, early identification of the
arrest. Preintubation hypotension, hypoxaemia and potential physiologically difficult airway and use of
obesity were factors associated with increased risk measures to prolong the safe apnoea time (time until
of cardiac arrest. This study suggests physiologic significant desaturation after inducing apnoea) become
factors and derangements are associated with increased crucial irrespective of anatomical airway difficulty.
postintubation complications.[4] A multicentre study Methods to prolong safe apnoea time (time until significant
done to determine prevalence and risk factors for desaturation following neuromuscular blockade)
cardiac arrest in ICU found that the incidence of include adequate preoxygenation and apnoeic
cardiac arrest was 2.7%, about 1 in 40 intubations, oxygenation. The aim of preoxygenation is to achieve
that increased both immediate and 28‑day mortality. maximal haemoglobin saturation and maximal partial
They attributed the risk factors for cardiac arrest to pressure of arterial oxygen, thus creating a reserve
preintubation hypotension, preintubation hypoxaemia, and prolongation of safe apnoea time. Optimising
obesity, nonperformance of preoxygenation, and preoxygenation leads to higher first‑pass success rate
age more than 75 years.[5] These studies suggest that and reduces the risk of desaturation and associated
physiologic derangements in critically ill patients make complications. Conventionally, preoxygenation was
them susceptible to untoward complications during done with help of a non‑rebreathing mask (NRM)
tracheal intubation. over 3–5 min.[7] However, due to improper mask seal
Knowledge about these physiological factors and and entrainment of air, effective fraction of inspired
derangements is essential for all airway operators. This oxygen is decreased, especially in critically ill
review will describe different physiologically difficult patients who are tachypnoeic and have high minute
airways and provide guidance to prevent complications ventilation. In the OR, patients are preoxygenated
in this high‑risk group during tracheal intubation. with a tight‑fitting mask connected to the anaesthesia

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 Vakil, et al.: Physiologically difficult airway

circuit with 100% oxygen and allowing the patient preoxygenation, a delayed sequence intubation
to breathe normal tidal volume breaths for 3–5 min. using ketamine to induce a dissociative state and
A study which evaluated different methods of improve effective preoxygenation may be done before
preoxygenation found bag‑mask ventilation and administration of neuromuscular blocking agent during
closed anaesthetic circuit to be more effective than rapid sequence intubation (RSI).[14]
NRM.[8] However, in critically ill patients with hypoxic
Optimising position during preoxygenation and
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respiratory failure, this may not improve apnoea

intubation can also lead to prolongation of safe apnoea
time due to prominent shunt pathology. Baillard
time. Head‑up position or the ramped position has
et al. compared non‑invasive ventilation (NIV) for
been compared with the supine position for intubation.
preoxygenation with conventional oxygen therapy
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The first attempt success rate was higher with ramped

