AbstractAirway management is a fundamental and complex process that involves a sequence of integrated tasks. Situations requiring emergency airway management may occur in the emergency department, intensive care units, and various other clinical settings A variety of challenges can arise during emergency airway preparation, intubation, and postintubation, which may result in significant complications for patients. Therefore, many countries are establishing step-by-step systemization and detailed guidelines and/or updating their content based on the latest research. This clinical review discusses the current trends in emergency airway management, such as emergency airway management algorithms, comparison of video and direct laryngoscopy, rapid sequence intubation, pediatric airway management, prehospital airway management, surgical airway management, and airway management education.
THE CONCEPT OF DIFFICULT AIRWAYS AND EXISTING MANAGEMENT ALGORITHMSIntroduction to the current guidelines of difficult airway managementThree difficult airway guidelines have been published in the past 5 years [1–4]. First, the Difficult Airway Society published the “overview of difficult intubation” guidelines in 2015 (Fig. 1) [5]. Separately, the American Society of Anesthesiologists published difficult airway guidelines in 2022, which provide recommendations on topics such as airway evaluation, preparation for difficult airway management, anticipated or unanticipated difficult airway management, endotracheal tube confirmation, extubation of the difficult airway, and follow-up care [4]. Additionally, these guidelines include algorithms for difficult airway management in both pediatric and adult patients, algorithms for awake tracheal intubation (ATI) and anesthesia, and updated standard and advanced airway management equipment. Finally, these guidelines emphasize awareness of the passage of time and limit the number of attempts made using different devices and techniques during difficult airway management [4].
Meanwhile, the Canadian Airway Focus Group is updating its 2013 guidelines [2,3]. At this time, two papers have been partially published, and their foci include difficult airway management encountered in an unconscious patient and planning and implementing safe management of the patient with an anticipated difficult airway. ATI may provide an extra margin of safety when an impossible video or direct laryngoscopy procedure is predicted, when difficulty is predicted with more than one mode of airway management (e.g., endotracheal intubation [ETI] and facemask ventilation), or when the predicted difficulty coincides with significant physiological or contextual issues [3].
The ATI guidelines published by the Difficult Airway Society emphasize the importance of ATI, which is not often used by clinicians owing to reluctance despite its relatively high success rate and safety in difficult airway management [1].
Anatomically difficult airways and the emerging role of ultrasound in airway managementAccording to the 2022 American Society of Anesthesiologists difficult airway guidelines, “measurement of facial and jaw features, anatomical measurements and landmarks, imaging with ultrasound or virtual laryngoscopy/bronchoscopy, three-dimensional printing, and bedside transnasal endoscopy” are adopted to evaluate a difficult airway [4]. As can be seen from the methods for predicting difficult airways, the traditional focus is on the anatomical and pathological structures of the airway. Bedside screening tests commonly used to predict difficult airways include the modified Mallampati test, measurement of thyromental distance, upper lip bite test, interincisor gap, and sternomental distance [6]. None of the existing bedside screening tests have high diagnostic value when performed alone.
Instead of bedside screening tests, which do not have high diagnostic value, difficult airway prediction methods using point-of-care ultrasound, which are already widely used in the field of emergency medicine (EM) and considered essential in the field of resuscitation, are also being studied [7,8]. Airway ultrasound examinations to predict a difficult airway can be divided into anterior tissue thickness domain (TTD), anatomic positioning, and oral space protocols. Here, the tissue thickness is determined using the pre-epiglottal tissue thickness, the anatomic positioning is determined using the hyomental distance, and the oral space is determined using tongue thickness (Figs. 2–4) [9,10]. Specifically, a difficult airway is predicted if the depth from the skin to the epiglottis (TTD) is greater than 2 to 2.5 cm, the hyomental distance is less than 5.29 cm, or the tongue thickness is less than 6.1 cm [11–13].
In addition to helping to predict difficult airways, ultrasound can be used for airway management in various ways; for example, the presence of vocal cord palsy can be confirmed using ultrasound in patients with stridor by checking for vocal cord movement [14]. If a “double-ring” sign is visible in the esophagus after intubation, it indicates esophageal intubation (Fig. 5) [15]. Ultrasound can also be used to examine the cricothyroid membrane when securing a surgical airway [7]; specifically, confirming the cricothyroid membrane using ultrasound can help identify anatomical landmarks. In a randomized controlled cadaver study by Siddiqui et al. [16], damage to the larynx and trachea as well as complications of incorrect insertion were reduced when using ultrasound compared to the classic digital palpation method, but the time required for final insertion was significantly longer. Considering that cricothyroidotomy is performed urgently, especially in “can’t intubate, can’t oxygenate (CICO)” situations, further research is needed to determine whether cricothyroidotomy using ultrasound is an appropriate modality, even in patients with anatomical structures that are not difficult to navigate in emergency airway management situations [4].
Physiologically difficult airwaysWhile an anatomically difficult airway is one in which obtaining a glottic view or passing an endotracheal tube is challenging, a physiologically difficult airway is one in which physiological derangements place the patient at greater risk of cardiopulmonary collapse with ETI and conversion to positive pressure ventilation [17]. Physiologically difficult airways include those of critically ill patients with hypoxia, hypotension, metabolic acidosis, right heart failure, or neurological damage; however, healthy patients, pregnant women, obese people, and children can also present with these airways [17–21].
The INTUBE (International Observational Study to Understand the Impact and Best Practices of Airway Management in Critically Ill Patients) study, involving 2,964 critically ill patients from 29 countries undergoing ETI, recorded at least one major adverse peri-intubation event in 45.2% of patients [22]. The predominant complication was cardiovascular instability (42.6%), followed by severe hypoxemia (9.3%) and cardiac arrest (3.1%). Risk factors for major adverse events included lower systolic arterial pressure, administration of a fluid bolus before ETI, a higher heart rate, and cardiovascular instability as a reason for ETI.
Therefore, critically ill patients may require the following treatments according to their physiological characteristics: sufficient preoxygenation and apneic oxygenation before and after ETI, use of vasopressors (including bolus administration), use of drugs that have minimal effects on blood pressure, and administration of fluids to correct hypovolemia and increase venous return during positive pressure ventilation [17,19,22]. Existing guidelines include bolus administration of 500 mL of crystalloid before or during peri-intubation in critically ill patients without heart failure to prevent hypotension that may occur after ETI [23–25]. Although there is insufficient evidence for the administration of a fluid bolus before ETI, an alternative strategy, such as the use of low-dose vasopressors or a combination of fluid and vasopressors, might be beneficial in preventing cardiopulmonary collapse in these patients and needs to be evaluated [26]. In hypoxemia, preoxygenation and apneic oxygenation are important. Also, in patients with shunt physiology due to pulmonary edema or acute respiratory distress syndrome, noninvasive positive pressure ventilation can improve oxygenation and alveolar recruitment [17]. If noninvasive positive pressure ventilation is not applicable, delayed sequence intubation may be considered. In patients with severe metabolic acidosis, it is important to maintain spontaneous ventilation during intubation or with mechanical ventilation; meanwhile, rapid sequence intubation (RSI) should be avoided if possible, but, if deemed necessary, a short-acting neuromuscular blocker such as succinylcholine may be used [17]. Additionally, in order to maintain respiratory compensation after intubation, it is recommended to use the ventilator mode, which allows the patient to maintain their own minute ventilation. Using the pressure-targeted ventilator mode will allow the patient to set the tidal volume and rate received [17]. In right ventricular failure, continuous norepinephrine infusion should be adopted prior to induction to maintain a higher mean arterial pressure than the pulmonary artery pressure in hypotensive patients [17]. The goals of mechanical ventilation include maintaining a low mean airway pressure and preventing hypercapnia, hypoxemia, and atelectasis, which increase right ventricular afterload [27].
