Module 6 · Airway & respiratory

Airway management

NewPhase 1

Plan every ICU intubation as a high-risk event: predict anatomical and physiological difficulty, preoxygenate properly (NIV or HFNC when hypoxaemic), choose haemodynamically safe induction drugs, use a video laryngoscope and bougie, follow a clear failed-airway plan to front-of-neck access, confirm with waveform capnography, and extubate safely.

6 topics

Drugs in this module

Doses written for this module's context. The same drug may read differently in another module.

Ketamine

NMDA antagonist dissociative anaesthetic

Indications
Induction in haemodynamically unstable patients, asthma, sepsis; analgosedation.
Adult dose
Induction 1-2 mg/kg IV (0.5-1 mg/kg in shock). Analgosedation 0.1-0.5 mg/kg/h.
Preparation (India)
50 mg/mL in 10 mL vials (also 10 mg/mL). For induction draw 200 mg to 20 mL = 10 mg/mL.
Cautions
Can still cause hypotension in catecholamine-depleted patients; tachycardia, hypertension, emergence reactions, raised secretions. Raised ICP concerns are no longer considered a contraindication.

Etomidate

Imidazole hypnotic

Indications
Induction when cardiovascular stability is needed.
Adult dose
0.2-0.3 mg/kg IV (0.15-0.2 mg/kg in shock).
Preparation (India)
2 mg/mL, 10 mL ampoules (lipid emulsion).
Cautions
Single dose transiently suppresses adrenal 11-beta-hydroxylase; myoclonus; no analgesia.

Propofol

GABA-A agonist hypnotic

Indications
Induction in haemodynamically stable patients; sedation after intubation.
Adult dose
Induction 1-2 mg/kg (0.5-1 mg/kg or less in elderly or unstable). Sedation 0.5-4 mg/kg/h.
Preparation (India)
1% (10 mg/mL) in 20 mL and 50 mL vials.
Cautions
Dose-related hypotension and myocardial depression; avoid full doses in shock.

Fentanyl

Synthetic opioid

Indications
Blunting the pressor response (head injury, aortic dissection, ACS); analgesia after intubation.
Adult dose
Pre-induction 1-3 mcg/kg (omit or reduce in shock). Infusion 0.5-2 mcg/kg/h.
Preparation (India)
50 mcg/mL ampoules (2 mL and 10 mL).
Cautions
Hypotension by removing sympathetic drive; chest wall rigidity with rapid large doses.

Rocuronium

Aminosteroid non-depolarising neuromuscular blocker

Indications
RSI paralysis (preferred where succinylcholine is contraindicated).
Adult dose
RSI 1.2 mg/kg IV (actual body weight); onset 45-60 s; duration 45-70 min.
Preparation (India)
10 mg/mL, 5 mL vials (50 mg). Store refrigerated (or check room-temperature shelf life).
Cautions
Long duration if you cannot intubate: have sugammadex available. Anaphylaxis is rare.

Succinylcholine (suxamethonium)

Depolarising neuromuscular blocker

Indications
RSI when rapid offset is valuable and no contraindication.
Adult dose
1.5 mg/kg IV (actual body weight); onset 45 s; duration 8-10 min.
Preparation (India)
50 mg/mL ampoules (2 mL = 100 mg); refrigerate.
Cautions
Contraindicated with hyperkalaemia, prolonged immobility (> 48-72 h), burns or crush > 24-48 h, denervation (stroke, spinal injury, GBS, neuromuscular disease), malignant hyperthermia history. Bradycardia with repeat doses.

Sugammadex

Selective relaxant-binding agent

Indications
Reversal of rocuronium (or vecuronium); immediate reversal in a can't-intubate situation when waking is a realistic plan.
Adult dose
16 mg/kg IV for immediate reversal after 1.2 mg/kg rocuronium; 2-4 mg/kg for routine reversal.
Preparation (India)
100 mg/mL, 2 mL vials. Expensive; keep in the airway trolley.
Cautions
Reversal does not fix an obstructed airway; anaphylaxis; bradycardia.

