RESPIRATORY SYSTEM: Edited by Giacomo BellaniAirway management in the critically illMyatra, Sheila NainanAuthor Information Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India Correspondence to Sheila Nainan Myatra, Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Dr Ernest Borges Road, Parel, Mumbai, India. Tel: +91 9820156070; e-mail: [email protected] Current Opinion in Critical Care: February 2021 - Volume 27 - Issue 1 - p 37-45 doi: 10.1097/MCC.0000000000000791 Buy Metrics Abstract Purpose of review To provide an evidence-based approach to improve first pass success in tracheal intubation while maintaining patient safety in the critically ill. Recent findings Despite advances in the management of critically ill patients, tracheal intubation in these patients remains a high-risk procedure associated with increased morbidity and mortality. Recent interventions to enhance patient safety and improve first pass success in tracheal intubation emphasize reducing repeated attempts at tracheal intubation, oxygen desaturation and cardiovascular collapse during airway management by optimizing patient physiology to mitigate risks and reduce complications. These include various strategies to improve peri-intubation oxygenation like use of noninvasive ventilation, high flow nasal cannula oxygen and gentle mask ventilation between induction of anesthesia and laryngoscopy; use of a videolaryngoscope and a bougie; careful selection of drugs including neuromuscular blocking agent; improved strategies to avoid haemodynamic collapse; rescue oxygenation strategies and human factor considerations. Summary Recognizing the challenges and using the appropriate interventions to improve first pass tracheal intubation success, while maintaining patient safety are essential during tracheal intubation in critically ill patients. This review will provide recommendations based on the current evidence, various guidelines and expert opinion in the field. Further research will help us better understand the best strategies to improve patient outcomes. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.