Personnel working in the intensive care environment will frequently be called upon to deal with a variety of airway problems, ranging from the emergency situation requiring prompt intervention to those situations in which careful, informed decisions have to be made about the appropriateness of various methods of long-term airway management. All ICU staff must be able to cope with the 'difficult' intubation: familiaritywith the various techniques available for dealing with this problem is essential, together with the necessary skills required for fibreoptic intubation. Awareness of the long-term complications resulting from intubation and tracheostomy has led to the development of thermolabile, non-irritant tubes with low-pressure cuffs, which have significantly reduced the incidence of laryngotracheal injury and the formation of stenotic lesions. However, other factors are involved and much can still be done to reduce problems associated with long-term intubation. In patients requiring long-term ventilation, the decision of when, and indeed if, to do a tracheostomy is a difficult one and must be individualized for each patient. There is no doubt that there are more severe complications associated with tracheostomy than with intubation; but at the same time, tracheostomy improves patient comfort, simplifies airway management, and can allow the patient to speak and take oral nutrition. In addition, there is some evidence that a tracheostomy tube may facilitate the weaning process and allow earlier discharge from the intensive care unit. Adequate humidification is fundamental to the proper management of patients with any form of tracheal tube that bypasses the normal humidification processes of the upper airways. Heat and moisture exchangers are efficient and reliable, but due to the heterogeneous nature of the ICU population, the may be unable to provide sufficient humidification in certain groups of patients and heated water humidification must then be used. The recent introduction of minitracheostomies for the treatment of sputum retention, and of non-invasive ventilation techniques in certain groups of patients, has extended the range of treatment options available in patients requiring some interventional support and respiratory care. No doubt further applications for these techniques will be developed in coming years. © 1990 Baillière Tindall. All rights reserved.
