How to Intubate in 2026—The Best Current Evidence

Written by Aaron Lacy

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This review covers airway management of patients in the acute care (i.e. ED or ICU) setting. It’s a solid 16 pages long, so we’ll summarize 10 things we know now and what questions we still have. 

Show me the evidence (or lack thereof). 

In 2026, here is how we should be performing tracheal intubation (TI):

Preparation

• Prepare for the difficult airway: The difficult airway can be either anatomic or physiologic. I am still not bullish on predictors of the anatomically difficult airway, as most prediction methods have low to moderate sensitivity at best. Consider all emergency intubations at risk of anatomical difficulty, preparing for this with appropriate backup options. The physiologically difficult airway is an umbrella term to describe the patient with pathophysiological alterations that increase their risk of an adverse event during TI. The major phenotypes of the physiologically difficult intubation include hypoxia, hypotension, metabolic acidemia, and right ventricular dysfunction.
• Use an intubation checklist: Enough said on this one. 
• Preoxygenation: unless contraindicated, preoxygenation should be with non-invasive positive pressure ventilation with 100% oxygen. Consider delayed sequence intubation (DSI) to facilitate oxygenation in patients who require assistance, most notably the agitated patient.
• Positioning: At this time there is no evidence for routine ramped positioning of the patient, and positioning should be patient specific (i.e., obesity vs. cervical pathology). 
• Physiologic optimization: Data are still lacking in generalized evidence-based methods to prevent cardiovascular collapse in patients undergoing TI. Clinicians should specifically work to address physiological derangements of their patient (e.g., hypoxia, hypotension, acidemia, RV strain) with targeted interventions. A one-size-fits-all approach does not work for patients with specific physiologic derangements.

The Procedure

• Induction agents: There has been much back and forth regarding etomidate versus ketamine as the induction agent of choice in the critically ill patient. I am getting more in line with the etomidate train, but you could reasonably choose ketamine as well. At this time, avoid propofol (although studies are ongoing comparing propofol to other agents). 
• NMB choice: At this time, patient-specific factors (such as hyperkalemia or presence of neuromuscular disease) should drive the choice between succinylcholine or rocuronium, as one has not been shown to be clearly superior.
• Technique and tools: Please use VL. Which VL is best (SGVL, HAVL, or channeled VL), and which blade size (SGVL 3 or 4) is still not fully elucidated. Bougie vs. stylet has generally been neutral or favored bougie, but you must use one of the other, no stylet-less ETTs please. 

Post-Intubation

• Tube confirmation: An unrecognized esophageal intubation should never happen. My preference is to not anchor on one sign of confirmation (color change, misting in the tube, etc.) and instead use a combination of continuous wave-form CO₂ detection with several other clinical signs to confirm tube placement.
• Post-intubation sedation: Clinicians must balance the risks of early, deep sedation (associated with worse outcomes) while avoiding undersedation during concurrent NMB use (associated with awareness with paralysis). Clinicians should avoid benzodiazepines as much as able (associated with increased ICU length of stay and delirium). 

How will this change my practice?
I am currently doing all of these things! However, what might change my practice moving forward depends on the answers to some key questions, some of which the article highlights:

• What order should we be administering drugs for RSI? Should we be doing paralytic first?
• Does paralytic choice change outcomes we haven’t fully investigated yet, like PTSD?
• VL is a no brainer, but is SGVL or HAVL better?
• What size VL blade is best?
• Do we really need paralytics for intubation in the age of VL? Could we just do sedatives?
• Is colorimetric confirmation of ETT placement good enough, or should everyone be doing wave-form capnography and/or ultrasound confirmation?

The world of airway management is always full of fresh questions and controversy, so I plan to stay tuned. 

Source
Airway management of adults in the acute care setting. BMJ. 2026 Apr 8;393:e086612. doi: 10.1136/bmj-2025-086612. PMID: 41951238.