| Abstract|| |
Background: The placement of a tube into a patient's trachea "the intubation" as we call is not as simple as it looks. It is a very tricky and tedious maneuver that entails skills to assess and perform. Nevertheless, often this is left to the chores of inefficient hands due to a paucity of the availability of experts. They seldom are able to complete the task and often wind up calling the attention of the unit. The present review is an attempt to describe the need to undertake intubation, the procedures and techniques, the complications, including morbidity and mortality and airway management. This overview includes explicit descriptions of the difficult airway which represents multifaceted interface amid patient factors, clinical setting, and skills of the practitioner. Materials and Methods: To accomplish the target, peer-reviewed English language articles published during third millennium up to 2013 were selected from Pub Med, Pub Med Central, Science Direct, Up-to-date, Med Line, comprehensive databases, Cochrane library, and the Internet (Google, Yahoo). Review of Literature: The review constituted a systematic search of literature on the requirements that necessitate the practice of intubation, different techniques that facilitate easy conduct of procedure, the complications, including, morbidity and mortality, and the airway management. Conclusion: Recording every single detail has been beyond the scope of this review, however; some aspects have been wrapped up in nutshell. Some areas of the review are too basic which the medics are well aware of and knowledgeable. Nevertheless, these are difficult to be dispensed with in consideration of their source to the awareness of a common man and a great majority of the patients.
Keywords: Complications, intubations, management, prerequisites, procedures and techniques
|How to cite this article:|
Alanazi A. Intubations and airway management: An overview of Hassles through third millennium. J Emerg Trauma Shock 2015;8:99-107
| Introduction|| |
Emergency intubation is a requisite that is immensely expended as a life-saving procedure in severe acute illness and injury associated with potential compromises to the patient's airway and ventilation. Although timely diagnosis and treatment can avert the airway disarrays, but the role of intubation is difficult to be absolutely ruled out and is very much relevant to significant life-saving measure.  Nevertheless, the techniques are associated with a very high potential of risk. If the skill is incorrectly performed, it could be detrimental to the patient. The medics who are supposed to have the expertise are anesthesiologists, intensive care unit (ICU), perinatal intensive care unit intensivists, ENT specialists, and the supportive staff, including paramedics and for these experts, emergency airway management is a required skill. In a study on the outcomes of tracheal intubation, Stephens et al.,  reported that in the hands of these experts, rapid sequence intubation (RSI) followed by direct laryngoscopy is a remarkably effective approach to emergency airway management. The paramedics are sufficiently trained in advanced airway skills, including tracheal intubation. Initial training in this skill requires the insertion of 25 tracheal tubes and further ongoing training is attained through clinical and manikin-based practice. The training standards for hospital-based practitioners are considerably great requiring approximately 200 tracheal intubations. Advanced airway management delivered by ambulance crews appears to be inadequate with such an infrequent exposure to the skill.  Prior to discussing the embarrassing situations in the airway management, it is important to preliminary confer the predicaments in the launch of an intubation. The professionals undertaking the intubation are supposed to have sufficient experience with the safe time of extubation to avoid subglottic edema, complications, including; stidor, and, the need for more respiratory support by reintubation. In view of the significance of intubation and to ward off severe medical exigencies, it was found imperative to undertake writing of this review on prerequisites, including different eventualities that warrant intubation, the different procedures and techniques, the complications and possible management of the airway disarrays, during the third millennium.
| Materials and Methods|| |
The articles selected to include in this review were based on their relevance and understanding of the literature in pursuit of different aspects of intubation and airway management. To accomplish the target, peer-reviewed English language articles published beyond 2001 (beginning of the third millennium) to 2013 were selected from Pub Med, Pub Med Central, Science Direct, Up-to-date, Med Line, comprehensive databases, Cochrane library, and the Internet (Google, Yahoo). The strategy to search incorporated the terms that included the title and the keywords relating the prerequisites that warrant intubation, techniques, complications, and management of intubation in airway disarrays.
| Review of Literature|| |
The review constituted a systematic search of literature during the millennium up to 2013 on the requirements that necessitate the practice of intubation, different techniques that facilitate easy conduct of the procedure, the complications, including morbidity and mortality and the management of intubations, the airway and ventilation, and conclusion. Some areas of review are well-known to the medics but a common man and great majority of the patients are ignorant. Hence, these are difficult to be dispensed with in consideration of their source to the awareness for a common man and great majority of the patients.
