Table 3 Key anesthetic principles for airway management strategies in ICU patients

1. Oxygenation, not intubation, is the priority at all times including during tracheal extubation.

2. Airway equipment should be purchased with the least experienced potential user in mind, and not the most experienced (i.e., ideally, devices should be intuitive and user-friendly, requiring a short training period).

3. Devices should have sufficient evidence from reliable research to support their clinical role.

4. Rescue devices should have a close to 100% success rate to ensure the minimal number of steps when securing the airway. A device with a high success rate in routine use may have a lower success rate when used as a rescue maneuver, especially when the difficult airway is unexpected. Urgency and operator’s anxiety of impending patient morbidity or mortality is likely to hinder the success of any device.

5. Devices should be trialed over an adequate period of time (several weeks or months in most cases, and a sufficient number of times, preferably more than 50) to ensure that they are used for a variety of airway problems and by an adequate cross-section of staff.

6. To be successful, extubation should be planned in a similar manner to intubation. To be more specific, extubation techniques should be tailored to the type of expected airway difficulties. Preparation for re-intubation should be part of the extubation management plan with a clear indication of when an intervention is or is not working and when to seek alternative methods.

7. Technical and non-technical training in all clinical environments must follow the implementation of new airway management and oxygenation devices.