New Trends in Airway Management During Endoscopic Retrograde Cholangiopancreatography: A Narrative Review

Over time, endoscopic retrograde cholangiopancreatography (ERCP) evolved into the preferred method for both diagnosing and treating diseases of the biliary, pancreatic, and ampullary systems. Traditionally performed under "conscious" sedation, anesthesiological management during ERCP increasingly involves the use of general anesthesia (GA) due to the complexity of procedures and patient comorbidities. This narrative review aims to underscore the current absence of definitive evidence supporting a single airway management strategy during ERCP. In each section, we examine the strengths and limitations of various airway management strategies, including spontaneous breathing, endotracheal intubation, and newer techniques such as high-flow nasal oxygen (HFNO) and supraglottic airway devices (SGAs), tailored for endoscopic procedures. We explore and discuss the multifactorial determinants that influence clinical decision-making, including patient-specific risk factors, procedural complexity, resource availability, and potential complications. Any anesthesiological choice must guarantee the immobility of the patient and the versatility of the position and must be integrated with the preferences and skills of the endoscopist, the available means in the endoscopic suite, and the internal protocols. Spontaneous breathing with sedation may be appropriate for low-risk, short-duration procedures but carries risks of hypoventilation and aspiration, while GA with a device to manage airways improves procedural conditions and perioperative risks. Still, it is resource-intensive and may delay recovery. Transitions between different strategies are inherently fluid, reflecting the need for a flexible, patient-centered approach tailored to the specific clinical context. Rigorous future research is essential to establish evidence-based guidelines that enhance both safety and efficiency of airway management in this setting.