Noradrenaline (norepinephrine)

Vasopressor

Indications
Prevent or treat peri-intubation hypotension (start before induction if SBP < 90 or shock index > 0.9).
Adult dose
Infusion 0.05-0.3 mcg/kg/min; push-dose 4-8 mcg aliquots from a 4-16 mcg/mL syringe (specialist use).
Preparation (India)
4 mg in 50 mL (80 mcg/mL) for infusion; push-dose syringe 1 mL of 80 mcg/mL diluted to 10 mL = 8 mcg/mL.
Cautions
Label push-dose syringes clearly; dilution errors are a known hazard.

Methylprednisolone

Corticosteroid

Indications
Prevention of post-extubation stridor in patients with a failed cuff leak test.
Adult dose
20 mg IV every 4 h for 4 doses before extubation (start ≥ 4 h, ideally 12 h, before extubation).
Preparation (India)
40 mg, 125 mg, 500 mg and 1 g vials.
Cautions
Hyperglycaemia.

Adrenaline (nebulised)

Catecholamine

Indications
Post-extubation stridor (temporising).
Adult dose
1 mg (1 mL of 1 mg/mL) in 4 mL NS nebulised, or up to 5 mL of undiluted 1 mg/mL; may repeat.
Preparation (India)
1 mg/mL ampoules.
Cautions
Tachycardia; rebound swelling; prepare for reintubation.

Module references (16)

  1. 1

    Myatra SN, Shah AP, Ramkumar V, et al. All India Difficult Airway Association 2025 guidelines for the management of unanticipated difficult airway in adults under general anaesthesia. Indian J Anaesth. 2025;69(11):1117-1141

  2. 2

    Myatra SN, Ahmed SM, Kundra P, et al. The All India Difficult Airway Association 2016 guidelines for tracheal intubation in the Intensive Care Unit. Indian J Anaesth. 2016;60(12):922-930

  3. 3

    Higgs A, McGrath BA, Goddard C, et al. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth. 2018;120(2):323-352

  4. 4

    Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827-848

  5. 5

    Popat M, Mitchell V, Dravid R, et al. Difficult Airway Society guidelines for the management of tracheal extubation. Anaesthesia. 2012;67(3):318-340

  6. 6

    Tracheal intubation in critically ill adults with a physiologically difficult airway. An international Delphi study. Intensive Care Med. 2024

  7. 7

    Acquisto NM, Mosier JM, Bittner EA, et al. Society of Critical Care Medicine clinical practice guidelines for rapid sequence intubation in the critically ill adult patient. Crit Care Med. 2023;51(10):1411-1430

  8. 8

    De Jong A, Molinari N, Terzi N, et al. Early identification of patients at risk for difficult intubation in the intensive care unit: development and validation of the MACOCHA score. Am J Respir Crit Care Med. 2013;187(8):832-839

  9. 9

    Russotto V, Myatra SN, Laffey JG, et al. Intubation practices and adverse peri-intubation events in critically ill patients from 29 countries (INTUBE). JAMA. 2021;325(12):1164-1172

  10. 10

    Gibbs KW, Semler MW, Driver BE, et al. Noninvasive ventilation for preoxygenation during emergency intubation (PREOXI). N Engl J Med. 2024;390(23):2165-2177

  11. 11

    Casey JD, Janz DR, Russell DW, et al. Bag-mask ventilation during tracheal intubation of critically ill adults (PreVent). N Engl J Med. 2019;380(9):811-821

  12. 12

    Prekker ME, Driver BE, Trent SA, et al. Video versus direct laryngoscopy for tracheal intubation of critically ill adults (DEVICE). N Engl J Med. 2023;389(5):418-429

  13. 13

    Driver BE, Semler MW, Self WH, et al. Effect of use of a bougie vs endotracheal tube with stylet on successful intubation on the first attempt among critically ill patients (BOUGIE). JAMA. 2021;326(24):2488-2497

  14. 14

    Casey JD, Seitz KP, Driver BE, et al. Ketamine or etomidate for tracheal intubation of critically ill adults (RSI trial). N Engl J Med. 2026;394(16):1608-1620 (online Dec 2025)

  15. 15

    Russell DW, Casey JD, Gibbs KW, et al. Effect of fluid bolus administration on cardiovascular collapse among critically ill patients undergoing tracheal intubation (PREPARE II). JAMA. 2022;328(3):270-279

  16. 16

    Girard TD, Alhazzani W, Kress JP, et al. An official American Thoracic Society/American College of Chest Physicians clinical practice guideline: liberation from mechanical ventilation in critically ill adults. Am J Respir Crit Care Med. 2017;195(1):120-133