Airway management and mechanical ventilation represent the cornerstones of ICU care for critically ill patients. In this chapter we deal with basic concepts and focus on the practical considerations that confront critical care practitioners on a daily basis.

AIRWAY MANAGEMENT

It is essential for critical care specialists to be profi – cient in securing an airway in a variety of patients and clinical scenarios. Critically ill patients often have hypoxia, acidosis, or hemodynamic instability and poorly tolerate delays in placing an airway. Further, underlying conditions such as intracranial hypertension and myocardial ischemia may be exacerbated by the attempt to secure an airway itself. Compounding the problem are the myriad of comorbid and associated conditions such as vascular disease, cervical fractures, facial trauma, laryngeal edema, and patient combativeness associated with the critically ill that complicate the situation.

Criteria for Intubation

Although never validated, the decision to establish a definitive airway is based on three general criteria:

1. Failure to protect or maintain airway, e.g., loss of protective airway reflexes in brain injured patients

2. Failure to oxygenate or ventilate, e.g., during cardiopulmonary arrest, acute respiratory distress syndrome (ARDS), septic shock, neuromuscular disease

3. Anticipation of a deteriorating clinical course, e.g., anatomical airway distortion. Serial clinical assessment is requisite to determine the ability of patients to protect their airway.