Airway management carries some of the highest risks in the ICU. Unlike the controlled environment of the operating theatre, critically ill patients present significant physiological challenges. At least one in four major in-hospital airway events occurs in the ICU and is associated with a high likelihood of serious injury or death. Recurring gaps in care include poor identification of at-risk patients, inadequate planning, insufficient staffing and equipment, delayed recognition of events, and failed rescue due to misinterpretation of capnography.
The Fourth National Audit Project (NAP4) concluded that most cases were avoidable with appropriate environmental management and training. More recently, the International Observational Study to Understand the Impact and Best Practices of Airway Management in Critically Ill Patients (INTUBE) found that most patients experienced at least one peri-intubation adverse event, with cardiovascular instability identified as the most frequent complication. From this evidence has emerged the concept of the physiologically difficult airway (PDA), a framework distinguishing patients whose intubation risk arises from anticipated physiological compromise rather than anatomical difficulty.
In a symposium session at #EA26, three international experts examined the latest frameworks for assessing and managing difficult airways in critically ill patients, presented the new ESAIC guidelines on tracheostomy, and highlighted the role of multidisciplinary training and equipment standardisation in optimising airway management.
Prof Sheila Nainan Myatra, Professor and Head of Anaesthesiology, Critical Care and Pain at Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India, argued that traditional algorithms designed for the operating theatre are insufficient when applied to ICU patients. She proposed appropriate updates and modifications and discussed the evidence supporting their validity, including improved recognition of PDAs, standardisation of escalation pathways, early use of advanced airway devices, and training for team-based responses.
Tracheostomy in patients requiring prolonged mechanical ventilation represents another area of airway management associated with significant risk. Multidisciplinary decision-making, appropriate timing, technique selection, management of specific patient groups, and decannulation protocols are all the focus of substantial research and guideline development. Prof Gianmaria Cammarota, Associate Professor, Department of Translational Medicine, Università degli Studi del Piemonte Orientale, outlined how the new ESAIC guidelines seek to clarify these major areas of risk and provide updated guidance for safer practice.
Airway complications are not solely technical in nature, but are also closely linked to human factors, including poor communication, lack of leadership and role clarity, and deficiencies in equipment management and availability. Structured training and team-based simulation can significantly improve performance and reduce the likelihood of error. Dr Andy Higgs, Consultant in Intensive Care Medicine and Anaesthesia, Warrington Teaching Hospitals, UK, presented evidence supporting the view that airway safety in the ICU should be approached as a systems issue rather than purely a technical skills problem. He discussed the importance of pre-intubation checklists, structured briefing and debriefing, clearly defined team roles, the evidence supporting video laryngoscopy as a first-line tool, standardisation of airway trolley contents across hospital sites, and the responsibility of institutions to provide simulation training for ICU teams.
Source: Euroanaesthesia 2026
Image Credit: iStock
