Difficult airway decoded: ultrasound insights, predictive tools, and extubation safety 

Encountering a difficult airway during induction can be extremely intimidating for the anaesthesiologist and a high-risk scenario for any patient. Predicting a difficult airway remains an imperfect science. Contemporary evidence shows that commonly used bedside assessments such as the modified Mallampati classification and thyromental distance fail to identify a substantial proportion of difficult airways when used in isolation. Large systematic reviews confirm that no single clinical test provides reliable predictive accuracy, reinforcing the need for multimodal or adjunctive approaches. (1)(2) These conventional bedside airway prediction scores were developed and validated primarily in the context of direct laryngoscopy. Now anaesthesiologists have access to a wide range of technology to support their assessment of the risk of a difficult airway. The use of ultrasound as an airway assessment tool has expanded substantially. Originally, it was used to confirm successful tracheal intubation. Now it can be used for real-time imaging of the airway from the mouth to the peripheral alveoli, and its advantages include being safe, quick, repeatable, portable, and widely available. (3) Videolaryngoscopy has been shown to improve patient outcomes, as it enables a more reliable examination than direct laryngoscopy. (4) However, despite the risks associated with encountering a difficult airway during intubation, the incidence of complications immediately after tracheal extubation may be higher than during tracheal intubation, yet it is significantly under-explored in the scientific literature. (5) 

In the symposium session “Difficult airway decoded: ultrasound insights, predictive tools, and extubation safety” three international experts will explore the principles of airway ultrasound assessment and how to operate ultrasound equipment effectively; understand the limitations and applicability of conventional airway prediction scores when using videolaryngoscopy; and recognise the pitfalls of difficult extubation, along with strategies to prevent or manage them. 

Dr. Michael Seltz Kristensen is a consultant anaesthesiologist at Copenhagen University Hospital, Rigshospitalet, Denmark, where he is head of development, research and clinical implementation. He is Chair of the International Liaison Committee of the Society for Airway Management (SAM) and has authored multiple publications on airway management and ultrasound, presenting on the topic globally. He is also President of the European Airway Management Society (EAMS). (6) He is among the most prolific researchers in airway ultrasound. This extensive experience will inform his presentation: “Difficult Airway Assessment: The Ultrasound Approach”. Through clearly highlighting how ultrasound can be used, he will demonstrate evidence of the real-time practical applications for ultrasound in predicting difficult intubation, confirming tracheal intubation and precisely locating the cricothyroid membrane, particularly in patients where palpation has a well-documented failure rate. (7)(8)(9) He will also discuss imitations of ultrasound airway assessment, including how success relies on the skill of the operator, individual patient factors, and the need for standardisation. 

Professor Dr. Jülide Ergil is an anaesthesiologist and intensivist with extensive clinical, academic, and leadership experience. She works at the Turkish Ministry of Health, Etlik City Hospital, Turkey. Her research includes airway management in challenging populations, videolaryngoscopy, supraglottic airway devices, and airway assessment in elderly patients. She is currently the Vice President of the Turkish Society of Anaesthesiology and Reanimation (TARD). (10) In her presentation “Difficult airway prediction scores: is there still any role in the video laryngoscope era?” Prof. Ergil will explore evidence whether videolaryngoscopy can eliminate the challenge of predicting a difficult airway or if traditional prediction scores retain some predictive value even if limited in accuracy. She will assess the limitations of videolaryngoscopy, how it can prove challenging in certain circumstances, and the value of enhanced and multimodal approaches to ensure safety. (11)(12) 

Evidence suggests that complication rates at extubation may exceed those at intubation, and that a disproportionate share of serious airway adverse events, including hypoxic brain injury and death, occur at or after extubation. Prof. Ellen O’Sullivan is a Consultant Anaesthesiologist at St James’s Hospital, Dublin, affiliated to Trinity College, Dublin, Ireland, where she is Director of the Fellowship in Advanced Airway Management and Simulation. She is Past President of the Difficult Airway Society (DAS) and Past President of the College of Anaesthesiologists of Ireland. Prof. O’Sullivan is a recognised expert in airway safety with direct involvement in major guidelines on extubation. She was a member of the ASA Task Force that produced the 2022 ASA Difficult Airway Guidelines. (13) Her presentation “Difficult extubation: the dark side of airway management” will cover established frameworks for risk stratification and safe management of extubation. She will explore why extubation is dangerous, how to identify an at-risk airway, structured extubation strategies, how to manage failures, and why human factors are important. She will draw on her vast experience and involvement in creating these guidelines, and what ongoing studies and emerging large-scale data may reveal about the true incidence and circumstances of severe extubation complications. (14)(15)(16) 

The symposium session “Difficult airway decoded: ultrasound insights, predictive tools, and extubation safety” will take place at the Euroanaesthesia Congress 2026 on Sunday, June 7 at 09:30–10:30 CEST in room ROTTERDAM A. 