using valve‑bag face mask in ICU patients needing
compared to supine in an observational study,
tracheal intubation and reported that preoxygenation
whereas another study found that the combination of
with NIV was associated with better oxygen saturation
ramped and sniffing positions significantly reduced
and the incidence of desaturation during intubation
complications. [15,16] Head‑up position improves
was significantly reduced (46% to only 7%, P < 0.01).
preoxygenation, prevents reduction in the functional
This was probably due to the recruitment of collapsed
residual capacity (FRC) and may reduce the risk of
alveoli and increasing end‑expiratory lung volume.[9]
pulmonary aspiration. The head‑up position has been
NIV as a method of preoxygenation in critically ill
recommended by recent guidelines in patients at high
patients has been recommended and incorporated in
risk of desaturation.[17,18] Gentle mask ventilation
the Montpellier ICU intubation bundle.[10]
during RSI after induction and before intubation
Another method of preoxygenation is to use high‑flow was evaluated in the PREVENT study, which found
nasal oxygen (HFNO). Humidified oxygen is delivered that patients who received ventilation had a lower
at a very high flow rate of around 50–60 L/min. These incidence of severe hypoxaemia without increasing
high flow rates reduce the dead space, help in recruiting the rate of pulmonary aspiration.[19]
alveoli as well as maintain positive end‑expiratory
Another method of maintaining saturation during the
pressure (PEEP). HFNO can be used for preoxygenation
apnoea time is to provide apnoeic oxygenation with the
as well as a method of providing apnoeic oxygenation
help of standard nasal cannula (15 L/min oxygen flow)
during attempts at tracheal intubation. A study by
or HFNO. This works on the principle of mass flow of
Miguel‑Montanes et al. compared HFNO with
oxygen because of the pressure generated due to the
bag‑mask reservoir facemask for desaturation during
differential diffusion capacity of oxygen and carbon
tracheal intubation and found that HFNO significantly
dioxide (CO2). A systematic review and meta‑analysis
improved preoxygenation and reduced the prevalence
on respiratory support during intubation in ICU setup
of severe hypoxaemia compared with nonrebreathing
showed apnoeic oxygenation with either HFNO or
bag reservoir facemask.[11] In the PROTRACH study,
standard nasal cannula was significantly associated
preoxygenation with HFNO compared to standard
with higher minimum SpO2 registered during the
bag‑valve‑mask oxygen in nonhypoxaemic patients
intubation procedure as compared to those who did
found reduction in intubation‑related adverse events in
not receive apnoeic oxygenation.[20] Jaber et al., in a
the HFNO group.[12] The FLORALI 2 study compared
proof of concept study (OPTINIV study), showed that
NIV and HFNO as methods of oxygenation during
the use of apnoeic oxygenation using HFNO combined
induction to laryngoscopy with NIV and during
with NIV for preoxygenation prevented desaturation
induction to tracheal intubation with HFNO. The
during intubation in hypoxaemic patients compared to
incidence of severe hypoxaemia during tracheal
using NIV alone for preoxygenation.[21]
intubation was 23.2% in the NIV group and 27.5%
in the HFNO group (P = 0.39).[13] Current evidence If feasible, preoxygenation for at least 3–5 min should
suggests that NIV is a better method of preoxygenation be performed in these high‑risk patients. Current
compared to conventional bag‑mask as well as HFNO guidelines recommend a minimum of 3 min of
in patients with moderate‑to‑severe hypoxaemia. preoxygenation in critically ill patients with the help
In patients who are agitated or uncooperative for of NIV with an inspiratory pressure of 5–15 cm H2O,

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 Vakil, et al.: Physiologically difficult airway

