Abstract

Endotracheal intubation is among the most commonly performed procedures in critically ill children. It is a high-risk procedure as up to 45% of critically ill children undergoing intubation experience at least one of the major peri-intubation adverse events, with cardiovascular instability being the most common (43%), followed by severe hypoxaemia (9%) and cardiac arrest (3%). These peri-intubation adverse events are associated with a higher risk of morbidity and mortality, and they are more common in children who require multiple intubation attempts. The higher risk of peri-intubation complications in critically ill children, compared with children who require intubation during elective surgery, is the consequence of pathophysiological processes and conditions in critically ill children (e.g., underlying respiratory failure, shock, cardiac dysfunction, severe metabolic acidosis) and, in this regard, airway management in acute/critical care has been defined as ʻphysiologically difficultʼ. The aim of this review is to provide an update on several types of physiologically difficult airways (hypoxaemia, cardiovascular instability/shock, severe metabolic acidosis, cardiac dysfunction, acquired/congenital heart disease, post-resuscitation, lung hyperinflation) in critically ill children and to evaluate interventions to mitigate adverse events in the peri-intubation period.

Key words: airway management, intubation, complications, difficult airway, peri-intubation, physiologically difficult airway