Airway management in obese and critically ill patients: challenges, strategies, and evidence-based practices—a comprehensive review

Abstract Airway management in obese and critically ill patients presents significant clinical challenges due to altered anatomy, impaired respiratory mechanics, and physiological instability. These high-risk populations are prone to difficult intubation, rapid desaturation, aspiration, and hemodynamic compromise during airway interventions. This comprehensive review synthesizes current evidence from guidelines, randomized trials, and observational studies to outline best practices for optimizing safety and outcomes. Obese patients require tailored approaches, such as ramped positioning, head-elevated laryngoscopy, and enhanced preoxygenation with noninvasive ventilation or a high-flow nasal cannula, to improve oxygen reserves. Critically ill patients demand modified rapid-sequence intubation with careful hemodynamic optimization, continuous monitoring, and readiness for rescue strategies. The use of video laryngoscopy and supraglottic devices has improved first-pass success and reduced complications, while point-of-care ultrasound enhances airway assessment and procedural accuracy. Pharmacologic management should be individualized to mitigate hypotension and ensure cardiovascular stability. Post-intubation care emphasizes lung-protective ventilation and ongoing airway reassessment. Simulation-based training, structured checklists, and team-based preparedness have proven essential in minimizing adverse events. Existing guidelines from the American Society of Anesthesiologists, the Difficult Airway Society, and critical care bodies provide a robust framework, though adaptations are required for obese and critically ill patients. Future directions include integrating artificial intelligence for airway prediction, expanding ultrasound applications, and establishing multicenter registries for outcome evaluation. Safe and effective airway management in these complex populations relies on an evidence-based, multidisciplinary, and individualized approach to reduce morbidity and improve patient-centered outcomes.