References 

1. Wang Z, Jin Y, Zheng Y, Chen H, Feng J, Sun J. Evaluation of preoperative difficult airway prediction methods for adult patients without obvious airway abnormalities: a systematic review and meta-analysis. BMC Anesthesiol. 2024 Jul 17;24(1):242. doi: 10.1186/s12871-024-02627-1. PMID: 39020308; PMCID: PMC11253413. https://link.springer.com/article/10.1186/s12871-024-02627-1 

2. Roth D, Pace NL, Lee A, Hovhannisyan K, Warenits AM, Arrich J, Herkner H. Airway physical examination tests for detection of difficult airway management in apparently normal adult patients. Cochrane Database of Systematic Reviews 2018, Issue 5. Art. No.: CD008874. DOI: 10.1002/14651858.CD008874.pub2. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008874.pub2/full 

3. Kristensen MS. Ultrasonography in the management of the airway. Acta Anaesthesiol Scand. 2011 Nov;55(10):1155-73. doi: 10.1111/j.1399-6576.2011.02518.x. Epub 2011 Sep 7. PMID: 22092121. https://onlinelibrary.wiley.com/doi/10.1111/j.1399-6576.2011.02518.x 

4. Saul SA, Ward PA, McNarry AF. Airway Management: The Current Role of Videolaryngoscopy. J Pers Med. 2023 Aug 29;13(9):1327. doi: 10.3390/jpm13091327. PMID: 37763095; PMCID: PMC10532647. https://www.mdpi.com/2075-4426/13/9/1327  

5. Chaverra Kornerup S, Parotto M. Extubation-Related Complications. Int Anesthesiol Clin. 2024 Oct 1;62(4):82-90. doi: 10.1097/AIA.0000000000000454. Epub 2024 Sep 5. PMID: 39233574. https://journals.lww.com/anesthesiaclinics/abstract/2024/06240/extubation_related_complications.9.aspx 

6. https://www.eamshq.net/organization/board/4181383148/michael-seltz-kristensen-md-feams/ 

7. KRISTENSEN, M.S. (2011), Ultrasonography and the airway. Acta Anaesthesiol Scand, 55: 1155-1173. https://doi.org/10.1111/j.1399-6576.2011.02518.x  

8. Kristensen MS, Teoh WH, Graumann O, Laursen CB. Ultrasonography for clinical decision-making and intervention in airway management: from the mouth to the lungs and pleurae. Insights Imaging. 2014 Apr;5(2):253-79. doi: 10.1007/s13244-014-0309-5. Epub 2014 Feb 12. PMID: 24519789; PMCID: PMC3999368. https://link.springer.com/article/10.1007/s13244-014-0309-5 

9. M. S. Kristensen, W. H. Teoh, S. S. Rudolph, M. F. Tvede, R. Hesselfeldt, J. Børglum, T. Lohse, L. N. Hansen, Structured approach to ultrasound-guided identification of the cricothyroid membrane: a randomized comparison with the palpation method in the morbidly obese, BJA: British Journal of Anaesthesia, Volume 114, Issue 6, June 2015, Pages 1003–1004, https://doi.org/10.1093/bja/aev123 

10. https://esaic2026.abstractserver.com/program/#/details/persons/763  

11. Sasu PB, Pansa JI, Stadlhofer R, et al. Nasendoscopy to Predict Difficult Videolaryngoscopy: A Multivariable Model Development Study. J Clin Med. 2023;12(10):3433. Published 2023 May 12. doi:10.3390/jcm12103433 https://www.mdpi.com/2077-0383/12/10/3433 

12. Aziz MF, Bayman EO, Van Tienderen MM, Todd MM; StAGE Investigator Group, Brambrink AM. Predictors of difficult videolaryngoscopy with GlideScope® or C-MAC® with D-blade: secondary analysis from a large comparative videolaryngoscopy trial. Br J Anaesth. 2016;117(1):118-123. doi:10.1093/bja/aew128 https://www.bjanaesthesia.org/article/S0007-0912(17)31408-3/fulltext 

13. https://ebpom.org/faculty/ellen-osullivan/   

14. Membership of the Difficult Airway Society Extubation Guidelines Group: M. Popat (Chairman), Mitchell, V., Dravid, R., Patel, A., Swampillai, C. and Higgs, A. (2012), Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia, 67: 318-340. https://doi.org/10.1111/j.1365-2044.2012.07075.x 

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 

16. https://dev-multi-sponsor-trials.xogene.com/trials/6442930