Emergency medicine updates: The physiologically difficult airway

Area of Science:

• Emergency Medicine
• Critical Care
• Anesthesiology

Background:

• Airway management is crucial for emergency clinicians, but physiologic challenges, termed the physiologically difficult airway, are often overlooked.
• These physiologic challenges can lead to decompensation during airway procedures, independent of anatomic difficulties.

Purpose of the Study:

• To review evidence-based updates on managing the physiologically difficult airway for emergency clinicians.
• To highlight key phenotypes and their associated management strategies.

Main Methods:

• Literature review of recent evidence concerning the physiologically difficult airway.
• Analysis of peri-intubation complications and their drivers in emergency settings.

Main Results:

• Physiologic instability, not just anatomy, drives peri-intubation complications.
• Key phenotypes include hypotension, hypoxemia, metabolic acidemia, and right ventricular dysfunction, each requiring specific interventions.
• Hypotension predicts peri-intubation cardiac arrest; hypoxemia management benefits from noninvasive ventilation and high-flow nasal oxygen.

Conclusions:

• Recent evidence enhances the understanding and management of physiologically difficult airways.
• Targeted, physiology-driven strategies are essential for risk mitigation and improving patient care.
• Maximizing first-attempt success and preparing for rapid deterioration are critical across all phenotypes.