Table 1.

Authors’ recommendations for airway management in critically ill patients

Topic	Recommendation	Comments
Positioning	1. Ramped plus “sniffing” (lower cervical spine is flexed, the upper cervical spine is extended, and the ear is leveled with the sternal notch) positions for all patients	1. If supine position planned, recommend preoxygenating in upright position to optimize oxygen delivery.
		2. Gastric ultrasound can help stratify risk.
	2. Gastric decompression when faced with a high risk of aspiration
Preoxygenation	1. Flush flow* rate oxygen should be the default preoxygenation method.	1. In patients with acute hypoxemic respiratory failure, a PaO2 to FiO2 ratio (or SpO2 to FiO2 equivalent) can be helpful to stratify preoxygenation.
	2. In patients with higher risk of desaturation, preoxygenation should be performed with HFNO or NIPPV.
		2. PaO2 to FiO2 ratio > 200 on NRB at flush rate = proceed with RSI
		3. PaO2 to FiO2 ratio < 100–200 on NRB at flush rate = escalate to NIPPV or HFNO
	3. For those most severely hypoxemic, where RSI is still planned, preoxygenation should be performed with NIPPV.
		4. PaO2 to FiO2 ratio < 100 on NIPPV or HFNO = consider awake intubation
	4. For those most severe where an awake intubation is planned, HFNO during the procedure should be used.
	5. Consider mask ventilation between induction and laryngoscopy when feasible.
	6. Apneic oxygenation should be used when feasible.
Hemodynamics	1. Hemodynamics should be assessed prior to intubation.	1. We recommend fluid resuscitation where appropriate.
	2. Optimization should be informed by the underlying physiology on assessment.	2. We recommend norepinephrine infusion as the default vasopressor or choice.
		3. We recommend an RV-guided resuscitation when necessary.
		4. Some patients are too unstable for RSI and need a staged awake intubation and gradual transition to positive pressure ventilation.
Laryngoscopy	1. We recommend VL as the default laryngoscope when available.	1. There are many advantages and very little downside to routine use of VL. In addition, there are many cost-effective options for VL that are widely available.
	2. Consider routine use of a bougie when using traditional Macintosh geometry laryngoscopy (either DL or VL).
	3. A second-generation supraglottic airway device should be used when available if rescue oxygenation cannot be accomplished with bag-valve-mask ventilation.

RSI, rapid sequence intubation; NIPPV, noninvasive positive pressure ventilation; HFNO, high-flow nasal oxygen; NRB, nonrebreathing mask; DL, direct laryngoscopy; VL, video laryngoscopy

*Flush flow rate oxygen refers to using a standard nonrebreathing reservoir mask and opening the valve from the wall regulator all the way, which generally provides between 50 and 80 l of oxygen depending on the hospital’s oxygen system pressurization