Episode #294 From Video Laryngoscopy To ECMO: What Keeps Airway Management Safe

Anesthesia professionals are specialists in airway management. Here are three key takeaways for airway management that you can use this week:

• Limit intubation attempts to less than or equal to 3 to reduce harm
• Aspiration risk management lacks clear evidence for optimal approach.
• Video laryngoscopy has improved success but risks deskilling in direct laryngoscopy and awake fiberoptic intubation.

Hello and welcome back to the Anesthesia Patient Safety Podcast. I’m your host, Alli Bechtel. When I’m not podcasting about patient safety, I provide patient care as an anaesthesiologist. Here is our roadmap for today. We will be talking about airway management including current tools and future questions. This is an important area for anesthesia professionals to help lead the way for patient safety. Let’s wash our hands and grab our laryngoscopes because this promises to be a high-yield episode.

Before we dive further into the episode today, we’d like to recognize GE Healthcare, a major corporate supporter of APSF. GE Healthcare has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, GE Healthcare – we wouldn’t be able to do all that we do without you!”

Our first featured article is from the October 2025 APSF Newsletter. It is “Airway Safety in the OR and Beyond: Balancing Innovation, Safety, and Core Skills” by Avery Tung and Allen Klock, Jr. To follow along with us, head over to APSF.org and click on the Newsletter Heading. The fourth one down is Newsletter archives. Then, click on October 2025 and scroll down until you get to our featured article today. I will include a link in the show notes as well.

Just like other areas of anesthesia care, airway management has come a long way in the past 3 decades with modern tools that include video laryngoscopy, supraglottic airways, and extracorporeal membrane oxygenation or ECMO, and improved outcomes. Challenges for airway management, especially outside the operating room, include cognitive errors, device over-reliance, and skill degradation. Going forward, anesthesia professionals will need to focus on maintaining core skills, improving decision-making, and enhancing collaboration with other specialists.

Here are a few more key takeaways when it comes to airway management and patient safety:

Airway events now occur more often in emergencies and non-OR settings

Cognitive errors like delayed calling for help or failure to escalate level of care are major safety threats

ECMO is emerging for select high-risk airways but requires coordination

And Preserving core airway skills and interprofessional readiness is essential.

Did you know that the number of publications per year with the keyword, “difficult airway” has increased from 79 in 1990 to over 450 per year in 2024? But over that same time, the number of closed claims for difficult tracheal intubation has not decreased and most recent claims tend to involve sicker patients and non-operating room locations? Even with our new equipment and updated approaches to difficult airway management, we have not reached the point of no patient harmed by airway management during anaesthesia care yet.

Let’s look a little closer at the epidemiology of difficult airway management. You can check out the 2019 review in Anesthesiology of closed malpractice claims due to airway management. Findings from this study included the following:

Compared to claims from 1993-1999, claims from 2000-2012 involved sicker patients, ASA III-V, patients undergoing emergency procedures, and more events occurred in nonoperating room locations.

Inadequate airway planning and judgement errors contributed to these claims

The study authors conclude that there is a need to improve both practitioner skills and systems responses with there is a difficult or failed intubation event.

There is a 2017 review article that looked at Norwegian malpractice claims for injuries related to airway management. 37% of these claims came from emergency procedures. In addition, over 50% of the mortality cases were due to failed intubation or misplaced endotracheal tube.

Then, if we look at the 2015 United Kingdom Fourth National Audit Program, we will find collected reports of airway management complications between 2008 and 2009. There were 33 events that resulted in death with 16 occurring in the intensive care unit and 3 in the Emergency Department.

Check out the show notes for these citations. The big takeaway here is that airway events that lead to severe injury occur more often during emergencies and in the ICU, emergency department and other non-OR locations than in the operating room during elective surgeries.

So, where should we direct our focus when it comes to improving airway management ? Remember, severe complications from difficult airway management are more likely to occur during emergencies and in non-operating room locations, so we need to make sure that our airway equipment is available for use outside the operating rooms. Keep in mind that during clinical emergencies, the additional pressure of difficult airway management, when seconds count, increases stress levels and the risk for cognitive errors.

