Difficult airway management is a core competency for any anaesthesiologist and can often mean the difference between life and death. Among the most complex and high-risk scenarios is the bloody airway, where active bleeding significantly impairs visibility and complicates even standard difficult airway techniques. Failure to control bleeding in the airway is a major contributor to airway-related mortality.
In a session at Euroanaesthesisa 2025, Dr Michael Seltz Kristensen, a leading airway management expert based in Copenhagen, Denmark, explored evidence-based strategies for managing this challenge. With a focus on practical solutions and clinical insights, he shared key recommendations drawn from research and real-world experience.
Video laryngoscopy and flexible optical (fibreoptic) laryngoscopy are widely used in difficult airway scenarios. However, their effectiveness can be drastically reduced when the field of view is compromised by blood. Dr Kristensen highlighted the limitations of these tools in such situations and introduced alternative approaches that can still provide a secure airway when visibility is lost.
A major theme of his lecture was adaptability. He stressed that when significant bleeding is anticipated, or already present, and conventional techniques are likely to fail, clinicians must be prepared to deviate from routine practice. Blood loss not only compromises airway visualisation but may also precipitate cardiovascular instability, making rapid decision-making and comprehensive planning critical.
Drawing on his landmark publication, “Managing and securing the bleeding upper airway: a narrative review,” co-authored with Dr Barry MacGuire, Dr Kristensen outlined techniques that can establish a definitive airway despite severely impaired visibility. These include flexible scope-guided intubation through a supraglottic airway device, cricothyroidotomy or tracheotomy, retrograde intubation, blind nasal or oral-digital intubation and light-guided and ultrasound-assisted techniques
He presented a structured algorithm for managing airway bleeding, which involves assessing the source and severity of bleeding, predicting intubation success via direct laryngoscopy, and evaluating the feasibility of front-of-neck access. In cases where traditional intubation is deemed feasible, Dr Kristensen recommended identifying the cricothyroid membrane in advance and proceeding with rapid sequence induction. For high-risk situations, he advocated for an awake approach using alternative techniques.
Dr Kristensen underscored that successful management of the bleeding airway is not just about technical proficiency. It also requires excellent non-technical skills. Team communication, clear role allocation, and calm, coordinated responses under pressure are essential components of good airway management in crisis situations.
Source and Image Credit: Euroanaesthesia 2025