Majority of endotracheal intubations (ETIs) that occur on patients are related with medical emergencies, including; Head and brain injuries, cervical and spinal cord injuries, chronic obstructive pulmonary disease (COPD), croup, airway obstructions, asthma, massive hemoptysis, myxedema coma, malignant interventions (thyroid carcinoma), pediatric emergencies, congenital diaphragmatic hernia in newborns, pediatric tumors, exposure to chemicals, drugs, over dosage and poisoning, [neurotoxins, ziprasidone, phenol, dettol, pine oil, isopropyl alcohol, domestos, quetiapine, organophosphates (OP), phenytoin, topiramate, ketamine], and other conditions which necessitate intubation, either prehospital or in hospital emergency.
Head and brain injuries
Prehospital ETI in moderate to severe traumatic brain injury (TBI) patients is linked with about fivefold increase in mortality.  Literature reports suggest the requirement of general anesthesia and tracheal intubation in the management of emergency department (ED) patients that require an urgent computed tomography of the brain performed in patients with minor head injury which generally involves 10% mortality.  The use of hyperventilation to reduce intracranial pressure may be life-saving in acute brainstem herniation in TBI. However, hyperventilation might increase the incidence of secondary brain injury through direct reduction of cerebral blood flow causing increase in mortality. Abnormal PCO2 after severe head trauma is suggested to be correlated with increase in hospital mortality. 
Cervical spinal cord injury
Although majority of the patients require tracheostomy after cervical spinal cord injury (CSCI), there is always an immediate need for pre-hospital or ED intubation. Complete CSCI at C1-C4 or C5-C7 levels, high injury severity score, facial fracture, and thoracic trauma are independently associated with the need for tracheostomy. 
COPD is a potential medical emergency that is treated with bronchodilators, glucocorticoids and supplemental oxygen. Nevertheless, in extreme cases, treatment with mechanical ventilation through endotracheal tube (ETT) is required to correct the acid-base imbalance caused by the disease process. A case of a 52-year-old female, with intense COPD requiring intubation failed extubation many times, was concurrently treated with lorazepam, for agitation. Based on the evidence for increased carbon dioxide retention associated with benzodiazepine use, the patient was weaned off the lorazepam, which in turn allowed the patient to be successfully weaned off the ventilator. 
Croup is a respiratory disease in children in the United States, which is responsible for up to 15% of ED visits. The symptoms of croup generally start like an upper respiratory tract infection, with mild fever and coryza that follows a barking cough and various degrees of respiratory distress. Viruses, including parainfluenza virus, cause croup. Some of the croup patients require hospital admission and intubation. 
Large mediastinal masses cause life-threatening major airway obstruction. It can lead to complete obstruction, requiring ETI, and cardiorespiratory resuscitation. Physician awareness and preparedness for respiratory complications are essential for proper management of children with mediastinal masses.  Epiglottitis is a life-threatening condition resulting from epiglottis infection of the epiglottis and surrounding structures, causing signs and symptoms related to inflammation, and progressive airway obstruction. In diagnosing epiglottitis, direct visualization is done by laryngoscopy. Lateral neck X-rays is also done but with less sensitivity than direct visualization. The rate of mortality due to epiglottitis has been reported to be 7% (both in adults and children).
