DIFFICULT AIRWAY IN CRITICAL SCENARIOS: A SYSTEMATIC REVIEW ON ASSESSMENT, TECHNOLOGIES, AND PATIENT SAFETY

Abstract

Objective: This systematic review aims to investigate the main strategies for the assessment and safe management of difficult airways in critically ill patients. Methodology: The research question was constructed using the PVO (Population, Variable, Objective) strategy. The literature search was performed in the PubMed, Embase, and Science Direct databases using the following English descriptors: (“difficult airway” OR “difficult intubation” OR “airway management”) AND (“critical care” OR “emergency department” OR “intensive care unit”) AND (“airway assessment” OR “predictive tests” OR ultrasound) AND (‘videolaryngoscopy’ OR “fiberoptic intubation”) AND (“patient safety” OR complications). Initially, 333 articles were identified. After applying the eligibility criteria, 12 studies were selected. Results: The identification and management of difficult airways in critically ill patients require integrated approaches that increase initial intubation success and reduce adverse events. Ultrasound has emerged as a useful complementary method, allowing assessment of subglottic anatomy, prediction of difficulties, and rapid confirmation of tube placement; studies show high agreement with radiography, especially using the tracheal rings method. During the intubation phase, videolaryngoscopy has demonstrated superiority over direct laryngoscopy, significantly reducing the need for multiple attempts. The use of bougie as an initial strategy (“bougie-first”), especially in combination with videolaryngoscopy, increased first-attempt success even during continuous chest compressions. Preoxygenation strategies also contribute to greater safety: high-flow nasal cannula (HFNC) proved superior to bag-valve mask in reducing desaturations and adverse events, maintaining continuous oxygenation during laryngoscopy. Conclusion: Taken together, the evidence indicates that the combination of video laryngoscopy, bougie-first, preoxygenation with HFNC, and ultrasound for assessment and confirmation represents the most effective set of contemporary strategies for recognizing and managing the difficult airway in critically ill patients.