COMPARISON OF ETI METHODS: VIDEO VS. DIRECT LARYNGOSCOPYETI can cause complications and may be harmful to patients. Numerous ideas for improving the process of glottic viewing and safe ETI have led to the application of fiber-optic technology in direct laryngoscopy (DL), and video laryngoscopy (VL) has become a mainstream intubation approach. After various VL devices were developed, their need for categorization was highlighted, and they were classified into Macintosh-style blades, hyperangular blades, and channel-type blades [28,29]. However, multiple studies designed to compare conventional DL devices to a variety of VL devices have debated priority, and their conclusions vary under certain circumstances. Studies comparing VL and DL have been conducted in various populations and situations, including neonates, children, adults, cervical spine immobilization, and pandemic disease [30–35].
In neonates, VL increases first-pass success (FPS) and success in two attempts [34,35]. Other research shows that VL also reduces the risk of major complications (desaturation and changes in heart rate or blood pressure) in children aged <1 or 0–18 years [34]. Moreover, there was no significant difference in the time to ETI between VL and DL in neonates, and there was no difference or a longer time in children aged 0–18 years [30,31,34,35].
For adults, who represent a larger scale study relative to children, the Cochrane review updated in 2022 reported that VL was associated with fewer failed attempts and complications like hypoxemia, and glottic views were also improved [29]. Recent studies using the National Emergency Airway Registry of emergency departments (EDs) ETI procedures also compared DL and VL [36–39]. In difficult airway patients, VL achieved a higher FPS rate than DL, and the rate of adverse events, such as esophageal intubation and vomiting, was also lower [38]. In patients with difficult airways due to blood or vomiting, the FPS of standard geometry VL devices (e.g., C-MAC, Karl Storz; McGrath MAC, Medtronic) was higher than that of hyperangulated VL devices (e.g., GlideScope, Verathon; King Vision, Ambu; C-MAC D-Blade, Karl Storz) [38]. In patients with trauma, VL also has a higher FPS than DL [37]. Additionally, in a study targeting EM trainees, FPS was higher in VL cases, and the FPS of postgraduate year 1 residents performing standard geometry VL was higher than that of postgraduate year 3+ residents performing DL [39].
Throughout the COVID-19 pandemic, a high number of studies evaluated laryngoscopes because the need to wear personal protective equipment (PPE) for aerosol-generating procedures led to alterations in ETI protocols for safety [32,40]. PPE plays an important role in preventing the spread of disease; however, previous studies have suggested that PPE may reduce the effectiveness of ETI [32,41]. Another study found no significant difference in the FPS rate compared to the control group when wearing extensive PPE, including an battery-powered air-purifying respirator [42]. In simulation studies using manikins and cadavers, there was also no difference found in the FPS rate between DL and VL (e.g., GlideScope, King Vision, and McGrath MAC) while wearing level C PPE, but the overall ETI time tended to be less during DL [32]. However, in a clinical study performed while wearing the same level of PPE, the FPS rate of C-MAC VL was found to be higher than that of DL [43].
RSI WITH PHARMACOLOGYRSI, the most widely used method in emergency airway management, reduces the risk of aspiration of gastric components by rapidly and continuously administering induction agents and neuromuscular blocking agents (NMBAs), and also optimizes the conditions for ETI [44].
Patient positioningPatient positioning before ETI is important to ensure FPS and to prevent and reduce complications that may occur during ETI. The “sniffing” position helps facilitate successful ETI by keeping the oropharyngeal–laryngeal axis as straight as possible and visualizing the vocal cords. The “ramped” position benefits preoxygenation by maintaining the functional residual capacity and reduces the risk of aspiration. However, there are conflicting results on the “ramped” position. Turner et al. [45] reported that “ramped” position increased FPS rate, while Semler et al. [46] said that the "ramped" position actually increased the procedural difficulty of ETI and consequently decreased FPS rate. Meanwhile, a large retrospective study reported that a combination of both positions reduced the rates of complications, including desaturation [47].
Preoxygenation and apneic oxygenationAdequate preoxygenation is essential for patient safety during emergency airway management. If sufficient preoxygenation is achieved, it prolongs the safe apnea time and prevents complications, such as hypoxemia, in susceptible patients. According to the previous study, preoxygenation was performed for three groups categorized by oxygen saturation by pulse oximetry (SpO2) level, as follows: a low-risk group (SpO2, 96%–100%), who received non-rebreather masks with maximal oxygen flow rate; a high-risk group (SpO2, 91%–95%), who received non-rebreather masks or continuous positive airway pressure or bag valve mask (BVM) treatment with positive end-expiratory pressure; and a hypoxemic group (SpO2, <90%), who received continuous positive airway pressure or BVM with positive end-expiratory pressure therapy [48]. In general, supplemental oxygen delivered via a nasal cannula or mask is used for preoxygenation; however, this approach is not sufficient for critically ill patients, such as those with hypoxemic respiratory failure. The FLORALI-2 study compared noninvasive ventilation and high-flow nasal cannula oxygen for preoxygenation in patients with hypoxemic respiratory failure [49]. There was no significant difference in the incidence of severe hypoxemia during ETI between the two groups; however, subgroup analysis suggested that patients with a PaO2 to fraction of inspired oxygen ratio of <200 gleaned a potential benefit from the use of noninvasive ventilation [49].
Apneic oxygenation is the continuous supply of oxygen via a nasal cannula during apnea following the administration of an NMBA, extending the safe apnea time. One study found that there was no benefit to apneic oxygenation after adequate preoxygenation before ETI in the intensive care unit [50]. However, a review paper on apneic oxygenation during intubation in the ED reported that apneic oxygenation lowered the occurrence of desaturation and increased the FPS rate [51]. This may be because the ED is an uncontrolled environment in which the patient is unstable and preoxygenation or preparation time is limited, and, in this situation, apneic oxygenation may be helpful.
Induction agents for sedationThe choice and dosage of drugs for pretreatment, induction, and paralysis in RSI are critical factors. This decision must be made individually, taking into account not only the drug's pharmacokinetic profiles and side effects but also patient factors like the indication of ETI, hemodynamics, and underlying disease [52]. Drugs commonly used for RSI are listed in Table 1.
