Airway misadventures in adult critical care: a concise narrative review of managing lost or compromised artificial airways.

Abstract

Loss or compromise of artificial airways in critically ill adults can lead to serious adverse events, including death. In contrast to primary emergency airway management, the optimal management of such scenarios may not be well defined or appreciated. Endotracheal tube cuff leaks may compromise both oxygenation and ventilation, and supraglottic cuff position must first be recognized and distinguished from other reasons for gas leakage during positive pressure ventilation. Although definitive management involves tube exchange, if direct visualization is possible temporizing measures can often be considered. Unplanned extubation confers variable and context-specific risks depending on patient anatomy and physiological status. Because risk factors for unplanned extubation are well established, bundled interventions can be employed for mitigation. Tracheostomy tube dislodgement accounts for a substantial proportion of death and disability related to airway management in critical care settings. Consensus guidelines and algorithmic management of such scenarios are key elements of risk mitigation. Management of lost or otherwise compromised artificial airways is a key skill set for adult critical care clinicians alongside primary emergency airway management.