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Tracheal intubation is commonly performed in critically ill patients. Unfortunately, this procedure also carries a high risk of complications; half of critically ill patients with difficult airways experience life-threatening complications. The high complication rates stem from difficulty with laryngoscopy and tube placement, consequences of physiologic derangement, and human factors, including failure to recognize and reluctance to manage the failed airway. The last 10 years have seen a rapid expansion in devices available that help overcome anatomic difficulties with laryngoscopy and provide rescue oxygenation in the setting of failed attempts. Recent research in critically ill patients has highlighted other important considerations for critically ill patients and evaluated interventions to reduce the risks with repeated attempts, desaturation, and cardiovascular collapse during emergency airway management. There are three actions that should be implemented to reduce the risk of danger: 1 ) preintubation assessment for potential difficulty (e.g., MACOCHA score); 2 ) preparation and optimization of the patient and team for difficulty-including using a checklist, acquiring necessary equipment, maximizing preoxygenation, and hemodynamic optimization; and 3 ) recognition and management of failure to restore oxygenation and reduce the risk of cardiopulmonary arrest. This review describes the history of emergency airway management and explores the challenges with modern emergency airway management in critically ill patients. We offer clinically relevant recommendations on the basis of current evidence, guidelines, and expert opinion.

Background: The 'sniffing position' is widely promoted for teaching airway positioning before intubation, but whether this analogy results in novices placing the head and neck appropriately has not been evaluated. We compared performance following the sniffing position instructions with an alternate analogy, 'win with the chin'. We also compared performance following simple anatomic instructions and no instructions., Methods: A randomized controlled study of medical students and PGY1 registrars in Surgery and Internal Medicine was performed. Subjects independently positioned a simulator manikin head and neck based upon their understanding of four written instructions in random order: (i) the 'sniffing position'; (ii) the 'win with the chin' analogy, (iii) anatomic instructions; and (iv) no instructions (control). Digital photographs following each instruction were analysed by two airway experts for (i) adequacy of overall positioning and (ii) the three components of airway positioning., Results: Eighty-one volunteers participated. The positioning was adequate most often (43.2%) following the 'win with the chin' analogy when compared with the other instructions (37.0% anatomic instructions; 19.8% control; 14.8% 'sniffing position' analogy). Positioning following the 'sniffing position' instructions was not different from no instruction (P=0.53). The 'win with the chin' and anatomic instructions were significantly better than no instructions (P=0.002 and 0.023, respectively)., Conclusions: The 'win with the chin' analogy resulted in adequate airway positioning significantly more often than the 'sniffing position' or control. It also maintained atlanto-occipital extension compared with anatomic instructions. Overall, 'win with the chin' was a superior teaching analogy and could replace the 'sniffing position' analogy.