Emergency Airway Management: From Devices to Systems

Introduction

Jeremy: Welcome back to the TIME Podcast. It's another glorious day on the ski slopes. I’m Jeremy

Hamish: And I’m Hamish. Today we’re tackling something that every emergency physician, intensivist, and retrieval clinician does—but that we probably don’t stop and re-examine often enough. Emergency airway management

Jeremy: Because if we’re honest, this is still one of the highest-risk things we do in acute care. And despite all the kit, all the training, and all the confidence we build over time—patients still come to harm around intubation

Hamish: What’s interesting is that over the last three to five years, the biggest changes haven’t really been about shiny new devices. They’ve been about systems. Governance. Human factors. And a shift away from heroic individual airway skills toward team-based reliability

Jeremy: Exactly. So today we’re going to unpack what’s genuinely changed, what the evidence actually says, and how this should influence what we do on our next sick airway—whether that’s in ED, ICU, or on the end of a retrieval call

The Contemporary Risk Landscape

Hamish: Let’s start by being really clear about the problem. Emergency airway management remains dangerous. Not theoretically—actually dangerous

Jeremy: Absolutely. When you look at contemporary reviews, complication rates during ED and ICU intubations are still sitting around forty percent. That includes hypoxaemia, hypotension, arrhythmias, and in some cases cardiac arrest.

Hamish: And those complications aren’t benign. We now have strong associations between peri-intubation hypotension or hypoxaemia and downstream morbidity and mortality. This isn’t just a blip on the monitor

Jeremy: The key point is that these patients aren’t elective anaesthetic patients. They’re hypoxic, acidotic, shocked. Often there’s no time for optimisation, and airway assessment is limited at best

Hamish: Add to that the human factors—crowded resus bays, noise, variable team composition, time pressure—and it’s not surprising that things go wrong

Jeremy: Which is why the recent shift has been less about finding a better laryngoscope, and more about asking: how do we reduce preventable harm in a system that’s inherently hostile to perfect airway management?

Standardisation & Governance

Hamish: This is where PG56 really matters. The 2025 ANZCA Guideline on Equipment to Manage Difficult Airways is a big deal—not because it’s new information, but because of where it applies

Jeremy: Exactly. This isn’t just an operating theatre document anymore. PG56 explicitly applies to emergency departments and ICUs

Hamish: And it reframes airway management as a hospital-wide safety system. Standardised difficult airway trolleys. Core equipment that must be present. Capnography. Oxygenation adjuncts. And importantly—named airway leads

Jeremy: That’s a subtle but profound shift. It moves airway safety out of the realm of individual clinician preference and into governance, audit, and accountability

Hamish: And it aligns really nicely with tools like the New South Wales Emergency Care Institute Airway Management Clinical Tool, which gives ED-specific checklists, role allocation, and preparation prompts

Jeremy: Or the Critical Care Airway Management—or CCAM—framework, which integrates Difficult Airway Society, or DAS, and Vortex principles and puts human factors front and centre

Hamish: The common theme here is consistency. When you’re stressed, tired, or facing a crashing patient, you fall back on systems—not memory

Video Laryngoscopy: Evidence, not Dogma

Jeremy: Let’s talk videolaryngoscopy, because this is probably the most visible practice change

Hamish: And the evidence base has matured. The DEVICE trial in 2023 was pivotal—randomising critically ill adults in EDs and ICUs to video versus direct laryngoscopy on the first attempt

Jeremy: First-pass success was significantly higher with video—eighty-five percent versus seventy percent. That’s not a marginal gain

Hamish: But the nuance matters. Meta-analyses since then show heterogeneity. Operator experience matters. Patient risk matters. And VL isn’t magic—it doesn’t abolish hypoxaemia or hypotension

Jeremy: Which is why PG56’s recommendation is sensible: DATs should include both Macintosh-style and hyperangulated video blades

Hamish: And DL isn’t dead. It remains a critical backup skill—especially when video fails, fogs, or blood turns your screen into abstract art

Jeremy: But for many critically ill ED and ICU patients, VL-first is now a defensible default

Oxygenation: Shifting the goalposts

Hamish: One of the most important conceptual shifts has been around oxygenation. We’ve stopped pretending we can guarantee a long safe apnoea

Jeremy: Exactly. The goal now is harm reduction—reducing the depth and duration of hypoxaemia

Hamish: HFNO has become more available, and in selected high-risk patients it can improve minimum saturations during induction