Most of the asthma patients lack awareness of dangers from smoking, not taking or irregularly taking medication, using inhaled short-acting beta (2) agonist alone, as needed, and not using inhaled corticosteroids. Such knowledge deficits among the asthma patients might exacerbate the disease. Treatment mainly using inhaled corticosteroids, in addition to increased knowledge and awareness of the dangers of asthma among the patients themselves, is important to prevent severe asthma attacks requiring tracheal intubation and mechanical ventilation.  Child patients with acute severe and life-threatening asthma unresponsive to initial medical therapy require ETI and mechanical ventilation. There is considerable morbidity in asthmatic children who are referred to pediatric intensive care. The most common complications are hypotension (requiring fluid resuscitation and/or inotropic support) and severe bronchospasm with acute hypercarbia. 
Coughing of blood or mucous containing blood is a serious medical emergency that can cause hemodynamic compromise requiring intensive care. A total of 29 patients who had massive hemoptysis were admitted to the medical ICU during a period of 5 years. The patients were monitored intensively and ETT in case of a danger of airway compromise. Fiberoptic bronchoscopy was performed to assess the bleeding site and patients had bronchial artery embolization if found suitable. Emergency surgery was performed in patients in whom bleeding was not controlled. 
Myxedema coma is the most lethal manifestation of hypothyroidism. It can result in intense hemodynamic instability and airway compromise. As thyroid hormone therapy can take a long time to reverse the manifestations, provisional therapy is serious till any clinical improvement. Some patients will require ETI and physicians have to be aware that posterior pharyngeal edema in myxedema coma could severely complicate airway management. A case of a woman who presented with myxedema coma is described. She required an urgent ETI and was found to have extensive posterior pharyngeal angioedema. The case discussed a rescue device in placement of ETI. 
Malignant intervention (thyroid carcinoma)
Acute respiratory crisis due to infiltration of upper airways is a complication of anaplastic thyroid carcinoma or thyroid lymphoma. In a case presented by Testini et al.,  a 73-year-old man had a painful neck mass, dyspnea, stridor, and dysphonia was evaluated in emergency. An emergency ETI was followed by total thyroidectomy. Histological examination confirmed the diagnosis of thyroid metastasis from renal cell carcinoma.
There are a number of specific aspects in the management of acute emergencies in children. The intubation, for example, requires knowledge of the particular anatomy of infants and young children. Moreover, a specific approach to oxygen requirement, blood volumes, thermoregulation, and the venous system is very much essential. There are a number of causes, such as; cardiac arrest, sudden infant death which predominates in babies, while in young and preschool children, trauma and drowning accidents represent most of the common events, which require intubation. 
Congenital diaphragmatic hernia in the newborns
Congenital diaphragmatic hernia in the newborns requires immediate intubation and gastric decompression to minimize gastric distention, as well as cautious ventilation to avoid pneumothorax. 
Pediatric oral tumors are always challenging for even the most skilled anesthesiologists. The traditional method of conscious intubation is not realistic in this age group and hence, the management is to work out a plan to intubate the child postinduction. The authors find a successful management for a case of giant ossifying fibroma in a child with sickle cell trait where nonconventional approach is used to secure the airway preoperatively and avoid possible medical complications. 
Exposure to chemicals, drugs, over dosage, and poisoning
The most common type of toxin ingested differs geographically, being prescribed medication in the developed countries and agricultural chemicals, hydrocarbons or traditional medicines in the under developed countries. The different types of poisoning can be deliberate, accidental, environmental, and industrial exposures. The general management will include mainly the airway and breathing before further deterioration in the circulation and disability.
Certain neurotoxins including organic lead compounds can result in death upon exposures. These compounds are found in fuel stabilizers, antiknock agents, and leaded gasoline. Wills et al.,  reported a case of a 13-year-old Iraqi male who accidentally ingested a fuel stabilizer containing 80%-90% tetraethyl lead. The patient developed severe neurologic symptoms including agitation, hallucinations, weakness, and tremor. These symptoms required ETI and a propofol infusion, in addition to adjunctive therapies including chelation, baclofen, and nutrition provided through a gastrostomy tube. The patient slowly recovered and was discharged.
