In-hospital emergency airway management in critically ill patients: a narrative review

Airway management in critically ill patients is a high-risk, complex procedure, particularly during in-hospital emergency settings outside the operating room. These patients often present with severe physiological instability, including hypoxemia, hypotension, metabolic acidosis, and limited cardiopulmonary reserve, all of which increase the risk of peri-intubation complications such as cardiovascular collapse and hypoxic injury. Peri-oxygenation is a critical component of emergency airway management. High-flow nasal oxygen in the head-up position represents an effective strategy for many critically ill patients, whereas non-invasive positive pressure ventilation may be preferred in selected patients. Apneic oxygenation may further prolong safe apnea time, although evidence regarding its standalone effectiveness remains inconsistent. Hemodynamic optimization is equally important, as routine fluid boluses may be ineffective or even harmful in patients with poor fluid responsiveness, while early vasopressor administration guided by dynamic assessment has emerged as a promising strategy in selected patients. Rapid sequence induction and videolaryngoscopy may improve first-pass success, particularly when performed by experienced operators within a structured airway management pathway, whereas awake tracheal intubation should be considered when significant airway challenges are anticipated. Point-of-care ultrasound provides valuable support for predicting anatomical difficulties, identifying the cricothyroid membrane, and confirming airway device placement. In addition, team-based strategies, structured airway protocols, and simulation-based training enhance team performance, reduce cognitive load, and improve patient safety. Evidence from large multicenter studies demonstrates that peri-intubation adverse events remain common, highlighting the importance of physiology-informed, multidisciplinary approaches. Embedding these principles into institutional protocols and continuous training programs may support safer emergency airway management, reduce variability in clinical practice, and improve patient outcomes across diverse in-hospital environments. The adoption of evidence-based, context-specific and physiology-informed strategies remains essential to optimize emergency airway management in critically ill patients.