Jeremy: But the evidence is mixed. Systematic reviews show heterogeneous results, and well-executed low-flow nasal apnoeic oxygenation may provide similar benefit in many settings

Hamish: PG56’s framing is spot on: HFNO should be available, but not mandatory. It’s an adjunct, not a solution

Jeremy: What matters more is structured preoxygenation—NIV where appropriate, upright positioning, routine apnoeic oxygenation—and making this part of the team brief

Adjuncts, Rescue, and the Reality of Failure

Hamish: Let’s talk about failure—because one of the most important shifts in modern airway management is that failure is now explicitly anticipated, rather than implicitly denied

Jeremy: Exactly. Contemporary airway frameworks, including PG56, are very clear on this point. They assume that upper-airway techniques may fail, and they emphasise the need for early transition to definitive rescue when oxygenation cannot be achieved

Hamish: You see this philosophy reflected even in how we think about adjuncts. Take bougies, for example. Evidence suggests bougie use is associated with higher first-pass success in emergency department intubations, particularly in difficult airways

Jeremy: But PG56 is careful here—it doesn’t treat adjuncts as generic solutions. Technique has to be matched to device geometry. Bougies often pair well with Macintosh-style blades, including Macintosh-geometry videolaryngoscopy, whereas hyperangulated blades usually require a shaped stylet

Hamish: The same systems-based thinking applies to supraglottic airway devices. Second-generation SADs are now mandated on difficult airway trolleys, not as optional rescue devices, but as core components of failed airway management

Jeremy: And in selected circumstances, they’re not just a bridge—they may be the most appropriate means of oxygenation while further plans are made

Hamish: But the most important—and most explicit—area of alignment across PG56, DAS, Vortex, and CCAM is what happens when oxygenation cannot be achieved

Jeremy: This is where PG56 uses very precise language. It refers to Emergency Front-of-Neck Access, or eFONA. That terminology is deliberate

Hamish: eFONA describes the establishment of a definitive airway via the front of the neck when attempts at oxygenation using facemask ventilation, supraglottic airway devices, and tracheal intubation have failed

Jeremy: And PG56 is unambiguous: when oxygenation cannot be achieved, there must be prompt progression to front-of-neck access, rather than repeated upper-airway attempts

Hamish: For most clinicians, this means a scalpel-based cricothyroidotomy, typically using a scalpel–bougie–tube technique, with equipment immediately available on the difficult airway trolley

Jeremy: Crucially, PG56 emphasises preparation and priming. That means early identification of risk, clear declaration of difficulty, role allocation, and readiness for eFONA before critical hypoxaemia develops

Hamish: This is a major cultural shift. Front-of-neck access is no longer framed as a last-ditch option after prolonged failure—it is an expected, rehearsed component of a failed airway pathway

Jeremy: And when teams hesitate, it’s rarely because they don’t know how to perform eFONA. It’s because the decision point wasn’t recognised or acted on early enough

Hamish: PG56 reframes that decision as a systems issue, not an individual failure. When eFONA occurs promptly, it reflects adherence to a safety framework—not loss of control

Jeremy: That framing matters. Because in emergency airway management, delay is often more dangerous than the procedure itself

Systems Evidence

Jeremy: We’ve talked a lot about devices, oxygenation strategies, and algorithms. But one of the most compelling arguments for systems-based airway management doesn’t come from randomised trials at all—it comes from large observational data

Hamish: Exactly. Because registries show us what actually happens in real emergency departments and ICUs, not what happens under idealised study conditions

Jeremy: The INTUBE study is probably the most frequently cited example. It was a large, international, prospective observational study of more than 2,900 tracheal intubations in ICUs across 29 countries

Hamish: And the headline finding was confronting. Complications were common—severe hypoxaemia, cardiovascular collapse, arrhythmias—and they weren’t rare edge cases

Jeremy: What’s really important, though, is what predicted harm. It wasn’t the patient diagnosis alone. One of the strongest and most consistent associations was multiple intubation attempts

Hamish: Every additional attempt increased the risk of major adverse events. That finding has been reproduced across multiple datasets, in adults and in children

Jeremy: Which immediately reframes airway safety as a systems issue. If outcomes deteriorate with repeated attempts, then the system’s job is to maximise first-pass success and to recognise early when the current strategy isn’t working

Hamish: And INTUBE also showed substantial variability between centres—far more than could be explained by case mix alone.