Unintentional pediatric exposure to ziprasidone (an antipsychotic used in the treatment of schizophrenia and bipolar mania in adults and also used off label in children and adolescents). A report of unintentional ingestion of ziprasidone by a 15-month-old, who required intubation secondary to respiratory failure is described. The child was flaccid and lethargic with no eye opening, developed worsening central nervous system depression with inability to protect his airway and underwent ETI. The patient was extubated approximately 14 h later and was discharged from the hospital shortly thereafter in good health without neurological sequelae. 
Phenol (carbolic acid) has been used for local analgesic therapy for a long time. Several complications of phenol therapy can occur by exposure through inhalational, oral, and dermal routes. Renal and pulmonary toxicity is caused from the exposure to injectable phenol. A case is described, where a 50-year-old man unintentionally received 10 cc of 89% phenol injection. The case highlighted potential development of multiple organ failure with persistence of organ dysfunction. He improved clinically with the recovery of renal function. Nevertheless, the chest X-ray and computed tomography scan showed persistent nodular pulmonary infiltrates which resolved by 6 months. 
Dettol, pine oil, isopropyl alcohol, and domestos
Although, dettol, pine oil, and isopropyl alcohol are labeled as nonpoisonous, they have been reported to cause delayed upper airway obstruction. Domestos (1%-5% sodium hypochlorite) is used as a household and toilet cleaner. Graham  reported a rare case in which these agents, when consumed in significant quantities caused stridor and impending airway obstruction requiring ETI in the ED.
A case of a 41-year-old man is reported. He came to the ED after ingesting 4500 mg of quetiapine (an antipsychotic drug) with respiratory failure ensued within 24 h requiring intubation and mechanical ventilation. Chest radiograph demonstrated signs of acute respiratory distress syndrome resulting from an overdose of quetiapine. 
Patients acutely poisoned with OP in developing countries require intensive care and mechanical ventilation. Despite adequate respiratory support, intensive care and specific therapy with atropine and oximes, mortality following OP poisoning remains high. Munidasa et al.,  reported one-third of the subjects that required mechanical ventilation and to reach ICU die within the first 72 h of poisoning. Systolic blood pressure of less than 100 mm Hg and the necessity of a FiO 2 >40% to maintain adequate oxygenation are predictors of poor outcome in patients mechanically ventilated in the ICU.
A case of phenytoin self-poisoning by 38-year-old man is reported. The patient was notable for delayed peak serum concentrations, multiple general complications, and permanent cerebellar injury. Initial conservative treatment was unsuccessful. Subsequently, the serum phenytoin concentration peaked to 354 μm/L on day 15 and the patient developed seizures, followed by a prolonged depression in conscious state requiring intubation. There was permanent cerebellar dysfunction. 
The medical records of two patients who took a topiramate overdose as a suicide attempt were reviewed. The medical and seizure histories, medications, neurologic examination, laboratory findings, their progress and laboratory abnormalities were recorded at the time of presentation following the overdose. Both patients progressed to coma and had generalized convulsive status epilepticus, requiring intubation and treatment with benzodiazepines. Though the patients recovered within 2 days but had a nonanion-gap metabolic acidosis that persisted for 5-6 days. 
Prolonged apnea following intramuscular administration of ketamine was developed in an 11-month-old female child. The child developed respiratory depression requiring intubation and ventilation but could recover after emergency airway management. 
Procedures and Technology
Before beginning to know the procedures and technology of intubations and the airway management, setting and area to intubate is of prime importance. In a study on comparison between the prehospital ETI done in the field with that done in more controlled circumstances in a trauma center, Tracy et al.,  found the former is associated with increased septic morbidity. The authors concluded that there is no increased risk of pneumonia for urgent prehospital intubation. Furthermore, the onset of pneumonia and similar bacteriology is reflective of severity of the injury and not of additional infectious risk posed by these prehospital maneuvers.