PEEP of 5 cm H2O and tidal volume of 6–8 mL/kg in a the right atrium increases due to positive pressure
head‑up position or with the help of HFNO.[22] Apnoeic ventilation, this increase in pressure decreases the
oxygenation should be considered to prolong safe venous return thereby decreasing the cardiac output.
apnoea time during intubation. In combative agitated While normal healthy patients can easily compensate
patients, use of ketamine to optimise preoxygenation for this reduction in cardiac output by increasing
in a technique termed “delayed sequence intubation” the stroke volume, heart rate and systemic vascular
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should be considered.[23] It should be borne in mind that resistance, critically ill patients who may already be
even with preoxygenation and apnoeic oxygenation, hypotensive and have exhausted their compensatory
the safe apnoea time may not be increased in this group mechanisms may worsen. Hence, it is imperative to
of patients due to the widespread damage to the alveoli, prevent hypotension using fluids or vasopressors if
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highlighting the importance of first‑pass intubation possible and identify and treat the hypotension early
success. The operator with the maximum experience if it occurs.
in tracheal intubation should preferably manage the The decision about the type of drugs used for induction
airway using tools to improve intubation success such and intubation also plays a role for peri‑intubation
as videolaryngoscope and bougie. haemodynamic changes. Etomidate is a relatively
Hypotension cardiostable drug. However, etomidate does not
Peri‑intubation hypotension is associated with suppress airway reflexes, thereby not preventing
adverse events such as bradycardia, cardiovascular the response to laryngoscopy. This in turn causes
collapse and death. In an observational study, the haemodynamic fluctuations which indirectly negates
incidence of cardiovascular collapse after intubation the purpose of its use. Ketamine is an option,
was 30% among critically ill patients.[24] Preexisting especially for critically ill patients with hypotension.
hypotension and shock index, i.e., heart rate/systolic Ketamine is a sympathomimetic drug that can
blood pressure more than 0.8 has been found to increase blood pressure. However, reports have shown
have increased risk of postintubation hypotension that ketamine can also cause cardiac arrest due to
and cardiac arrest.[25] Even though the presence of its direct cardiac depressant activity, particularly
hypotension before tracheal intubation is associated in catecholamine‑depleted states. A study which
with increased cardiovascular complications in the compared etomidate with ketamine as induction
postintubation period, not all patients will be in shock agent among critically ill during RSI did not find
due to reflex compensatory mechanisms. An elevated any difference in intubating conditions or severe
shock index is an early sign of shock despite otherwise adverse events.[27] Propofol suppresses airway reflexes
normal vitals. Common causes of hypotension among effectively but causes haemodynamic suppression
critically ill patients are hypovolaemia, decreased due to its sympatholytic effect. Transient hypotension
peripheral vascular resistance, capillary leak and secondary to vasodilation due to anaesthetic drugs may
positive pressure ventilation following tracheal be treated with vasopressors.
intubation. If hypovolaemia is present, adequate fluid Right ventricular failure
resuscitation should be performed before intubation The right ventricle (RV) is an often neglected chamber.
unless contraindicated. In patients who do not respond The RV is a highly compliant, low‑pressure chamber.
to fluids or are at risk of fluid overload following fluid Its unique structure allows it to accommodate greater
therapy, a vasopressor infusion may be started to volume, i.e., preload. However, it does not tolerate
maintain the vascular tone and prevent hypotension increases in afterload too well. The conditions
and cardiac arrest. that increase RV afterload are chronic pulmonary
In a spontaneously breathing person, negative hypertension secondary to lung or left heart disease,
intrathoracic pressure helps improve the venous pulmonary embolism and left ventricular failure. The
return. Negative intrathoracic pressure helps the right RV responds to this increase in afterload by increasing
atrium to siphon blood from the peripheral veins contractility, preload and eventually undergoing
(vis a fronte). The gradient between the peripheral hypertrophy. These patients need to be evaluated for
venous pressure and the right atrium also helps in the presence of RV dysfunction where some function
the movement of blood. [26] When the pressure in of RV is preserved and for RV failure (RVF) where

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 Vakil, et al.: Physiologically difficult airway

RV is unable to meet increased demands that can lead patients with severe metabolic acidosis are at increased
to dilatation, retrograde flow, decreased coronary risk of complications during intubation as brief periods
perfusion, hypotension and cardiovascular collapse. of apnoea can cause a sharp rise in CO2 that can derange
In patients with RVF, mechanical ventilation has acid‑base balance. Following tracheal intubation, the
deleterious effects. Positive pressure ventilation can increased ventilation requirements may not be met
lead to increase in airway pressure which in turn gets with the limitations due to lung‑protective strategies
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transmitted to the pulmonary vasculature, resulting in used which can lead to a drop in arterial pH and
an increase in afterload in addition to a reduction in precipitate cardiac arrest. Hence, these patients should
preload. Thus, there is a high risk of cardiovascular be allowed to breathe spontaneously and tracheal
collapse in patients with RVF. intubation should be avoided if possible. A trial of NIV
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may be given to reduce work of breathing during which

