Tracheal intubation in the critically ill: beyond the airway, toward hemodynamic precision

To the Editor, We read with interest the recent narrative review by Kotani et al., which highlights tracheal intubation in critically ill patients as a complex physiological event extending beyond airway instrumentation alone [1].By emphasizing the sequential hemodynamic insults associated with induction, apnea, positive-pressure ventilation, and post-intubation care, the review provides an important framework for understanding peri-intubation cardiovascular instability and the concept of the physiologically difficult airway [1][2][3].We believe this framework may be further strengthened through a physiology-based approach that classifies patients according to dominant physiological vulnerabilities during the peri-intubation period.Although preload dependence, vasoplegia, and right ventricular (RV) dysfunction are discussed, these states are not explicitly integrated into a bedside decision model.Such an approach may facilitate more individualized peri-intubation management.