Although atropine and lidocaine have also been used as pretreatments before the induction in RSI, there is currently no obvious benefit associated with either. However, when it is necessary to prevent an increase in intracerebral blood pressure or cardiovascular hyperactivity before ETI, low doses of fast-acting opioids can be administered as pretreatment. Fentanyl is a short-acting synthetic opioid that can be used to suppress the increase in sympathetic tone 3 to 5 minutes before induction [53].
Among the induction agents, ketamine acts on various receptors to maintain the patient's respiratory effort and induces hypnosis in addition to its sedative and analgesic effects. For this reason, it is used for “delayed sequence intubation or medication-assisted preoxygenation,” which is a method of administering an NMBA with a significant delay after induction. When performing ETI in uncooperative or agitated patients, there is an advantage to patient safety by ensuring sufficient preoxygenation time after ketamine administration [54]. However, the use of ketamine has some controversies and adverse effects; for example, there is controversy about the use of ketamine in patients with head trauma or traumatic brain injury due to the risk of increased intracranial pressure [55,56]. However, several clinical studies have not recorded significant increases in intracranial pressure when using ketamine, and it is widely considered safe for use in this patient population [57,58]. Additionally, ketamine is suggested as an induction agent for patients with shock and those at risk of postintubation hypotension due to its effect of increasing blood pressure, but there are also claims that it actually increases the incidence of postintubation hypotension [59,60]. Ketamine also maintains the patient's respiratory effort; however, it should be noted that high doses can cause respiratory depression or apnea [61]. Other adverse effects that may occur include nystagmus, sialorrhea, and emergence phenomena [52].
Etomidate has a rapid onset and a short duration of action, making it an ideal RSI induction agent. Additionally, it does not cause hypotension or cardiovascular instability; therefore, it is frequently used during ETI in critically ill patients [62]. One side effect is that it may cause temporary adrenal insufficiency, as etomidate acts as a selective adrenocortical 11 β-hydroxylase inhibitor. For this reason, some have raised the issue that etomidate should be avoided in patients with sepsis, but whether avoiding its use is clinically meaningful remains controversial [63]. In addition, there is also evidence that hydrocortisone supplementation reduces the risk of adrenal insufficiency when etomidate is administered for ETI to patients with septic shock [64].
Propofol causes vasodilatation and cardiac depression and may provoke hemodynamic instability when used as an induction agent. This trend is particularly evident in patients with impaired cardiac function and hypovolemia. If propofol needs to be used in these patients, titrating the dose and/or ensuring hemodynamic optimization using vasopressor agents and judicious fluid administration may prevent significant hemodynamic perturbations [65].
NMBAs for paralysisThe choice of NMBAs in RSI is determined by a variety of factors, and, except in some special situations, their use is recommended. NMBAs reduce upper airway muscle tone and facilitate facemask ventilation and supraglottic airway (SGA) insertion. They also optimize the intubation conditions by reducing the number of ETI attempts [66].
Succinylcholine, a depolarizing neuromuscular blocker, boasts a rapid onset and short duration of effect and is ideal for RSI. However, despite its advantages, succinylcholine is associated with several life-threatening conditions. Succinylcholine causes depolarization of upregulated nicotinic acetylcholine receptors, resulting in a shift of intracellular potassium into the plasma. This process can lead to acute hyperkalemia in susceptible patients [67]. Patients with reduced plasma cholinesterase activity due to burns or trauma within the last 24 to 72 hours and myopathy should avoid the use of succinylcholine for paralysis [67]. Succinylcholine has also been associated with malignant hyperthermia, a rare yet fatal condition [68].
Rocuronium and vecuronium, both nondepolarizing neuromuscular blockers, are not associated with life-threatening complications but have a longer duration of action, and their effects are dose dependent. Sugammadex, a modified γ-cyclodextrin, binds and encapsulates steroidal NMBAs in the plasma, thus reducing their concentration and rapidly terminating their blocking effect [69]. When an RSI dose of rocuronium was used, the effects of the neuromuscular block were reversed 3 minutes after the administration of sugammadex (16 mg/kg).
There are few papers comparing the efficacy of NMBA. According to a 2015 Cochrane review, succinylcholine provides better intubating conditions compared to rocuronium [70]. However, this study only involved intubated patients in the operating room or intensive care unit and did not include ED patients. In a later study evaluating FPS by using the National Emergency Airway Registry database, there was no difference in FPS rates between succinylcholine and rocuronium (87% vs. 87.5%) [71]. Elsewhere, although there was no difference in mortality among patients with low-severity head injuries, succinylcholine led to increased mortality compared to rocuronium in patients with high-severity head injuries [72].
Anesthesia and sedation for ATIATI is considered when an anatomically or physiologically difficult airway is expected and/or when eliminating spontaneous breathing threatens patient safety. In ATI, an NMBA is not administered, and a lower dose of the induction agent is used compared to that in RSI. Appropriate airway anesthesia and judicious sedation are important to reduce patient anxiety and discomfort during the procedure, and airway patency must be maintained. A backup plan should be prepared in case of failure.
The success of ATI depends upon the effective application of local anesthetic to the airway. Local anesthetics can be administered by topical application or injection into the airway, either separately or simultaneously. Following topical application, airway secretions may dilute the local anesthetic or wash it away from areas requiring anesthesia. Adding glycopyrrolate is useful because it reduces airway secretions; a dose of 0.1 to 0.2 mg/kg should be administered at least 3 to 5 minutes before the application of local anesthetic [52]. Appropriate application of local anesthetic allows adequate airway assessment in patients without the administration of sedatives. Lidocaine is the most commonly used local anesthetic and has low cardiovascular effects and systemic toxicity [73].
Generally, in the ATI of critically ill patients, sedatives are used after optimization with a local anesthetic. Oversedation may cause a loss of airway patency, hypoxia, aspiration, or cardiovascular instability; therefore, sedation must be adjusted with careful monitoring [1]. Remifentanil and dexmedetomidine are also associated with greater patient satisfaction and a lower risk of oversedation and airway obstruction when used in ATI [74]. When considering combination therapy rather than a single drug for sedation, remifentanil and midazolam can be used [1].
PEDIATRIC AIRWAY MANAGEMENTIt is uncommon to experience pediatric airway management in an ED, and, as children rarely develop serious diseases, EM physicians inevitably have little experience in pediatric airway management [75]. However, pediatric airway management requires skill, as it is very different from that in adults [76].
Children's airways are small and thin; therefore, even if they are slightly narrowed by secretions, resistance increases significantly, and structures such as the occipital bone, tongue, and tonsils are larger relative to the airway, making them more prone to obstructing [75]. Because of children’s small lung capacity and high oxygen consumption, safe apnea time is short, and caution must be exercised with preoxygenation [77]. Because of these anatomical and physiological characteristics, which are different from those of adults, difficult airways are even more complex in children than in adults [78,79]. Another challenging aspect of pediatric airway management is the need to use different tools depending on the patient’s age and size [80].
Previously, it was known that the larynx in children is funnel-shaped; therefore, an uncuffed tube has been traditionally used [81]. Among the recent updates to the knowledge of children's airways, the most significant is the finding that their larynxes grow in an oval shape [82]. The use of cuffed tubes has thus become a trend, and follow-up studies have shown that the incidence of complications is lower in association with cuffed tubes than uncuffed tubes [79,81]. Currently, the American Heart Association guidelines recommend the use of cuffed tubes for pediatric airway management [83].
