Difficulties in endotracheal intubation increase morbidity and mortality in intensive care patients. We studied the problem in surgical intensive care patients with the aim of risk reduction. Patients intubated in the intensive care unit were evaluated. The intubations were performed or supervised by anaesthetists following the algorithm valid at the time of the study. Fifty percent of the 198 intubations were performed by specialist anaesthetists, 41.5% by anaesthesia trainees and 8.5% by surgical trainees. The initial attempt was by direct laryngoscopy (n=173), flexible fibrescope (n=8) or blind nasal technique (n=17). When direct laryngoscopy failed (n=7), intubation was accomplished with an intubating laryngeal mask airway (n=5), Frova stylet (n=1) or fibrescope (n=1). Thirty percent were rated as easy, 47% as moderately easy and 23% as difficult. Difficult intubations were associated with a higher incidence of anatomic anomalies, difficult bag-mask ventilation and severe oxygen desaturation. Every intubation in the ICU setting should be considered potentially difficult. The existing algorithm should be modified to incorporate the American Society of Anesthesiologists difficult airway algorithm adapted to the needs of the intensive care unit. A training program for alternative methods of airway management for difficult intubations should be established.