Other conditions that increase pulmonary pressures
correction of underlying acidosis can take place. RSI is
and subsequently worsen RVF are hypoxia and
avoided and if deemed necessary, a short‑acting muscle
hypercarbia. Therefore, patients with RVF should be
relaxant such as succinylcholine should be used.
carefully managed during airway management. A brief
Following tracheal intubation, ventilator modes should
duration of apnoea can cause sufficient hypoxia and be chosen that allows the patient to maintain their
hypercarbia leading to raised pulmonary pressures.[28,29] respiratory compensation. Modes such as pressure
HFNO as a mode of apnoeic oxygenation is useful control mode and pressure support mode where
as it prevents hypoxia and flushes out CO2 by the the patient determines tidal volume and respiratory
flow‑dependent ventilatory exchange.[30] Moreover, rate are preferred. However, these patients with high
HFNO prevents atelectasis which can help to prevent minute ventilation are at risk of developing relative
hypoxic pulmonary vasoconstriction. Other methods hypoventilation, flow starvation, patient‑ventilator
to decrease pulmonary pressures include the use of asynchrony and worsened acidosis.[2]
pulmonary vasodilators such as epoprostenol and
inhaled nitric oxide, use of NIV before intubation Neurological injury
with a low CPAP, and upright position to prevent In patients with neurologic injury such as traumatic
atelectasis.[31] brain injury, it is important to maintain cerebral
perfusion pressure and avoid secondary injuries such
Bedside echocardiography can be used to look for as hypoxia and hypercapnia. When these patients
RV function. An enlarged RV and a flattened septum need tracheal intubation due to a low Glasgow
during systole, suggest right ventricular dysfunction.[32] Coma Score or are scheduled for surgery, induction
In patients with RV dysfunction, judicious fluid loading of anaesthesia can lead to hypotension which may
may be beneficial. However, in patients with RVF, this compromise cerebral perfusion pressure. Following
may be deleterious as it may worsen left ventricular induction, laryngoscopy and tracheal intubation can
filling and stroke volume. Vasopressors such as lead to sympathetic stimulation which may increase
noradrenaline can be used before intubation with the the intracranial pressure. Any hypoxia or hypercarbia
goal of increasing the mean arterial pressure without during tracheal intubation can worsen the neurological
increasing pulmonary artery pressures. If the patient injury.[21,33]
requires tracheal intubation, the goals are to avoid
hypoxia and hypercarbia during the peri‑intubation When neurologically injured patients require
period and maintenance of a low mean airway pressure. tracheal intubation, the induction agent with least
haemodynamic effects such as etomidate should be
Metabolic acidosis used. Ketamine may also be used safely as it has been
Patients who are critically ill may have associated disproven that its use leads to increase in intracranial
metabolic acidosis. Common causes are diabetic pressure. Measures to reduce the tracheal intubation
ketoacidosis, lactic acidosis and salicylate poisoning. response such as prior administration of lignocaine,
In metabolic acidosis, the presence of organic acids fentanyl and esmolol may be used.[34] The duration
increases in proportion to the nonorganic ions. This from laryngoscopy to tracheal intubation should
leads to a compensatory increase in alveolar ventilation be minimised. Hypoxia and hypercarbia should be
to wash out CO2 to maintain acid‑base balance. These avoided.[35]

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 Vakil, et al.: Physiologically difficult airway

Paediatric Patients hypoxaemia in these patients due to the short safe apnoea
time, making tracheal intubation challenging.[39] Figure 1
The paediatric airway differs from the adult both
depicts differences in desaturation in a normal healthy
anatomically and physiologically. The most dreaded
adult, a critically ill adult, a child and an obese patient
complication anticipated during tracheal intubation in a
after administration of a neuromuscular blocking agent.
child is hypoxaemia. The average oxygen consumption
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is around 6 mL/kg/min compared to only 3 mL/kg/min