To overcome the short safe apnea time in children, apneic oxygenation is actively performed during ETI [77]. This supplies oxygen through the nasal cannula, laryngoscope, and high-flow nasal cannula during ETI [75,82]. A modified RSI method that provides assistance with positive pressure ventilation at some point is commonly used not only in the emergency room environment but also in the operating room [77].
Using an NMBA ensures an appropriate depth of anesthesia during ETI, increases the success rate, and reduces cardiac side effects such as hypotension and arrhythmia [75,79]. Because bradycardia commonly occurs during pediatric intubation, there is controversy over the use of atropine as a pretreatment; however, because bradycardia due to hypoxia cannot be prevented, it can be used selectively [75].
Several new technologies and intubation tools have recently been developed [77]. Currently, most assistive devices used in adults (videoscopes, SGA, etc.) have been developed as miniature versions, and companies market them in various sizes [75,77]. Point-of-care ultrasound can be useful in determining endotracheal size, confirming endotracheal tube placement, and identifying landmarks during cricothyroidotomy. Several studies have reviewed recent advances in three-dimensional printing and machine learning [82,84]. Three-dimensional printing can be used to produce models for training in unfamiliar pediatric airway areas. Machine learning is continuously evolving in various fields, including its use in evaluating difficult airways through large-scale data, providing guidelines during ETI to inexperienced clinicians by automatically recognizing anatomical structures, and implementing an alarm system for monitoring; therefore, continuous updates are needed [82,84].
PREHOSPITAL AIRWAY MANAGEMENT AND CARDIAC ARREST SITUATIONSBVM and orotracheal and nasotracheal intubation in prehospital settingIn most scenarios, it is advisable to initiate basic airway and ventilatory support as a preliminary step before considering advanced airway management techniques. Generally, BVM ventilation and non-rebreather masks are suitable for patients requiring airway or ventilatory support. BVM ventilation should be promptly administered to patients with apnea or hypoventilation. Whenever feasible, BVM ventilation should be performed using a two-rescuer technique while considering the use of the oropharyngeal or nasopharyngeal airways to optimize the procedure [85]. Nasal cannulas should be avoided in patients with compromised airways [86].
Adjustments in patient or rescuer positioning aimed at optimizing the airway management process, such as raising the bed or stretcher to align with the rescuer's waist level or positioning the patient supine, can affect the quality of laryngoscopic views during airway management. Notably, well-documented techniques such as the “sniffing position” and head-elevation methods, extensively discussed in the otolaryngology, anesthesia, and EM literature, are widely recognized for their capacity to enhance glottic exposure [87,88]. In addition, elevating the backboard in cases involving trauma patients requiring immobilization and the use of prone or kneeling positions when intubating patients situated on the ground can potentially improve intubation performance [89,90].
Numerous techniques are currently available for ETI. Techniques such as the "backwards–upwards–rightwards pressure" method and external laryngeal manipulation have been documented to improve vocal cord exposure during orotracheal intubation in the prehospital setting [91,92]. In cases where orotracheal approaches are not feasible, owing to factors such as clenched teeth, tongue edema, or the need for a seated position, nasotracheal intubation can be a viable alternative [93,94]. Additionally, some small prehospital studies have reported the use of gum elastic bougie [95,96]. Prehospital intubation plays an important role in maintaining an intact airway and ventilation during transport. However, recent studies have proposed that trauma patients, especially those with a traumatic brain injury, have a poor prognosis when prehospital intubations are performed [97,98]. In traumatic brain injury patients, it is believed that ETI induces hyperventilation and worsens neurological injury compared to BVM [97]. Therefore, prehospital intubation for traumatic brain injury should be performed considering various confounding factors.
SGA in the prehospital settingThe choice of SGA as either a primary or secondary prehospital airway intervention depends upon various factors, including clinician expertise and the specific circumstances available for airway interventions. Previous studies have reported the use of SGAs as rescue airway devices in cases where ETI attempts have proven unsuccessful, with varying success rates [99,100]. However, as SGAs do not provide full protection against gastric insufflation, regurgitation, or aspiration, it is imperative to exercise caution during use and to maintain vigilant observation. To enhance safety, continuous-waveform end-tidal CO2 monitoring should be employed. Additionally, it is advisable to limit SGA-insertion attempts to a maximum of three for optimal patient care [5].
Airway management in cardiac arrestThe choice of an airway management strategy in cases of out-of-hospital cardiac arrest (OHCA) can be influenced by multiple factors, including the circumstances of the arrest, the patient's condition, the stage of resuscitation, the available equipment, and the skill level of the emergency medical service clinician [101,102]. Additionally, the timing of different airway techniques may vary, with the significance of oxygenation and ventilation increasing as resuscitation efforts continue. According to the US Agency for Healthcare Research and Quality 2023 updated guideline, BVM, SGA, and ETI are recommended with the same level of evidence for prehospital airway management [103]. While there are limited data available, it is noteworthy that patient-centered outcomes in recent studies appear to be better with ETI or SGA than with BVM among adult cardiac arrest cases [104,105]. However, because these were retrospective studies, it is still too early to generalize, so additional research is needed. Two methods are used for chest compressions and ventilation during cardiopulmonary resuscitation (CPR), including synchronous CPR, which consists of a cycle of 30 uninterrupted chest compressions with a cycle of two ventilations, and asynchronous CPR, which consists of uninterrupted ventilation with advanced airway management. Interruption of ventilation due to synchronous CPR can significantly affect the chest-compression fraction. In contrast, advanced airway management using ETI or SGA is an asynchronous CPR method that allows ventilation without interruption of chest compression and may have shown a better prognosis in cases of OHCA because it can increase the chest-compression fraction [106]. However, since this has not yet been established, additional well-designed studies will be needed for clinical application.
While advanced airway management is an important aspect of OHCA treatment, emergency medical service clinicians should prioritize interventions known to enhance patient outcomes during cardiac arrest resuscitation, irrespective of the chosen airway management approach. These include ensuring high-quality chest compressions (e.g., optimizing the rate, depth, recoil, and chest-compression fraction), prompt administration of defibrillation for shockable rhythms, and addressing reversible causes of the arrest. Maintaining high-quality CPR while managing airways is crucial. This can be achieved by carefully timing airway interventions, avoiding interruptions in chest compressions when placing advanced airways, and minimizing the potential harm associated with ventilation following the insertion of advanced airways [107].
EMERGENCY INVASIVE AIRWAY AND COMPLICATIONSThe scenario known as CICO can occur when attempts to use facemasks, SGA devices, or endotracheal tubes fail, necessitating the prompt performance of a cricothyroidotomy. However, because the incidence of CICO is very low, even experienced doctors have difficulty performing cricothyrotomy due to a lack of experience, with the reported failure rate reaching 25% [108,109].
