Improving the safety of emergency tracheal intubation.

PURPOSE OF REVIEW: Emergency tracheal intubation in critically ill patients remains associated with high rates of hypoxemia, hemodynamic instability, and cardiac arrest. Over the past decade, several large randomized trials and multicenter cohorts have evaluated strategies to improve the safety of this high-risk procedure. This review summarizes recent evidence to guide clinicians toward safer, physiology-focused airway management in emergency and critical care settings.

RECENT FINDINGS: Recent studies support the use of noninvasive ventilation for preoxygenation to reduce severe hypoxemia, routine use of videolaryngoscopy to improve first-pass success, and careful selection of induction agents to limit hemodynamic collapse. While neuromuscular blockade improves intubating conditions, its impact on patient-centered outcomes remains uncertain, and no clear difference has been demonstrated between rocuronium and succinylcholine. Growing attention is also directed toward team preparation, structured airway plans, and human factors.

SUMMARY: Emergency intubation is becoming safer through improvements in preparation, preoxygenation, pharmacologic strategies, and device selection. However, many interventions improve procedural success without consistently demonstrating benefit on clinical outcomes. Future research should prioritize pragmatic trials addressing unresolved questions and integrating human-factors approaches to further reduce peri-intubation complications.