Jeremy: That’s the key insight. When outcomes vary widely between hospitals caring for similar patients, it points toward differences in preparation, equipment standardisation, team training, and escalation culture

Hamish: This pattern is echoed in UK and European airway registries, where centres with structured airway bundles, clear attempt limits, and early escalation pathways tend to have fewer catastrophic complications

Jeremy: It’s also consistent with paediatric data. NEAR4KIDS and the Paediatric Difficult Intubation registry show the same signal—multiple attempts strongly predict desaturation and airway-related adverse events

Hamish: Across all of these datasets, the message is remarkably consistent. The things that matter most are not subtle technical preferences. They’re big, boring, system-level factors

Jeremy: Preparation. Role allocation. Standardised equipment. Shared mental models. Clear thresholds for escalation

Hamish: This is why guidelines like PG56 matter so much. They don’t tell you how to intubate—they ensure the system reliably supports safe decision-making when things start to go wrong

Jeremy: And this is also where quality improvement comes in. Registries aren’t just about reporting bad outcomes—they’re about identifying patterns of risk that clinicians can’t see in single cases

Hamish: For example, recognising that hypotension before induction, inadequate preoxygenation, or more than two attempts dramatically increases risk allows systems to redesign workflows around those inflection points

Jeremy: That’s how airway management moves from being reactive to proactive

Hamish: And importantly, these data challenge the idea that airway complications are inevitable in the critically ill. They’re not. Many are predictable, and therefore preventable, at a systems level

Jeremy: Which brings us back to the central theme of this episode. The strongest evidence we have doesn’t argue for a better laryngoscope. It argues for better-designed airway systems

Hamish: Systems that reduce variability, support early recognition of failure, and make the safest next step the easiest one to take under pressure

Paediatrics and Special Populations

Hamish: Let's spend some time on paediatrics, because paediatric airway management really deserves to be thought about separately

Jeremy: Absolutely. Children make up a smaller proportion of emergency intubations, but the risk profile is completely different—and often underestimated

Hamish: Large registry data make that pretty clear. The NEAR4KIDS registry shows that paediatric emergency intubation is associated with substantial rates of desaturation and other clinically important adverse events

Jeremy: And one of the strongest predictors of harm is repeated attempts. That finding is remarkably consistent. You see it again in the Paediatric Difficult Intubation registry—multiple attempts correlate strongly with airway-related complications

Hamish: Which reframes paediatric airway safety as a systems problem, not a technical one. This isn’t about individual finesse. It’s about first-pass success, preparation, and escalation

Jeremy: That systems framing is reflected very explicitly in PG56. The guideline doesn’t treat paediatrics as an afterthought—it incorporates paediatric airway management directly

Hamish: Including the recommendation for dedicated paediatric difficult airway trolleys, stocked across neonatal, infant, and paediatric sizes, and standardised within institutions.

Jeremy: Because paediatric airway crises are unforgiving of improvisation. You don’t want to be mentally converting sizes, hunting for equipment, or adapting adult setups under pressure

Hamish: Predictable layout, correct sizing, and clear escalation pathways are what make safe performance possible when things deteriorate quickly

Jeremy: Hypoxaemia remains the most common peri-intubation adverse event in children

Hamish: And the evidence base is evolving. A multicentre randomised trial published in The Lancet Respiratory Medicine demonstrated reduced hypoxaemia during paediatric emergency and ICU intubation when nasal high-flow oxygen was used during apnoea

Jeremy: But the effect sizes were modest and context-dependent, which is an important nuance

Hamish: Exactly. The take-home isn’t that HFNO is a magic solution. It’s that oxygenation should be treated as a bundle—optimised preoxygenation, routine apnoeic oxygenation at least with low-flow nasal oxygen, and strict limitation of attempts

Jeremy: That’s very consistent with PG56, which supports HFNO as an available adjunct, not a universally superior strategy

Hamish: Paediatric videolaryngoscopy is another area where evidence is still emerging

Jeremy: But PG56 takes a readiness-based approach here as well—supporting availability of appropriately sized videolaryngoscopes and second-generation supraglottic airway devices

Hamish: In practice, VL is often valuable in paediatric airways not just for visualisation, but for shared supervision, teaching, and structured escalation when things aren’t going smoothly

Jeremy: And second-generation SADs remain critical rescue devices, particularly when oxygenation is the immediate priority

Hamish: The Difficult Airway Society’s paediatric guidelines reinforce all of this—age-specific algorithms, explicit planning, early help-seeking, and strict attempt limitation