in adults. This, combined with a lower FRC and a Pregnant Patients
higher closing capacity (CC), makes children very The obstetric airway is handled only when a
vulnerable to rapid desaturation and hypoxia. The need arises to give general anaesthesia during an
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younger the child, the faster is the rate of desaturation. obstetric emergency related to the foetus or mother
These factors make children vulnerable to rapid (emergency caesarean delivery) or critical illness of the
desaturation during tracheal intubation.[36,37] mother. The obstetric airway is considered a difficult
airway and the incidence of failed intubation in obstetrics
Obese Patients was found to be 1 in 224 patients as per UK national
study.[40] The reason is not restricted to anatomical
The incidence of difficult tracheal intubation in
changes, but also due to physiological alterations in
nonobstetric obese patients (body mass index >30 kg/m2)
the parturient. The FRC is low during pregnancy and
has been estimated as 1.8%–7.5%.[38] These patients
further reduces during active labour. Oxygen demand is
may have an anatomically difficult airway. In addition,
high and further increases during active labour. Anaemia
these patients have a physiologically difficult airway
related to pregnancy may contribute to decreased oxygen
due to the higher resting metabolic demand and higher
reserves. These factors reduce the safe apnoea time while
oxygen consumption as well as a higher cardiac output
securing the airway of the parturient, increasing the risk
by a margin of 100 mL/min for each kilogram increase
of hypoxaemia. In addition, the decrease in the tone of
in adipose tissue. It is also an independent risk factor
the lower oesophageal sphincter due to the action of
for heart failure due to the structural and functional
progesterone and delayed gastric emptying makes them
changes in the heart resulting from volume and
vulnerable for gastric reflux and pulmonary aspiration.[41]
pressure overload and vascular stiffness. The resulting
progressive decrease in compliance of the left ventricle
and its hypertrophy causes left ventricular failure. Patients at Risk for Aspiration
Pregnancy, obesity, gastroesophageal reflux disease,
Obese patients have a diminished total lung capacity
diabetes, intestinal obstruction and those with
and vital capacity. This, along with the decreased chest
wall compliance and increased intra‑abdominal pressure,
significantly reduces the FRC and the CC to the extent
that often the CC is higher than the FRC, thereby
closing the smaller airways even during normal tidal
volume breathing. These patients often have associated
obstructive lung disease or other underlying lung
pathology. Obese patients may have obstructive sleep
apnoea causing intermittent and repeated upper airway
collapse, leading to partial or total airway occlusion for
short periods during sleep. This results in an irregular
breathing pattern, episodic sleep‑associated oxygen
desaturation and hypercarbia, along with cardiovascular
dysfunction and excessive daytime sleepiness. Such
frequent episodes of hypoxia and hypercarbia may Figure 1: Graph showing differences in the time to critical
lead to an increase in pulmonary arterial pressures oxygen desaturation in a normal healthy adult, a critically ill
with subsequent right ventricular dysfunction in these adult, a child and an obese patient after administration of
patients. These factors result in an increased risk of neuromuscular blockade

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 Vakil, et al.: Physiologically difficult airway

inadequate fasting status are considered to have a difficult airway. However, recently a new system
full stomach. These patients are at an increased risk has been introduced which aims at looking not only
for regurgitation and pulmonary aspiration during at the anatomical but also the physiological aspects
induction and tracheal intubation. Pulmonary aspiration of the difficult airway along with the operator
can lead to hypoxia, pneumonitis, pneumonia, ARDS experience. De Jong et al. introduced a new scoring
and even cardiovascular collapse and death. In these system called the MACOCHA system.[42] This score
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patients, RSI with predetermined doses of induction looks at the Mallampati score III or IV, obstructive
agent and muscle relaxant, avoidance of positive sleep apnoea, decreased cervical mobility, mouth
pressure ventilation and application of cricoid pressure opening <3 cm, coma (Glasgow Coma Score <8),
until confirmation of tracheal intubation and inflation
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severe hypoxaemia and a nonanaesthesiologist.

of the tracheal cuff should be routine practice.
It, therefore, takes into account the anatomical,
physiological and operator characteristics. The score
Strategies to Prevent Complications During has a maximum of 12 points, with 0 points predicting
Tracheal Intubation easy intubation and 12 points predicting a very difficult
Risk assessment one. This test has a sensitivity of 73% for direct
The traditional use of different scoring systems laryngoscopy; however, it has not been validated for
always aimed at the anatomical aspects of the videolaryngoscopy.