The different procedures and technologies are the tracheal tube placement, thoracic sonography, ultrasonography, lightwand technique, laryngoscopic technique for awake, bronchoscopy, laryngeal mask airway (LMA), easyTube, king laryngeal tube disposable (LTD), LMA, anesthetic agents that facilitate emergency ETI and alternative devices in airway emergency.
Tracheal tube placement
Several methods are used to confirm proper placement of ETI. Grmec  reported comparative verification of the three most commonly used methods of tracheal tube placement in emergency intubation. Tube position was initially assessed by auscultation. Then, capnometry was performed with infrared capnometry and capnography with infrared capnography. Determination of final tube placement was performed by a second direct visualization with laryngoscope. In this study, the ETT placement was found to be of vital importance. The author concluded that capnography is the most reliable method to confirm ETT placement in emergency conditions in the prehospital setting.
Most of the methods of ETT placement are often unreliable and/or unavailable in certain settings. Previously, thoracic sonography was used to detect pneumothoraces, however; it has not been tested to assess ETT placement. Chun et al.,  hypothesized that thoracic sonography can correlate with pulmonary ventilation and help to confirm proper placement of ETT. The authors concluded that thoracic sonography may be another tool to help proper placement of ETT. The technique has merits in extreme environments, such as in remote, prehospital settings, or medical transports during aerospace, in which auscultation is impossible due to noise, or capnography is not available.
Ultrasonography to locate placement
The ETT placement is generally confirmed by visualization of the vocal cords and end-tidal capnography. Capnography is not always reliable to visualize the vocal cord and the ventilation of the lungs is required to confirm placement. Werner et al.,  determined the accuracy of ultrasonography to detect ETT placement into the trachea in controlled environment of the operating room.
Lightwand technique versus laryngoscopic technique for awake ETI
Nishikawa et al.,  investigated the efficacy of the lightwand technique compared with that of the laryngoscopic technique for awake ETI in patients requiring emergency surgery and found that the lightwand technique produce less stress following tracheal intubation than the conventional laryngoscopic technique for awake intubation. Lightwand-assisted awake intubation is considered to be a useful means for induction of anesthesia in cases of emergency surgery.
Laryngoscopy vs. bronchoscopy
In a study of comparison between direct laryngoscopy with a Macintosh blade versus indirect bronchoscopy with a Trachway stylet, for ETI with a left-sided double-lumen tube, Hsu et al.,  found left endobronchial intubation with a double-lumen tube is slower using direct laryngoscopy and causes more hoarseness than indirect bronchoscopy with a Trachway stylet.
In the pursuit for an alternative to bag-mask ventilation and ETI for management of ventilation in infants and children in the prehospital setting, Youngquist et al.,  found LMA may be the best alternative airway with the most promise to add to the armamentarium of the prehospital provider. The LMA is reported to offer a safe alternative in children and adults to ETI. There were no observed increased risks of airway complications in the use of LMA in patients undergoing otologic surgery.  McCall et al.,  reported that Intubation via the intubating LMA to be as successful as conventional laryngoscopic intubation. It requires fewer attempts. These intubations were successful without the use of any sedation or paralytic medication.
In case of difficult airway management in a prehospital setting, easyTube is used as a device that combines the advantages of both an infraglottic and supraglottic airway. It has a very high success rate in ventilation and there is a low failure rate after a short training period. 
King LTD is used as a primary airway in patients requiring RSI. Paramedics were reported to successfully place and use this device in patients meeting the EMS system indications for RSI.  Guyette et al.,  have shown LTD as a new superglottic alternate airway. In their experience of King airway placements, all were successfully placed. No immediate complications were observed and no prehospital surgical airways were performed.