Emergency invasive airway accessIn the 2015 Difficult Airway Society guidelines overview released in the United Kingdom, the process of securing an open airway in front of the neck for rapid and appropriate oxygen supply in CICO situations is referred to as Emergency Front-of-Neck Access (eFONA) [110]. The eFONA techniques include scalpel cricothyroidotomy, cannula cricothyroidotomy, surgical tracheostomy, and percutaneous tracheostomy.
The American Society of Anesthesiologists introduced practical guidelines for difficult airway management in 2022, which describe invasive airway techniques, including surgical cricothyrotomy, needle cricothyrotomy using pressure-regulated devices, large-bore cannula cricothyrotomy, and surgical tracheostomy. Additionally, elective invasive airway techniques, including retrograde wire–guided intubation, percutaneous tracheostomy, rigid bronchoscopy, and extracorporeal membrane oxygenation, are discussed [4].
The eFONA or an emergency invasive airway creation is feasible in all CICO cases, and there are no absolute contraindications. Relative contraindications include possible or known tracheal surgery, a fractured larynx, laryngotracheal disruption, and pediatric status [111]. Cricothyrotomy is a relative contraindication in children 0 to 12 years because of the funnel shape of the pediatric airway and a theoretically increased risk of subglottic stenosis [112].
Complications of emergency invasive airwaysThe rate of complications varies across clinical scenarios, levels of education, procedural settings, and studies, ranging from 0% to 54% [113]. Anatomically, because the superior thyroid artery and vein cross the cricothyroid membrane, bleeding is the most common complication of this procedure. Some degree of bleeding is inevitable during the procedure; however, if severe bleeding persists, applying pressure to the area or attempting hemostasis with gauze packing may be necessary. Other potential complications include injury to the thyroid, cricoid, or tracheal cartilage; airway perforation; creation of a false tract, and the possibility of infection [114,115]. Long-term complications may include subglottic stenosis and changes in voice quality [116].
EDUCATION AND TRAINING PROGRAMEmergency airway management is taught as one of the key elements in EM training because it is the most important initial treatment for preventing suffocation in patients who are unconscious or unable to breathe independently [117]. However, inappropriate management of difficult or failed airways can cause serious complications. To overcome these difficulties, educators are actively introducing guidelines from various countries into clinical practice to respond appropriately to emergency situations, and several devices and methods for airway management have been designed for use in clinical practice [117,118].
Currently, education takes the form of an integrated course consisting of lectures, small-group practical training, and simulations using case scenarios [119]. Accordingly, various types of emergency airway management education programs have been introduced in many countries; representative examples include “The Difficult Airway Course—Emergency” in the United States [120], the “Training Emergency Airway Management Course” in the United Kingdom [121], and the “Airway Intervention & Management in Emergencies Program” in Canada [122]. Similarly, in Korea, simulation-based comprehensive emergency airway management training courses have been implemented for nurses and EM residents under the supervision of the Korean Emergency Airway Management Society [123].
The COVID-19 pandemic has had a significant impact on all aspects of airway training worldwide, as changes were introduced to clinical practice to ensure the safety of patients and medical staff [124]. As opportunities for hands-on airway management experience became rare, training opportunities for trainees decreased by 65%, and new educational methods that use video platforms emerged in response [124]. During the pandemic, trainees participated in online meetings, shared their clinical experiences and knowledge, and learned about airway management. They also participated in hybrid workshops consisting of an online video lecture and a hands-on course to learn technical skills. This type of training reduced the possibility of spreading viruses by decreasing contact time in the pandemic era. With this approach, the limitations of simulation-based education, such as the long preparation time for education compared to the small number of trainees, limited locations, and the need for large costs due to the relatively small number of trained educators, can be overcome [125]. Similarly, in Korea, the Korean Emergency Airway Management Society conducted a face-to-face learning workshop following a preliminary training video (EMCORE [Emergency Core Procedure Course], Seoul, Korea; https://emcore.co.kr/) to help trainees improve their practical skills. In addition, although it is difficult to include it in the formal curriculum, a method employing virtual reality, which is useful for teaching specific skills, is being introduced as a new form of airway management education [126].
Education, especially for those receiving EM training, needs to be thoroughly inspected and developed to teach airway management in anticipated and unforeseen situations because it is related to patients’ complications. Moreover, it is important to develop various educational methods so that trainees can grow through the acquisition of new information and skills and to create an environment where such education becomes active and where trainees can actively participate.
CONCLUSIONEmergency airway management must be performed by all possible means in a timely, efficient, and safe manner to avoid significant complications. Improved technology and knowledge of emergency airway management have enabled safer airway management and appropriate treatments for difficult airways. Therefore, ED clinicians must be aware of current trends in emergency airway management to ensure patient safety.
NOTESREFERENCES1. Ahmad I, El-Boghdadly K, Bhagrath R, et al. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia 2020; 75:509-28.
2. Law JA, Duggan LV, Asselin M, et al. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient. Can J Anaesth 2021; 68:1373-404.
3. Law JA, Duggan LV, Asselin M, et al. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway. Can J Anaesth 2021; 68:1405-36.
4. Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists practice guidelines for management of the difficult airway. Anesthesiology 2022; 136:31-81.
5. Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth 2015; 115:827-48.
6. Vannucci A, Cavallone LF. Bedside predictors of difficult intubation: a systematic review. Minerva Anestesiol 2016; 82:69-83.
7. Ultrasound guidelines: emergency, point-of-care, and clinical ultrasound guidelines in medicine.. Ann Emerg Med 2023; 82:e115-55.
8. Gottlieb M, O'Brien JR, Ferrigno N, Sundaram T. Point-of-care ultrasound for airway management in the emergency and critical care setting. Clin Exp Emerg Med 2024; 11:22-32.
9. Bhargava V, Rockwell NA, Tawfik D, Haileselassie B, Petrisor C, Su E. Prediction of difficult laryngoscopy using ultrasound: a systematic review and meta-analysis. Crit Care Med 2023; 51:117-26.
10. Lin J, Bellinger R, Shedd A, et al. Point-of-care ultrasound in airway evaluation and management: a comprehensive review. Diagnostics (Basel) 2023; 13:1541.
11. Yao W, Wang B. Can tongue thickness measured by ultrasonography predict difficult tracheal intubation? Br J Anaesth 2017; 118:601-9.
12. Falcetta S, Cavallo S, Gabbanelli V, et al. Evaluation of two neck ultrasound measurements as predictors of difficult direct laryngoscopy: a prospective observational study. Eur J Anaesthesiol 2018; 35:605-12.
13. Wu H, Wang H. Diagnostic efficacy and clinical value of ultrasonography in difficult airway assessment: based on a prospective cohort study. Contrast Media Mol Imaging 2022; 2022:4706438.
14. Adi O, Kok MS, Wahab SF. Focused airway ultrasound: an armamentarium in future airway management. J Emerg Crit Care Med 2019; 3:31.
15. Adi O, Chuan TW, Rishya M. A feasibility study on bedside upper airway ultrasonography compared to waveform capnography for verifying endotracheal tube location after intubation. Crit Ultrasound J 2013; 5:7.
