Rethinking the Difficult Airway: Physiology, Evidence, and Education

Flora Liu, MD

Traditionally, difficult airway management has focused on anatomy. The session, “The Physiologically Difficult Airway: Turning New Evidence into Widespread Practice,” held on Friday, May 1, at the 2026 Annual Meeting, presented by IARS and SOCCA, challenged that paradigm by highlighting the physiologically difficult airway encountered in the intensive care unit that is associated with high morbidity and mortality. Moderated by Kunal Karamchandani, MD, professor in the Department of Anesthesiology and Pain Management at the University of Texas Southwestern Medical Center, the expert speakers reviewed the evidence on physiologic difficult airway, associated outcome, preoxygenation strategies, induction agent selection to prevent of cardiovascular collapse, and concluded by addressing the urgent need for cross‑disciplinary education to translate this knowledge into routine clinical practice.

Ravindra Alok Gupta, MD, associate professor of anesthesiology and critical care at Northwestern University Feinberg School of Medicine, opened the session with “Intubating Critically Ill Patients: The Outcomes Should Scare You.” Dr. Gupta defined the physiologically difficult airway as derangements in physiology that place patients at high risk of cardiovascular collapse upon the transition to positive pressure ventilation. These include conditions such as severe hypoxemic respiratory failure, obesity, pregnancy, elevated intracranial pressure, right ventricular dysfunction, and hemodynamic instability.

Intubation in the ICU carries a substantially higher risk than in the operating room or emergency department. Data from the INTUBE study demonstrated that 45.2% of critically ill patients experienced at least one major peri‑intubation adverse event, most commonly cardiovascular instability (42.6%), followed by hypoxemia (9.3%) and cardiac arrest (3.1%). Beyond patient factors, ICU intubations are complicated by environmental constraints, unfamiliar team dynamics, and logistical challenges. Dr. Gupta emphasized that structured approaches could mitigate risk such as a preintubation checklist involving anesthesia providers, the ICU team, bedside nursing staff, and a postintubation debrief. All of which takes less than five minutes to complete and has been shown to reduce adverse periintubation events.

Next, Craig S. Jabaley, MD, FCCM, associate professor of anesthesiology at Emory University School of Medicine and associate director of the Emory Critical Care Center, presented “Challenging Old Practices with New Evidence: How to Mitigate Hypoxemia and Hemodynamic Collapse.” Dr. Jabaley reviewed ventilation–perfusion mismatch and shunt physiology being the major reasons for hypoxia. As shunt physiology does not respond to increases in FiO₂, the application of positive end‑expiratory pressure during preoxygenation is critical.

The OPTINIV trial demonstrated that noninvasive ventilation provided superior preoxygenation compared with high‑flow nasal cannula and conventional oxygen therapy. Dr. Jabaley also returned to INTUBE data, which showed a clear association between increased intubation attempts and mortality, underscoring the importance of first‑pass success.

Avoiding cardiovascular collapse during induction is critical. Among variables associated with adverse outcomes in the INTUBE cohort, the most modifiable factor was the use of propofol. Dr. Jabaley discussed the RSI trial published in 2025, which randomized 2,365 critically ill patients to ketamine or etomidate for rapid sequence intubation and found no difference in 28‑day mortality. However, ketamine was associated with a slightly higher incidence of hemodynamic instability. Further comprehensive guide can be found in Tracheal Intubation in Critically Ill Adults with a Physiologically Difficult Airway, developed by the Society of Critical Care Anesthesiologists (SOCCA) Physiologically Difficult Airway Task Force.

Understanding the physiologically difficult airway is essential, but teaching it is equally crucial. Mary Jarzebowski, MD, medical director of the cardiovascular intensive care unit at Henry Ford Jackson Hospital, closed the session with “‘But It’s Not on the Test’: Advancing Physiologically Difficult Airway Management Through Collaborative Education.” Dr. Jarzebowski highlighted that multiple specialties, including anesthesiology, emergency medicine, pulmonary critical care, and surgery, manage the physiologically difficult airway, yet none clearly define physiologic difficult airway competencies within their certification requirements.

She presented work on CASCADE: Curriculum for Airway Skills in Critically Ill Adults A Delphi Evaluation, which engaged a diverse group of clinical expert educators to define core competencies for airway management in critically ill patients. Consensus domains included educational scope, core versus desirable skills, teaching methods, patient preparation and optimization, patient‑specific risk factors, and competency assessment. This work, currently submitted for publication, represents an important step toward standardized, cross‑specialty training adaptable to diverse practice settings and resource levels.