Tracheal intubation in the intensive care unit is a high-risk procedure, with hypoxemia, cardiovascular collapse, and cardiac arrest remaining frequent despite substantial progress. This narrative review outlines the evolution of ICU intubation from a primarily technical intervention to a physiologically complex procedure requiring systematic anticipation, optimization, and teamwork. Current evidence supports individualized respiratory preparation, including noninvasive ventilation and high-flow nasal oxygen in selected hypoxemic patients, head-up positioning, and cautious peri-induction ventilation. Hemodynamic management should account for the combined effects of critical illness, induction agents, and positive-pressure ventilation; routine fluid loading alone is insufficient, whereas early vasopressor support and avoidance of propofol in high-risk patients may improve safety. Videolaryngoscopy, routine use of a stylet or bougie, capnography, and structured rescue plans can improve first-pass success and reduce complications. Future advances will rely on personalized physiological phenotyping, implementation of existing evidence across diverse settings, and carefully validated integration of artificial intelligence, simulation, and robotic technologies into airway management.