LMA has gained wide acceptance for routine airway management and with an increasing emphasis on day care surgery it is immensely used. The intubating LMA has a high success rate as a ventilatory device and as a flexible lightwand-guided tracheal intubation for out-of-hospital cardiopulmonary resuscitation by emergency physicians. 
Anesthetic agents that facilitate emergency ETI
Etomidate is an anesthetic agent is shown to be cerebroprotective, with rapid onset, short duration of action, and with a stable hemodynamic profile. It is reported to be used to facilitate emergency ETI in the prehospital air medical setting, with a success rate of 89%. At doses used in the study, the hemodynamic parameters remained stable, but intubation was difficult or unsuccessful in 27% of patients. Masseter muscle spasm, which may represent orofacial myoclonus or inadequate relaxation, is common in patients who cannot be intubated with etomidate. 
Alternative devices in airway emergency
Although oral ETI is the definite airway, but in most of the EMS systems, it may prove challenging in some patients due to abnormal anatomy, trauma, or inadequate relaxation or maybe there are no qualified and competent persons to perform the technique. In cases of difficult or failed ETI, alternate airways are designed to provide suitable oxygenation and ventilation until a definitive airway can be established. The most common devices are esophageal obturator airway, esophageal gastric tube airway, pharyngeotracheal lumen airway, esophageal-tracheal combitube, LMA, king laryngeal tube airway. The other rescue airway techniques include the percutaneous approaches of needle cricothyrotomy and surgical cricothyrotomy. 
Most complications of intubations and airways cause comorbidities and some may even cause mortality. Multiple comorbidities are recorded in patients undergoing ETI. These reports guide a systemic organization of paramedic airway management care and education.  There are specific factors that may complicate ETI. Difficulties encountered during ETI included blood, vomit/debris, and secretions in the upper airway. Furthermore, anatomical reasons, patient position and surrounding conditions, make laryngoscopy more difficult. However, despite various factors increasing the difficulties in managing the airway in the field, definitive airway control by ETI seems to be safe practice.  The frequently observed complications are ventilator-associated pneumonia (VAP), development of pneumonia after trauma, difficult intubation.
Eckert et al.,  reported VAP occurs in 50% of the patients requiring urgent intubation. Intubation was assessed as an independent risk factor in trauma patients urgently intubated in the prehospital and ED settings.
Development of pneumonia after trauma
Prehospital intubation is a major risk factor for the development of posttraumatic pneumonia. Other predictors include head and extremity injuries, shock, blunt trauma, and related high severities, which have been identified as risk factors for the development of pneumonia after trauma. 
Failure to intubate is rare (0.1%) and the incidence of difficult tracheal intubation is 7.4%, independent of cardiorespiratory status, if prehospital medical airway management is standardized and performed by trained operators. The authors concluded that the factors associated with difficult intubation are a history of ear, nose, or throat neoplasia or surgery; obesity; facial trauma; the operator's status; and the operator's position. 
Failure to place ETI
Wang et al.,  showed that out-of-hospital rescuing team, including paramedics, often fails to accomplish ETI in patients requiring invasive airway management. In a study to analyze the factors, the authors reported that the paramedics are not competent to successfully place the ETT. The following factors were found as the possible reasons for failure of successful ETI;
- Presence of clenched jaw/trismus,
- Inability to pass the ETT through the vocal cords,
- Inability to visualize the vocal cords,
- Intact gag reflex,
- Intravenous access established prior to ETI attempt,
- Increased weight, Trachway and
- AN electrocardiographic monitoring established prior to ETI attempt.
Patient factors that make intubation more difficult
Jbeili et al.,  reported management of morbid obese patients in the context of the out-of-hospital emergency medicine is often linked with specific and major technical difficulties. Several diagnostic and therapeutic devices are not adapted to the most severe overweight patients. Obese trauma patients requiring emergency intubation are at increased risk for unsuccessful intubation and airway-related complications due to anatomic and physiologic characteristics that make their intubation more challenging. A number of airway and early respiratory complications, in addition to mortality, are observed. 