Let’s talk about cognitive errors. The literature that we reviewed today highlights that judgement errors are important factors during adverse events related to difficult airway management. Some examples include lack of a backup airway management plan, failure to call for help early, failure to use a supraglottic airway as a bridge to oxygenation, and failure or reluctance to awaken a patient or progress to a surgical airway when all other non-invasive options have failed. If we return to the 2019 American Society of Anesthesiologists closed claims study, the investigators found that judgement errors where more common during elective compared to urgent airway management. In these cases, the airway managers may have failed to recognize predictors of difficult airway management during the preoperative evaluation or that our screening exams may not always predict airway difficulty. These errors are serious errors that can cause serious harm and this is where cognitive training can help. Anesthesia professionals need to avoid cognitive traps that may occur during airway management including failure to promptly move to a surgical airway when indicated, repeated attempts at intubation when previous attempts have failed, reluctance to admit defeat, or not clearly declaring failure of the conventional airway management techniques. Simulation and metacognitive reflection can help clinicians to learn about these traps and train to avoid them during simulated difficult airway scenarios. Other important considerations include debriefing after adverse events or even near misses occur and participating in focused case conferences to help improve airway management performance.

The literature reveals that repeated airway instrumentation decreases the likelihood of subsequent successful intubation and worsens outcomes. The 2022 ASA guidelines recommend limiting intubation or supraglottic airway attempts to 3 or fewer if possible. It is vital to avoid repeated intubation attempts or an unwillingness to admit failure. This will just delay successful intubation and may lead to serious patient harm.

Another component of airway management involves concurrent management of cardiorespiratory insufficiency. Let’s take a look at the INTUBE study. This was an international, multicenter, prospective cohort study involving consecutive critically ill patients undergoing tracheal intubation in the intensive care units, emergency departments, and wards that included almost 3000 patients requiring intubation in the ICU. The results revealed that almost 50% of these patients experienced cardiovascular instability, severe hypoxemia, or cardiac arrest during the intubation. The secondary outcome was ICU mortality which was found to be 32.8% for overall ICU mortality.

Patients undergoing elective anticipated difficult airway management are also at risk for cardiorespiratory instability. The next study that we are going to look at is from last year. It is a single centre prospective study of almost 1300 episodes of elective and anticipated difficult airway management. During the study, trained observers recorded airway management decisions and process complications. The authors describe the clinical decisions and outcomes including number of attempts, need for bag mask ventilation, and cardiovascular instability. For the results: no cases were cancelled for failure to intubate, but the incidence of hypoxemia was high at 50%, the frequency of cardiovascular destabilization was 20%, and 30% of patients need 3 or more attempts before successful intubation.

The takeaway from these studies for anesthesia professionals is that difficult airway management should be expected to be difficult from a cognitive and technical perspective. It is important to anticipate cardiovascular instability or a failed airway attempt and be prepared with the following:

An airway strategy with sequences of backup plans, your plan A, B, C, and D

Training to avoid cognitive pitfalls such as preservation, failure to call for help, losing track of time during a crisis, and reluctance to proceed with a surgical airway.

As we look to the future, we are going forward with an array of tools in our airway toolbox to help keep our patients safe including the video laryngoscope, supraglottic airway, other advanced airway tools, rapidly reversible neuromuscular blocker, and recognition of the cognitive traps during difficult airway management. There are some important safety challenges though that we are going to talk about now.

First up, the relative role of different intubating devices. The video laryngoscope has become a staple of difficult airway management and we have seen the cost and learning curves go down combined with more widespread use with good results. There is a 2023 multi-centre, randomized trial of direct compared to video laryngoscopy for critically ill patients requiring intubation in the Emergency department or ICU. The results revealed a higher first pass success rate with video laryngoscopy compared to direct. So, should video laryngoscopy become the standard for intubation? We need to be cautious about a self-reinforcing loop where a preference for first attempt with a video laryngoscope leads to gradual deskilling with direct laryngoscopy which then skews future trials towards video laryngoscope which completes the loop of first attempt video laryngoscope preference. There is a real risk for loss of direct laryngoscopy skills over time.