Jeremy: Paediatric eFONA is rare, but the consequences of delay are catastrophic. That’s why the emphasis is on rehearsal and simulation, even though most clinicians will never perform it in real life

Hamish: The goal is cognitive readiness, not frequency

Jeremy: What’s interesting is how much this overlaps with other special populations

Hamish: Exactly. Obese patients, obstetric patients, and those with significant cardiopulmonary disease share many of the same challenges as children—limited physiological reserve and poor tolerance of repeated attempts

Jeremy: Across all of these groups, modern practice converges on the same principles: videolaryngoscopy-first strategies, optimised positioning, structured oxygenation, strict attempt limitation, and early priming for neck rescue

Hamish: It’s a physiology-first approach, rather than an anatomy-only mindset

Jeremy: And once again, it reinforces the core theme of this episode—safe airway management is a systems problem, not a test of individual bravado

Jeremy: When you look ahead over the next few years, what’s striking is that emergency airway management probably isn’t heading toward disruption—it’s heading toward maturity

Hamish: Exactly. The big changes are unlikely to come from brand-new devices. Instead, we’re seeing progressive refinement of airway systems—how equipment, teams, and governance fit together under pressure

Jeremy: Videolaryngoscopy is a good example. It’s very likely to become the de facto first-line approach across EDs and ICUs—not because it’s perfect, but because it supports first-pass success, shared visualisation, and supervision

Hamish: But that doesn’t mean direct laryngoscopy disappears. If anything, DL becomes more clearly framed as a core backup and rescue skill—and something we’ll need to protect deliberately against skill decay

Jeremy: Oxygenation is heading the same way. We’re moving toward protocolised oxygenation bundles embedded into airway checklists—focusing on preparation, positioning, and strict attempt limitation

Hamish: HFNO will still have an important role, but its use is likely to become more context-specific rather than universal. The emphasis stays on preventing hypoxaemia, not on faith in any single technology

Jeremy: At a system level, airway governance is going to matter more and more. PG56-aligned structures—airway leads, standardised equipment, training, and audit—are likely to become baseline expectations rather than aspirational goals

Hamish: And as those systems mature, we should see less variability between EDs, ICUs, theatres, and retrieval environments. That consistency is a safety feature in itself

Jeremy: Airway registries and quality improvement programs will probably play a larger role too—helping identify high-risk patterns and guiding data-informed redesign

Hamish: Education is also shifting. Less focus on isolated technical skills, and more emphasis on non-technical skills, multidisciplinary simulation, and rehearsal of rare but catastrophic events—like paediatric CICO and emergency front-of-neck access

Jeremy: Taken together, the direction of travel is pretty clear. The future of emergency airway management is about reliability, consistency, and system design—not novelty

Conclusion

Hamish: So where does that leave us as specialist clinicians?

Jeremy: Probably with a slightly uncomfortable truth. Emergency airway management has entered a phase of relative technical maturity. Most of the tools we need are already available. And yet adverse events remain common. Which tells us something important: outcomes are determined less by the device we choose, and more by how reliably our systems function when things get difficult

Hamish: The most meaningful advances in airway safety over the past decade haven’t been technical breakthroughs. They’ve been systems-level changes—standardised equipment, structured preparation and oxygenation, strict limitation of attempts, early escalation, and rehearsed rescue pathways

Jeremy: Those principles are now embedded in contemporary guidelines and reinforced by real-world registry data across both adult and paediatric populations

Hamish: For emergency physicians, intensivists, anaesthetists, and retrieval clinicians, excellence in airway management is no longer defined solely by technical virtuosity

Jeremy: It’s defined by the ability to operate effectively within a system—preparing teams, recognising failure early, adapting strategy decisively, and prioritising physiology over fixation on intubation success

Hamish: The direction of travel is clear. High-performing emergency airway care will be characterised by predictable systems, shared mental models, and governance structures that make safe behaviour the default

Jeremy: And that aligns closely with the ethos of the TIME conference —translating evidence into practice, reducing unwarranted variation, and designing emergency care environments that support clinicians to perform optimally when the stakes are highest

Outro

Hamish: That's it for this episode! Thanks for joining us on TIME—lovely chatting, Jeremy, as always

Jeremy: Same here, mate. Thanks, everyone, for tuning in, and thanks to Clintix for making these episodes and this conference possible!

Hamish: Mind yourself. Talk soon, folks!