Impact of delayed intubations
Initially some of the moderately injured trauma patients appear to be stable, but later deteriorate and require intubation, Miraflor et al.,  postulated that delay in intubation would have higher mortality, especially in cases of rib fractures.
Cline et al.,  found that expedited admission (<2 h) of critically ill patients requiring intubation and mechanical ventilation from the ED to the ICU was linked with reduced durations of mechanical ventilation and ICU length of stay.
Early versus late tracheostomy
In a study to evaluate the benefits and safety of early versus late tracheostomy in traumatic spinal cord injury patients requiring mechanical ventilation, Romero et al.,  found that early tracheostomy following short orotracheal intubation is beneficial. It was found that early placement (before day 7 of mechanical ventilation) offers advantages for shortening of mechanical ventilation coupled with reducing ICU stay and lowering rates of complications, such as tracheal granulomas and concentric tracheal stenosis.
Delayed complications of tracheal intubation
Most of the studies have described about the immediate complications of tracheal intubation. However, there is dearth of literature on the delayed complications. Using a structured datasheet, Sakles et al.,  abstracted delayed complications occurring within 7 days of intubation from medical records. The different complications scrutinized were acute myocardial infarction, stroke, airway trauma from the intubation, and new respiratory infections. In this study three patients underwent emergent cricothyrotomy as they could not be orally intubated, while a 7-month-old infant developed subglottic stenosis and could not be intubated. Tracheotomy was done on this patient. Respiratory infections, aspiration pneumonia, acute myocardial infarction were commonly observed. Cobas et al.,  reported a 31% incidence of failed prehospital intubations in a large metropolitan trauma center. There were no differences observed in mortality between patients who were properly intubated and those who were not, supporting the use of bag-valve-mask as an adequate method of airway management for critically ill trauma patients in whom intubation cannot be achieved promptly in the prehospital setting.
Malignant intervention that required stent placement
Esophageal cancer and postoperative lymph node metastasis compress and infiltrate the trachea causing dyspnea. Employing metallic expandable stents to relieve airway obstruction are extremely effective in advanced stage cancer patients. It may be concluded that metallic expandable stent placement is an effective strategy to palliate malignant tracheal stenosis. 
The development in the emergency airway management has led the use of intubation techniques by experts and prehospital technical personnel other than the anesthesiologists and this is no more restricted to the jurisdiction of operating theaters. The clinical outcomes for select patients who require intubation are improved by the application of suitable rapid-sequence intubation and the use of drugs, mainly neuromuscular blocking agents and additional medicines. Nevertheless, a routine use of these techniques is difficult to be adopted due to dearth of experienced physicians in the ICU. Nevertheless, several management protocols are described in the literature.
Ketamine treatment of asthmatics
Children experiencing severe asthma exacerbations often deteriorate to respiratory failure and require ETI and mechanical ventilation. Mechanical ventilation is often life-saving but also exposes the asthmatic child to substantial iatrogenic risk. Denmark et al.,  reported two cases of severe asthma in prepubertal children, for whom the administration of a bolus of intravenous ketamine followed by a continuous infusion of a relatively large dose of ketamine led to prompt improvement, obviating the need for mechanical ventilation.
Most of the asthma patients in both the intubation group and nonintubation group are often dissenting with inhaled corticosteroids. Despite a long duration of symptoms and knowledge of systemic corticosteroids (SC), majority neither implement self-management with SC nor contact a health care provider. Early initiation of SC can avert intubation in the high-risk group. Most of the patients are extubated successfully in <48 h. 
Preventive measures to avoid intubation
In children up to their 18 th month of life with a clinical diagnosis of bronchiolitis, the need for immediate intubation can be avoided by treatment with either three doses of racemic albuterol or one dose of racemic epinephrine plus two saline nebulizers. Treatment of bronchiolitis with nebulized racemic albuterol led to more successful discharges than nebulized epinephrine. 
