Airway management in the Intensive Care Unit (ICU): strategies for high-risk patients 

Airway management carries some of the highest risk in the ICU. Unlike the controlled operating theatre environment, critically ill patients present significant physiological challenges. At least one in four major in-hospital airway events occur in the ICU, with a high likelihood of serious injury or death. (1) Recurring gaps in care include poor identification of at-risk patients, inadequate planning, insufficient staffing and equipment, delayed event recognition, and failed rescue due to capnography misinterpretation. The Fourth National Audit Project (NAP4) concluded that most cases were avoidable with correct environmental management and training. (2) More recently, the International Observational Study to Understand the Impact and Best Practices of Airway Management in Critically Ill Patients (INTUBE) study subsequently found that most patients experienced at least one peri-intubation adverse event, with cardiovascular instability the most frequent complication. (3) From this evidence has emerged the concept of the “physiologically difficult airway” (PDA), a framework distinguishing patients whose intubation risk stems from anticipated physiology rather than anatomy. (4)(5) 

In the symposium session “Airway management in the Intensive Care Unit (ICU): strategies for high-risk patients”, three international experts will explore the latest frameworks for assessing and managing difficult airways in critically ill patients, present the new ESAIC guidelines on tracheostomy, and highlight the role of multidisciplinary training and equipment standardisation in optimising airway management.  

Prof. Sheila Nainan Myatra is Professor and Head of Anaesthesiology, Critical Care and Pain at Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai in India. She is one of the most widely cited researchers in the field of ICU airway management globally, with particular expertise in difficult airway classification, physiological optimisation before intubation, preoxygenation strategies, and the development of ICU-specific algorithms. She is Chair of the ICM Committee of the WFSA, Past President of the Indian Society of Critical Care Medicine (ISCCM) and All India Difficult Airway Association (AIDAA). (6) She was the lead author of The All-India Difficult Airway Association 2016 guidelines for tracheal intubation in the Intensive Care Unit that introduced a stepwise plan for the safe management of the airway in critically ill patients. (7) In her presentation “Difficult airway management in the ICU: redefining classification and algorithm implementation”, she will argue that traditional algorithms designed for the operating theatre are insufficient when applied to ICU patients. (8) She will suggest appropriate updates and modifications and detail the evidence that highlights their validity, including the appropriate recognition of PDAs, standardisation of escalation pathways, early use of advanced devices, and training for team-based responses.  

Tracheostomy in patients requiring prolonged mechanical ventilation represents another area of airway management that carries acute risk for the patient. Multidisciplinary decision-making, correct timing, technique selection, specific patient populations, and decannulation protocols are the focus of a substantial body of research and guideline development. In his presentation “Tracheostomy in Critically Ill Patients — The ESAIC Guidelines”, Prof. Dr. Gianmaria Cammarota will highlight how new ESAIC guidelines propose to clarify these key areas of risk and offer new insights for safe procedures. Prof. Cammarota is an associate professor at the Department of Translational Medicine, Università degli Studi del Piemonte Orientale, and a physician in anaesthesiology and intensive care at Azienda Ospedaliero-Universitaria Maggiore della Carità. He is a member of the Airway and Mechanical Ventilation subcommittee of the ESAIC, an active member of the PLUG (Perioperative Lung Ultrasound Group), and a scientific coordinator of the Lung Ultrasound Course by SIAARTI. (9)  

Airway complications are not just technically difficult, but include human factors issues such as poor communication, lack of leadership and role clarity, and equipment management and availability. Structured training and team-based simulation can significantly improve performance and reduce the chances of error. (10) In the final presentation of this session “Training, team dynamics, and equipment readiness: the pillars of airway safety in critical care”, Dr. Andy Higgs will show the evidence for treating airway safety in the ICU as a systems problem, not merely a technical skills problem. He will cover the importance of pre-intubation checklists, structured briefing and debriefing, the benefit of defining team roles, the evidence for video laryngoscopy as a first-line tool, standardisation of airway trolley contents across hospital sites, and the duty of institutions to provide simulation training for ICU teams. (11)(12) Dr. Higgs is a Consultant in ICM and Anaesthesia at Warrington Teaching Hospitals, Cheshire, UK, and holds the title of DAS Professor of Anaesthesia and Airway Management. He is a former Honorary Treasurer of the Difficult Airway Society (DAS), founding executive of the Safe Airway Society (SAS), and an executive of the Project for Universal Management of the Airway (PUMA). (13) He is also a key author in an extensive body of relevant publications and guidelines. (14)(15) 

The symposium session “Airway management in the Intensive Care Unit (ICU): strategies for high-risk patients” will take place at the Euroanaesthesia Congress 2026 on Monday, June 8 at 15:00 – 16:00 CEST in room DELTA B. 

