Difficult Airway Management in the Intensive Care Unit: A Narrative Review of Algorithms and Strategies.

The management of difficult airways is one of the most critical and challenging aspects of emergency and ICU care. Despite technological advances, unanticipated airway difficulty can result in serious complications, including hypoxia, brain injury, and death. This comprehensive narrative review aims to consolidate current algorithms and evidence-based strategies to guide clinicians in the assessment and management of difficult airways. A comprehensive literature review was conducted using PubMed, Embase, and Google Scholar to identify relevant studies, clinical guidelines, and expert consensus documents related to difficult airway management. The focus was placed on both pre-intubation assessment tools and intervention strategies used in various clinical contexts. Airway difficulty is best anticipated through a combination of history, physical examination, and validated tools such as the Mallampati score. Several algorithms, including those from the American Society of Anesthesiologists (ASA) and the Difficult Airway Society (DAS), provide structured approaches that emphasize preoxygenation, preparedness for failed intubation, and the use of adjuncts such as video laryngoscopy, supraglottic airway devices, and awake intubation techniques. Crisis algorithms such as the Vortex approach help simplify decision-making during emergencies. It is important to have adjuncts available in cases of anticipated difficult airways, such as fiberoptic intubation, while surgical airway access is an important component of a stepwise airway management algorithm when critical scenarios are encountered. Effective difficult airway management requires anticipation, a structured plan, familiarity with advanced airway tools, and adherence to validated algorithms. Training in crisis resource management and multidisciplinary rehearsal of airway scenarios are essential to improving outcomes.