16. Siddiqui N, Arzola C, Friedman Z, Guerina L, You-Ten KE. Ultrasound improves cricothyrotomy success in cadavers with poorly defined neck anatomy: a randomized control trial. Anesthesiology 2015; 123:1033-41.
17. Mosier JM, Joshi R, Hypes C, Pacheco G, Valenzuela T, Sakles JC. The physiologically difficult airway. West J Emerg Med 2015; 16:1109-17.
18. Kornas RL, Owyang CG, Sakles JC, Foley LJ, Mosier JM; Society for Airway Management’s Special Projects Committee. Evaluation and management of the physiologically difficult airway: consensus recommendations from society for airway management. Anesth Analg 2021; 132:395-405.
19. Myatra SN, Divatia JV, Brewster DJ. The physiologically difficult airway: an emerging concept. Curr Opin Anaesthesiol 2022; 35:115-21.
20. Myatra SN, Dhawan I, D'Souza SA, Elakkumanan LB, Jain D, Natarajan P. Recent advances in airway management. Indian J Anaesth 2023; 67:48-55.
21. Tan NE, Yoong KP, Yahya HM. Use of HEAVEN criteria for predicting difficult intubation in the emergency department. Clin Exp Emerg Med 2022; 9:29-35.
22. Russotto V, Tassistro E, Myatra SN, et al. Peri-intubation cardiovascular collapse in patients who are critically ill: insights from the INTUBE study. Am J Respir Crit Care Med 2022; 206:449-58.
23. Myatra SN, Ahmed SM, Kundra P, et al. The All India Difficult Airway Association 2016 guidelines for tracheal intubation in the Intensive Care Unit. Indian J Anaesth 2016; 60:922-30.
24. Higgs A, McGrath BA, Goddard C, et al. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth 2018; 120:323-52.
25. Quintard H, l'Her E, Pottecher J, et al. Experts' guidelines of intubation and extubation of the ICU patient of French Society of Anaesthesia and Intensive Care Medicine (SFAR) and French-speaking Intensive Care Society (SRLF): in collaboration with the pediatric Association of French-speaking Anaesthetists and Intensivists (ADARPEF), French-speaking Group of Intensive Care and Paediatric emergencies (GFRUP) and Intensive Care physiotherapy society (SKR). Ann Intensive Care 2019; 9:13.
26. Myatra SN, Russotto V, Bellani G, Divatia JV. A fluid bolus before tracheal intubation in the critically ill does not prevent peri-intubation cardiovascular collapse: time to consider alternatives? Anaesth Crit Care Pain Med 2022; 41:101158.
27. Jardin F, Vieillard-Baron A. Right ventricular function and positive pressure ventilation in clinical practice: from hemodynamic subsets to respirator settings. Intensive Care Med 2003; 29:1426-34.
28. Cavus E, Byhahn C, Dorges V. Classification of videolaryngoscopes is crucial. Br J Anaesth 2017; 118:806-7.
29. Hansel J, Rogers AM, Lewis SR, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation: a Cochrane systematic review and meta-analysis update. Br J Anaesth 2022; 129:612-23.
30. Abdelgadir IS, Phillips RS, Singh D, Moncreiff MP, Lumsden JL. Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in children (excluding neonates). Cochrane Database Syst Rev 2017; 5:CD011413.
31. Hu X, Jin Y, Li J, Xin J, Yang Z. Efficacy and safety of videolaryngoscopy versus direct laryngoscopy in paediatric intubation: a meta-analysis of 27 randomized controlled trials. J Clin Anesth 2020; 66:109968.
32. Ludwin K, Bialka S, Czyzewski L, et al. Video laryngoscopy for endotracheal intubation of adult patients with suspected/confirmed COVID-19. A systematic review and meta-analysis of randomized controlled trials. Disaster Emerg Med J 2020; 5:85-97.
33. Singleton BN, Morris FK, Yet B, Buggy DJ, Perkins ZB. Effectiveness of intubation devices in patients with cervical spine immobilisation: a systematic review and network meta-analysis. Br J Anaesth 2021; 126:1055-66.
34. de Carvalho CC, Regueira SL, Souza AB, et al. Videolaryngoscopes versus direct laryngoscopes in children: ranking systematic review with network meta-analyses of randomized clinical trials. Paediatr Anaesth 2022; 32:1000-14.
35. Lingappan K, Neveln N, Arnold JL, Fernandes CJ, Pammi M. Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates. Cochrane Database Syst Rev 2023; 5:CD009975.
36. Brown CA, Kaji AH, Fantegrossi A, et al. Video laryngoscopy compared to augmented direct laryngoscopy in adult emergency department tracheal intubations: a National Emergency Airway Registry (NEAR) study. Acad Emerg Med 2020; 27:100-8.
37. Trent SA, Kaji AH, Carlson JN, et al. Video laryngoscopy is associated with first-pass success in emergency department intubations for trauma patients: a propensity score matched analysis of the National Emergency Airway Registry. Ann Emerg Med 2021; 78:708-19.
38. Ruderman BT, Mali M, Kaji AH, et al. Direct vs video laryngoscopy for difficult airway patients in the emergency department: a National Emergency Airway Registry study. West J Emerg Med 2022; 23:706-15.
39. Garcia SI, Sandefur BJ, Campbell RL, et al. First-attempt intubation success among emergency medicine trainees by laryngoscopic device and training year: a National Emergency Airway Registry study. Ann Emerg Med 2023; 81:649-57.
40. Kluj P, Fedorczak A, Fedorczak M, et al. Comparison of three video laryngoscopes and direct laryngoscopy for emergency endotracheal intubation while wearing PPE-AGP: a randomized, crossover, simulation trial. Healthcare (Basel) 2023; 11:884.
41. Castle N, Owen R, Hann M, Clark S, Reeves D, Gurney I. Impact of chemical, biological, radiation, and nuclear personal protective equipment on the performance of low- and high-dexterity airway and vascular access skills. Resuscitation 2009; 80:1290-5.
42. Choi J, Shin TG, Park JE, et al. Impact of personal protective equipment on the first-pass success of endotracheal intubation in the ED: a propensity-score-matching analysis. J Clin Med 2021; 10:1060.
43. Kim DS, Jeong D, Park JE, et al. Endotracheal intubation using C-MAC video laryngoscope vs. direct laryngoscope while wearing personal protective equipment. J Pers Med 2022; 12:1720.
44. Di Filippo A, Gonnelli C. Rapid sequence intubation: a review of recent evidences. Rev Recent Clin Trials 2009; 4:175-8.
45. Turner JS, Ellender TJ, Okonkwo ER, et al. Feasibility of upright patient positioning and intubation success rates at two academic EDs. Am J Emerg Med 2017; 35:986-92.
46. Semler MW, Janz DR, Russell DW, et al. A multicenter, randomized trial of ramped position vs sniffing position during endotracheal intubation of critically ill adults. Chest 2017; 152:712-22.
47. Khandelwal N, Khorsand S, Mitchell SH, Joffe AM. Head-elevated patient positioning decreases complications of emergent tracheal intubation in the ward and intensive care unit. Anesth Analg 2016; 122:1101-7.
48. Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med 2012; 59:165-75.
49. Frat JP, Ricard JD, Quenot JP, et al. Non-invasive ventilation versus high-flow nasal cannula oxygen therapy with apnoeic oxygenation for preoxygenation before intubation of patients with acute hypoxaemic respiratory failure: a randomised, multicentre, open-label trial. Lancet Respir Med 2019; 7:303-12.
50. Semler MW, Janz DR, Lentz RJ, et al. Randomized trial of apneic oxygenation during endotracheal intubation of the critically ill. Am J Respir Crit Care Med 2016; 193:273-80.
51. Binks MJ, Holyoak RS, Melhuish TM, Vlok R, Bond E, White LD. Apneic oxygenation during intubation in the emergency department and during retrieval: a systematic review and meta-analysis. Am J Emerg Med 2017; 35:1542-6.
52. Engstrom K, Brown CS, Mattson AE, Lyons N, Rech MA. Pharmacotherapy optimization for rapid sequence intubation in the emergency department. Am J Emerg Med 2023; 70:19-29.
53. Stollings JL, Diedrich DA, Oyen LJ, Brown DR. Rapid-sequence intubation: a review of the process and considerations when choosing medications. Ann Pharmacother 2014; 48:62-76.
54. Merelman AH, Perlmutter MC, Strayer RJ. Alternatives to rapid sequence intubation: contemporary airway management with ketamine. West J Emerg Med 2019; 20:466-71.
55. Gardner AE, Olson BE, Lichtiger M. Cerebrospinal-fluid pressure during dissociative anesthesia with ketamine. Anesthesiology 1971; 35:226-8.
56. Wyte SR, Shapiro HM, Turner P, Harris AB. Ketamine-induced intracranial hypertension. Anesthesiology 1972; 36:174-6.
57. Loflin R, Koyfman A. When used for sedation, does ketamine increase intracranial pressure more than fentanyl or sufentanil? Ann Emerg Med 2015; 65:55-6.
59. April MD, Arana A, Schauer SG, et al. Ketamine versus etomidate and peri-intubation hypotension: a National Emergency Airway Registry study. Acad Emerg Med 2020; 27:1106-15.
60. Mohr NM, Pape SG, Runde D, Kaji AH, Walls RM, Brown CA. Etomidate use is associated with less hypotension than ketamine for emergency department sepsis intubations: a NEAR cohort study. Acad Emerg Med 2020; 27:1140-9.
61. Kakazu C, Lippmann M, Hsu D. Ketamine: a positive-negative anaesthetic agent. Br J Anaesth 2016; 117:267.
62. Oglesby AJ. Should etomidate be the induction agent of choice for rapid sequence intubation in the emergency department? Emerg Med J 2004; 21:655-9.
63. Flynn G, Shehabi Y. Pro/con debate: is etomidate safe in hemodynamically unstable critically ill patients? Crit Care 2012; 16:227.
64. Jung B, Clavieras N, Nougaret S, et al. Effects of etomidate on complications related to intubation and on mortality in septic shock patients treated with hydrocortisone: a propensity score analysis. Crit Care 2012; 16:R224.
65. Koenig SJ, Lakticova V, Narasimhan M, Doelken P, Mayo PH. Safety of propofol as an induction agent for urgent endotracheal intubation in the medical intensive care unit. J Intensive Care Med 2015; 30:499-504.
66. Asai T. Airway management inside and outside operating rooms: circumstances are quite different. Br J Anaesth 2018; 120:207-9.
67. Martyn JA, Richtsfeld M. Succinylcholine-induced hyperkalemia in acquired pathologic states: etiologic factors and molecular mechanisms. Anesthesiology 2006; 104:158-69.
69. Naguib M. Sugammadex: another milestone in clinical neuromuscular pharmacology. Anesth Analg 2007; 104:575-81.
70. Tran DT, Newton EK, Mount VA, Lee JS, Wells GA, Perry JJ. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev 2015; 2015:CD002788.
71. April MD, Arana A, Pallin DJ, et al. Emergency department intubation success with succinylcholine versus rocuronium: a National Emergency Airway Registry study. Ann Emerg Med 2018; 72:645-53.
72. Patanwala AE, Erstad BL, Roe DJ, Sakles JC. Succinylcholine is associated with increased mortality when used for rapid sequence intubation of severely brain injured patients in the emergency department. Pharmacotherapy 2016; 36:57-63.
73. El-Boghdadly K, Pawa A, Chin KJ. Local anesthetic systemic toxicity: current perspectives. Local Reg Anesth 2018; 11:35-44.
74. Johnston KD, Rai MR. Conscious sedation for awake fibreoptic intubation: a review of the literature. Can J Anaesth 2013; 60:584-99.
75. Miller KA, Nagler J. Advances in emergent airway management in pediatrics. Emerg Med Clin North Am 2019; 37:473-91.
76. Engelhardt T, Fiadjoe JE, Weiss M, et al. A framework for the management of the pediatric airway. Paediatr Anaesth 2019; 29:985-92.
77. Stein ML, Park RS, Kovatsis PG. Emerging trends, techniques, and equipment for airway management in pediatric patients. Paediatr Anaesth 2020; 30:269-79.
78. Hsu G, Fiadjoe JE. The pediatric difficult airway: updates and innovations. Anesthesiol Clin 2020; 38:459-75.
79. Sohn L, Peyton J, von Ungern-Sternberg BS, Jagannathan N. Error traps in pediatric difficult airway management. Paediatr Anaesth 2021; 31:1271-5.
80. Burton L, Bhargava V. A scoping review of ultrasonographic techniques in the evaluation of the pediatric airway. J Ultrasound Med 2023; 42:2463-79.
81. Kim JH, Ahn JH, Chae YJ. Pediatric application of cuffed endotracheal tube. West J Emerg Med 2023; 24:579-87.
82. Hsu G, von Ungern-Sternberg BS, Engelhardt T. Pediatric airway management. Curr Opin Anaesthesiol 2021; 34:276-83.
83. Topjian AA, Raymond TT, Atkins D, et al. Part 4: pediatric basic and advanced life support. 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2020; 142(16_suppl_2):S469-523.
84. Matava C, Pankiv E, Ahumada L, Weingarten B, Simpao A. Artificial intelligence, machine learning and the pediatric airway. Paediatr Anaesth 2020; 30:264-8.
85. Rehn M, Hyldmo PK, Magnusson V, et al. Scandinavian SSAI clinical practice guideline on pre-hospital airway management. Acta Anaesthesiol Scand 2016; 60:852-64.
86. Panchal AR, Bartos JA, Cabanas JG, et al. Part 3: adult basic and advanced life support. 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2020; 142:S366-468.
87. Adnet F, Baillard C, Borron SW, et al. Randomized study comparing the "sniffing position" with simple head extension for laryngoscopic view in elective surgery patients. Anesthesiology 2001; 95:836-41.
88. Takenaka I, Aoyama K, Iwagaki T, Ishimura H, Kadoya T. The sniffing position provides greater occipito-atlanto-axial angulation than simple head extension: a radiological study. Can J Anaesth 2007; 54:129-33.