References 

1. Schwartz, David E. MD; Matthay, Michael A. MD; Cohen, Neal H. MD. Death and Other Complications of Emergency Airway Management in Critically Ill Adults : A Prospective Investigation of 297 Tracheal Intubations. Anesthesiology 82(2):p 367-376, February 1, 1995. | DOI: 10.1097/00000542-199502000-00007 https://journals.lww.com/anesthesiology/fulltext/1995/02000/death_and_other_complications_of_emergency_airway.7.aspx 

2. Cook TM, Woodall N, Harper J, Benger J; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth. 2011 May;106(5):632-42. doi: 10.1093/bja/aer059. Epub 2011 Mar 29. PMID: 21447489. https://www.bjanaesthesia.org/article/S0007-0912(17)33210-5/fulltext 

3. Russotto V, Myatra SN, Laffey JG, et al. Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries. JAMA. 2021;325(12):1164–1172. doi:10.1001/jama.2021.1727 https://jamanetwork.com/journals/jama/fullarticle/2777715 

4. Myatra SN, Divatia JV, Brewster DJ. The physiologically difficult airway: an emerging concept. Curr Opin Anaesthesiol. 2022 Apr 1;35(2):115-121. doi: 10.1097/ACO.0000000000001102. PMID: 35165233. https://journals.lww.com/co-anesthesiology/abstract/2022/04000/the_physiologically_difficult_airway__an_emerging.3.aspx 

5. Karamchandani, K., Nasa, P., Jarzebowski, M. et al. Tracheal intubation in critically ill adults with a physiologically difficult airway. An international Delphi study. Intensive Care Med 50, 1563–1579 (2024). https://doi.org/10.1007/s00134-024-07578-2  

6. https://esaic2026.abstractserver.com/program/#/details/persons/177  

7. Myatra SN, Ahmed SM, Kundra P, Garg R, Ramkumar V, Patwa A, Shah A, Raveendra US, Shetty SR, Doctor JR, Pawar DK, Ramesh S, Das S, Divatia JV. The All India Difficult Airway Association 2016 guidelines for tracheal intubation in the Intensive Care Unit. Indian J Anaesth. 2016 Dec;60(12):922-930. doi: 10.4103/0019-5049.195485. PMID: 28003694; PMCID: PMC5168895. https://journals.lww.com/ijaweb/fulltext/2016/60120/the_all_india_difficult_airway_association_2016.7.aspx 

8. Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM; Difficult Airway Society; Intensive Care Society; Faculty of Intensive Care Medicine; Royal College of Anaesthetists. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth. 2018 Feb;120(2):323-352. doi: 10.1016/j.bja.2017.10.021. Epub 2017 Nov 26. PMID: 29406182. https://www.bjanaesthesia.org/article/S0007-0912(17)54060-X/fulltext  

9. https://sciprofiles.com/profile/1400548  

10. Ahmad I, El-Boghdadly K, Iliff H, Dua G, Higgs A, Huntington M, Mir F, Nouraei SAR, O’Sullivan EP, Patel A, Rivett K, McNarry AF. Difficult Airway Society 2025 guidelines for management of unanticipated difficult tracheal intubation in adults. Br J Anaesth. 2026 Jan;136(1):283-307. doi: 10.1016/j.bja.2025.10.006. Epub 2025 Nov 7. PMID: 41203471. https://www.bjanaesthesia.org/article/S0007-0912(25)00693-2/fulltext  

11. De Jong A, Myatra SN, Roca O, Jaber S. How to improve intubation in the intensive care unit. Update on knowledge and devices. Intensive Care Med. 2022 Oct;48(10):1287-1298. doi: 10.1007/s00134-022-06849-0. Epub 2022 Aug 20. PMID: 35986748; PMCID: PMC9391631. https://link.springer.com/article/10.1007/s00134-022-06849-0 

12. De Jong A, Jaber S, Myatra SN. Best practices in airway management in critically ill adults. Intensive Care Med. 2025 Dec;51(12):2414-2417. doi: 10.1007/s00134-025-08181-9. Epub 2025 Nov 3. PMID: 41182388. https://link.springer.com/article/10.1007/s00134-025-08181-9  

13. https://www.researchgate.net/profile/Andy-Higgs-2 

14. Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM; Difficult Airway Society; Intensive Care Society; Faculty of Intensive Care Medicine; Royal College of Anaesthetists. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth. 2018 Feb;120(2):323-352. doi: 10.1016/j.bja.2017.10.021. Epub 2017 Nov 26. PMID: 29406182. https://www.bjanaesthesia.org/article/S0007-0912(17)54060-X/fulltext 

15. Ahmad I, El-Boghdadly K, Iliff H, Dua G, Higgs A, Huntington M, Mir F, Nouraei SAR, O’Sullivan EP, Patel A, Rivett K, McNarry AF. Difficult Airway Society 2025 guidelines for management of unanticipated difficult tracheal intubation in adults. Br J Anaesth. 2026 Jan;136(1):283-307. doi: 10.1016/j.bja.2025.10.006. Epub 2025 Nov 7. PMID: 41203471. https://www.bjanaesthesia.org/article/S0007-0912(25)00693-2/fulltext