Emergency tracheal intubation in the postanesthesia care unit: physician error or patient disease? Inadequate airway maintenance has been a major factor in perioperative morbidity. To determine the incidence and etiology of emergency tracheal intubations in the postanesthesia care unit (PACU), we retrospectively reviewed 13,593 consecutive admissions to our PACU from October 1986 through October 1988. Twenty-six patients (26/13,593 = 0.19%) required the insertion of an endotracheal tube while in the PACU. Seventy-seven percent (20/26) of the intubations occurred within 1 h of extubation and/or admission to the PACU. Intubation was more common at the extremes of age; 54% of those intubated were more than 60 yr old (P = 0.003); 19% were less than 3 yr old (P less than 0.05). Twenty-three percent of the intubated patients had undergone otolaryngologic procedures (P = 0.008). Interestingly, 73% of the intubations occurred during the months of January through June (P = 0.016). Median PACU admission scores were lower for the intubated group (P less than 0.001). There was no association between intubation and gender (P = 0.74), anesthetic technique (P = 0.41), or anesthetic agent (P = 0.49). Of the 26 intubations, 18 (69%) were considered to be directly related to anesthetic management. Despite the extremely low incidence of emergency tracheal intubation in a heterogeneous group of patients admitted to our PACU, preventable anesthesia-related etiologic factors including excessive sedative or anesthetic effect, inappropriate fluid management, persistent muscle relaxant effect, and upper airway obstruction contributed to the majority of these intubations. 