Table 1: Strategies to prevent complications during tracheal intubation in patients with a physiologically
difficult airway
Intervention Strategy
Airway Consider using the MACOCHA scoring system in critically ill patients
assessment
Team preparation Presence of two airway operators (at least one experienced in airway management)
Airway concerns, plan and backup should be discussed with all team members along with the roles
and responsibilities of each member
Position of patient Head‑up or ramped position should be preferred over supine position
This position improves preoxygenation by preventing reduction in functional residual capacity and
may reduce risk of pulmonary aspiration of gastric contents
Preoxygenation NIV should be the method of choice for preoxygenation in severely hypoxic patients
HFNO use has shown lesser intubation‑related complications as compared with bag valve mask in
patients who are not severely hypoxaemic
Apnoeic oxygenation may be used after optimal preoxygenation to prolong the time to desaturation
Gentle mask ventilation should be considered between induction and laryngoscopy in patients at high
risk for desaturation
RSI Should be considered in patients at a high risk of aspiration such as full stomach patients, pregnant
patients, etc., Rapid onset neuromuscular blocking agents such as succinylcholine and rocuronium
are preferred during RSI
Delayed sequence In patients who are agitated or uncooperative, ketamine may be used to induce a dissociative state
intubation and improve effective preoxygenation before proceeding with RSI
Induction agents Cardiostable agents such ketamine and etomidate are preferred in critically ill patients
Device VL improves glottic visualisation as compared to a direct laryngoscope and should be considered for
all intubations
Use of a bougie should be considered for initial tracheal intubation in critically ill patients
If available, a hyperangulated VL along with a rigid stylet should be preferred over a traditional
geometry VL during an anticipated difficult airway
Confirmation of Waveform capnography
tracheal intubation
HFNO: High-flow nasal oxygen; MACOCHA: Mallampati III or IV, a sleep apnoea syndrome, a decrease in cervical mobility, a mouth
opening < 3 cm, a coma defined by a Glasgow Coma Score <8, severe hypoxaemia and nonanaesthesiologist; NIV: Noninvasive
ventilation; RSI: Rapid sequence intubation; VL: Videolaryngoscope

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 Vakil, et al.: Physiologically difficult airway

Planning, preparation and procedure 7. Baraka AS, Taha SK, Aouad MT, El‑Khatib MF,
Kawkabani NI. Preoxygenation: Comparison of maximal
These include team preparation, appropriate
breathing and tidal volume breathing techniques.
patient positioning, peri‑intubation oxygenation Anesthesiology 1999;91:612‑6.
strategies, careful selection of induction agents, use 8. Groombridge C, Chin CW, Hanrahan B, Holdgate A.
of neuromuscular blocking agents, RSI in patients Assessment of common preoxygenation strategies outside
at risk of aspiration and use waveform capnography of the operating room environment. Acad Emerg Med
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2016;23:342‑6.
to confirm tracheal intubation. These strategies are 9. Baillard C, Fosse JP, Sebbane M, Chanques G, Vincent F,
summarised in Table 1. Courouble P, et al. Noninvasive ventilation improves
preoxygenation before intubation of hypoxic patients. Am J
Conclusion
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Respir Crit Care Med 2006;174:171‑7.

10. De Jong A, Jung B, Jaber S. Intubation in the ICU: We could
Critically ill patients, as well as paediatric, obstetric and improve our practice. Crit Care 2014;18:209‑15.
obese patients, have a physiologically difficult airway. 11. Miguel‑Montanes R, Hajage D, Messika J, Bertrand F,
The physiologic alterations in these patients put them Gaudry S, Rafat C, et al. Use of high‑flow nasal cannula
oxygen therapy to prevent desaturation during tracheal
at an increased risk for hypoxaemia or cardiovascular
intubation of intensive care patients with mild‑to‑moderate
collapse during tracheal intubation. Recognising the hypoxemia. Crit Care Med 2015;43:574‑83.
challenges involved during tracheal intubation in 12. Guitton C, Ehrmann S, Volteau C, Colin G, Maamar A,
these patients, using appropriate strategies to improve Jean‑Michel V, et al. Nasal high‑flow preoxygenation
first‑pass success in tracheal intubation and avoiding for endotracheal intubation in the critically ill patient:
A randomized clinical trial. Intensive Care Med
complications is essential. Further research will help 2019;45:447‑58.
us better understand the optimal strategies to improve 13. Frat JP, Ricard JD, Quenot JP, Pichon N, Demoule A,
patient outcomes in these categories of patients. Forel JM, et al. Non‑invasive ventilation versus high‑flow
nasal cannula oxygen therapy with apnoeic oxygenation
Financial support and sponsorship for preoxygenation before intubation of patients with acute
Nil. hypoxaemic respiratory failure: A randomised, multicentre,
open‑label trial. Lancet Respir Med 2019;7:303‑12.
Conflicts of interest 14. Weingart SD, Trueger NS, Wong N, Scofi J, Singh N,
There are no conflicts of interest. Rudolph SS. Delayed sequence intubation: A prospective
observational study. Ann Emerg Med 2015;65:349‑55.
15. Turner JS, Ellender TJ, Okonkwo ER, Stepsis TM,
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