Airway issues in anesthesia are a large source of morbidity and mortality. However, most of the airway complications can be avoided or minimized by proper technique and vigilance. Emergency thoracotomy surgery is done in patients who suffer lower tracheal trauma, especially when the patient suffers tracheal perforation during ETI. Hence, it is important for clinicians to be skilled in the use of airway devices and to be prepared for any unexpected eventuality. 
Invasive procedures, including tube thoracostomy place the patients at risk for complications. Complications detected in the ED were defined as immediate, whereas those discovered later were defined as delayed. Complications requiring corrective surgical intervention, administration of blood products, or intravenous antibiotics were defined as major. Major complications included one intercostal artery laceration, one retroperitoneal placement, and empyema, motor vehicle accidents were associated with immediate complications and spontaneous pneumothorax was associated with delayed complications. 
In the management of benign airway stenosis, indwelling tracheal stents are becoming increasingly common. The stents frequently block with granulation tissue and may require removal. A combined open and endoscopic removal maximizes airway protection and minimizes potential complications. The removal of stent is done under bronchoscopic and transtracheal guidance, and tracheotomy. 
Tracheotomy dates back to ancient Egypt and India some 3000 years ago. Once, it has been to bypass upper airway obstruction, however; today, due to advancement in intensive care and the extensive use of mechanical ventilation, the procedure is very common elective therapeutic procedure used mostly to facilitate prolonged intubation and ventilation of the critically ill. It is used on a regular basis by most hospital physicians in many fields. Nevertheless, owing to severe complications and high mortality rate, the emergency tracheotomy is discouraged and there is a rampant search for alternative routes to obtain immediate airway control in the acutely obstructed upper airway. 
Reduced glasgow coma score
Patients with a Glasgow coma score (GCS) of 8 or less generally require airway protection. It is observed that a number of these patients can be managed without any need of an advanced airway support in a well-monitored ward environment. Assessment by experienced medical staff (rather than physiological variables) is significant enough to determine the requirement of intubation in poisoned patients with reduced GCS.  Hardcastle and Goff,  reported GCS (less than 8) as the most common indication for intubation, typically in the polytrauma patient with suspected head injury due to motor vehicle accident. Emergency doctors managed 100% of definitive airway in-hospital and RSI was the favored method.
The mallampati score
The Mallampati score is one of the multiple predictors proposed to assist in identifying the preoperative assessment of patients who would predict difficult airway management in the operating room. Clinical instability and lack of patient cooperation were factors that excluded evaluation in patients whose assessment was unsuccessful. Major events included two cricothyrotomies in the nonassessed group. 
Blair et al.,  reported that RSI is the most commonly used first-line technique for airway management and is also the principal back-up technique when other oral or nasal intubation methods fail. Emergency physicians manage the majority of ED intubations, including those requiring rescue techniques.
| Conclusion|| |
This review on intubation and airway management constituted a systematic search of literature published in peer-reviewed journals during the third millennium (2001-2013). The review in brief has included the need to undertake intubations, the procedures and techniques, complications, and management. Recording every single detail has been beyond the scope of this review, however; some aspects have been wrapped up in nutshell. These are the different requirements and preconditions for intubation, exposure to chemicals, drugs, over dosages and poisoning, the procedures and techniques, the complications, and the management. Some areas of the review are too basic which the medics are well aware of and knowledgeable. Nevertheless, these are difficult to be dispensed with in consideration of its source to the awareness for a common man and a great majority of the patients.
| Acknowledgment|| |
The succor rendered by Dr. Shoeb Qureshi in compilation of the review is immensely acknowledged.
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Dr. Abdullah Alanazi
Department of Pediatric Emergency, College of Applied Medical Sciences, King Saud Bin Abdul-Aziz University for Health Sciences, Riyadh
Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None