Another clinical challenge is the role of awake flexible bronchoscopic intubation. This is something that requires skill and training so if there is a preference for alternative techniques using video laryngoscopy and supraglottic airways, then there may be similar deskilling over time. Further studies are needed going forward to help determine the role for awake flexible bronchoscopic intubation during difficult airway management.

The next safety challenge pertains to airway management expertise. There is a more rapid learning curve for video laryngoscopy, so clinicians in the emergency department and ICU may be able to achieve basic airway expertise with fewer repetitions and thus be able to provide a wider range of airway management services. Anesthesia professionals are in high demand in the operating room and this may help to better meet the needs of hospital staffing while maintaining patient safety during airway management. There are some important considerations before making this change including the following:

When and how to bring anesthesia and surgery professionals to an airway management event initiated by a non-anesthesia clinician

Pitfalls that include failure to recognize the difficult airway and the likelihood of airway damage or worsening conditions with repeated attempts

Creation of a multidisciplinary difficult airway response team keeping in mind that this team will need to be called in a timely fashion by the initiating service when help is needed.

Aspiration is a serious complication during airway management and we still don’t know the best approach for airway management in patients at increased risk for aspiration. The current data tells us that asleep intubation with cricoid pressure does not reduce aspiration risk for high-risk patients and may make laryngoscopic views worse, but we don’t know if an awake, topicalized, or fiberoptic bronchoscopic approach is better. There are no randomized trials evaluating these two techniques. We have an older prospective observational trial from 1989 that showed no clear aspiration in 123 high-risk patients following awake fiberoptic bronchoscopic intubation. There were complications though with 10 patients developing laryngospasm and severe coughing in 32 patients. Future safety questions include:

• How can we best preserve the skills for awake fiberoptic bronchoscopic intubation for anesthesia professionals?
• What is the best approach for patients at high risk for aspiration?

There is one more key takeaway that we haven’t addressed yet: the role for ECMO for patients with very difficult airways such as a large substernal goiter. Venovenous or venoarterial ECMO can decrease the risk of oxygen desaturation or hypercarbia and provide hemodynamic support for these patients who may be difficult for surgical access or even passage of the endotracheal tube beyond an area of tracheal compression. If you have worked with an ECMO team, then you already know that this support requires technical skills and strong teamwork between the ECMO clinician and the airway managers. Considerations include the following:

• Initiation of ECMO in an awake patient prior to airway management
• Standby support with sheaths inserted in the femoral vessels prior to airway management
• Preparation for cannulation for emergent rescue in the case of failed airway management
• ECMO training for successful time-dependent execution in an urgent or emergent situation
• Location and availability of ECMO services which are often limited to major academic or urban medical centers.

Questions that we will need to address going forward include:

• Will accessibility for ECMO services improve with advances in technology?
• What is the best way to train ECMO clinicians for rescue cannulation?
• How can we best deploy ECMO services for anticipated and unanticipated difficult airway events?

We made it to the end of the article. Modern airway management often involves video laryngoscopy for previously difficult airways and supraglottic airway devices for rescue and with intubating tools to help secure the airway. Maintaining safe airway practice and the appropriate skills is more complex then ever and we have important questions that need to be answered:

How do we best to preserve direct laryngoscopy skills when VL is becoming the first choice for routine airways?

• What is the best way to mitigate aspiration in high-risk patients?
• What are the behavioral strategies that we need to avoid cognitive traps and how do we train anesthesia professionals so that they can best incorporate these strategies?
• And finally how do we integrate ECMO support into pre-emptive, standby, or rescue scenarios in patients with high-risk airways?

The authors tell us that the solutions to these questions are likely to make airway management even safer in the future.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

Do you work in an anesthesia department with trainees? If so, can you send this to a consultant anesthetist or attending anesthesiologist who acts as a supervisor or mentor? Your support helps us reach more listeners and spread awareness about the importance of safety in anesthesia for the next generation of anesthesia professionals. You can listen wherever you listen to podcasts or head over to APSF.org and click on the Patient Safety Resources Heading. Second one down is the Anesthesia Patient Safety Podcast and you can find all of our episodes, show notes, and transcripts.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

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