89. Adnet F, Cydulka RK, Lapandry C. Emergency tracheal intubation of patients lying supine on the ground: influence of operator body position. Can J Anaesth 1998; 45:266-9.
90. Pinchalk M, Roth RN, Paris PM, Hostler D. Comparison of times to intubate a simulated trauma patient in two positions. Prehosp Emerg Care 2003; 7:252-7.
91. Takahata O, Kubota M, Mamiya K, et al. The efficacy of the "BURP" maneuver during a difficult laryngoscopy. Anesth Analg 1997; 84:419-21.
92. Ochroch EA, Levitan RM. A videographic analysis of laryngeal exposure comparing the articulating laryngoscope and external laryngeal manipulation. Anesth Analg 2001; 92:267-70.
93. O'Brien DJ, Danzl DF, Hooker EA, Daniel LM, Dolan MC. Prehospital blind nasotracheal intubation by paramedics. Ann Emerg Med 1989; 18:612-7.
94. O'connor RE, Megargel RE, Schnyder ME, Madden JF, Bitner M, Ross R. Paramedic success rate for blind nasotracheal intubation is improved with the use of an endotracheal tube with directional tip control. Ann Emerg Med 2000; 36:328-32.
95. Phelan MP, Moscati R, D'Aprix T, Miller G. Paramedic use of the endotracheal tube introducer in a difficult airway model. Prehosp Emerg Care 2003; 7:244-6.
96. Jabre P, Combes X, Leroux B, et al. Use of gum elastic bougie for prehospital difficult intubation. Am J Emerg Med 2005; 23:552-5.
97. Jung E, Cho YS, Ryu SJ, Kim DK, Lee JH, Han JH. The impact of prehospital endotracheal intubation on mortality in traumatic brain injury. Am J Emerg Med 2022; 55:152-6.
98. Ji F, Zhou X. Effect of prehospital intubation on mortality rates in patients with traumatic brain injury: a systematic review and meta-analysis. Scott Med J 2023; 68:80-90.
99. Hubble MW, Wilfong DA, Brown LH, Hertelendy A, Benner RW. A meta-analysis of prehospital airway control techniques part II: alternative airway devices and cricothyrotomy success rates. Prehosp Emerg Care 2010; 14:515-30.
100. Cook T, Howes B. Supraglottic airway devices: recent advances. Contin Educ Anaesth Crit Care Pain 2011; 11:56-61.
101. Jang Y, Kim TH, Lee SY, et al. Association of transport time interval with neurologic outcome in out-of-hospital cardiac arrest patients without return of spontaneous circulation on scene and the interaction effect according to prehospital airway management. Clin Exp Emerg Med 2022; 9:93-100.
102. Lim HJ, Song KJ, Shin SD, Kim KH, Ro YS, Yoon H. Interactive effect of multi-tier response and advanced airway management on clinical outcomes after out-of-hospital cardiac arrest: a nationwide population-based observational study. Clin Exp Emerg Med 2022; 9:187-97.
103. Jarvis JL, Panchal AR, Lyng JW, et al. Evidence-based guideline for prehospital airway management. Prehosp Emerg Care 2024; 28:545-57.
104. Jung E, Ro YS, Ryu HH, Shin SD. Association of prehospital airway management technique with survival outcomes of out-of-hospital cardiac arrest patients. PLoS One 2022; 17:e0269599.
105. Song SR, Kim KH, Park JH, Song KJ, Shin SD. Association between prehospital airway type and oxygenation and ventilation in out-of-hospital cardiac arrest. Am J Emerg Med 2023; 65:24-30.
106. Shimizu K, Wakasugi M, Kawagishi T, Hatano T, Fuchigami T, Okudera H. Effect of advanced airway management by paramedics during out-of-hospital cardiac arrest on chest compression fraction and return of spontaneous circulation. Open Access Emerg Med 2021; 13:305-10.
107. Carlson JN, Colella MR, Daya MR, et al. Prehospital cardiac arrest airway management: an NAEMSP position statement and resource document. Prehosp Emerg Care 2022; 26:54-63.
108. Cook TM, Woodall N, Frerk C; 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 1: anaesthesia. Br J Anaesth 2011; 106:617-31.
109. Melchiors J, Todsen T, Konge L, Charabi B, von Buchwald C. Cricothyroidotomy: the emergency surgical airway. Head Neck 2016; 38:1129-31.
110. Price TM, McCoy EP. Emergency front of neck access in airway management. BJA Educ 2019; 19:246-53.
112. Scrase I, Woollard M. Needle vs surgical cricothyroidotomy: a short cut to effective ventilation. Anaesthesia 2006; 61:962-74.
113. McKenna P, Desai NM, Tariq A, Morley EJ. Cricothyrotomy [updated 2023 Feb 4]. In: StatPearls [Internet]. StatPearls Publishing; [cited 2024 Jan 31]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537350/.
114. Erlandson MJ, Clinton JE, Ruiz E, Cohen J. Cricothyrotomy in the emergency department revisited. J Emerg Med 1989; 7:115-8.
115. Bair AE, Panacek EA, Wisner DH, Bales R, Sakles JC. Cricothyrotomy: a 5-year experience at one institution. J Emerg Med 2003; 24:151-6.
116. Spaite DW, Joseph M. Prehospital cricothyrotomy: an investigation of indications, technique, complications, and patient outcome. Ann Emerg Med 1990; 19:279-85.
117. Rothstein J, Gullo J, Cuningham L, Murphy P, Sochor M. Training emergency medicine residents-the skill of endotracheal intubation: comparison of human cadavers vs mannequins. Panam J Trauma Crit Care Emerg Surg 2014; 3:8-10.
118. Saracoglu K, Saracoglu A. Airway management education: an update. It is high time to realize professional airway training as an art. Acta Anaesth Belg 2017; 68:175-86.
119. Kennedy CC, Cannon EK, Warner DO, Cook DA. Advanced airway management simulation training in medical education: a systematic review and meta-analysis. Crit Care Med 2014; 42:169-78.
120. Airway Management Education Center (AMEC). The Difficult Airway Course: Emergency [Internet]. AMEC; [cited 2024 Jan 31]. Available from: https://www.theairwaysite.com/a-course/the-difficult-airway-course-emergency/.
121. Royal College of Anesthetists. UK Training Emergency Airway Management (TEAM) [Internet]. Royal College of Anesthetists; [cited 2024 Jan 31]. Available from: https://rcoa.ac.uk/events/uk-training-emergency-airway-management-team-2.
122. Canadian Association of Emergency Physicians (CAEP). Airway Intervention and Management in Emergencies (AIME) [Internet]. CAEP; [cited 2024 Jan 31]. Available from: https://caep.ca/cpd-courses/aime/.
123. Korean Emergency Airway Management Society (KEAMS). Airway courses [Internet]. KEAMS; [cited 2024 Jan 31]. Available from: https://keams.or.kr/english/index.php#.
124. Hickman J, McNarry AF, Kelly FE. Practical strategies for delivering airway training in the COVID-19 era. Br J Anaesth 2021; 127:188-91.
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