Airway rescue assist: A critical intervention in airway management

INTRODUCTION

Securing and maintaining a patent airway is the cornerstone of effective resuscitation, anaesthesia, and critical care. While many patients can be managed with basic airway manoeuvres or tracheal intubation, some present with anatomically or physiologically advanced complex airways. As was shown, unexpected difficulty with airway management can occur frequently if standard airway assessment methods are used.[1] A dramatic case of failed airway rescue assist was published in the literature.[2] In such cases, airway rescue assist becomes essential as it can make the difference between life or death. Calling for help is usually straightforward, but if you or your team are the rescuers, the role of an anaesthesiologist requires expertise.

Airway rescue strategies aim to ensure oxygenation and ventilation while avoiding or rapidly resolving hypoxic injury. This editorial outlines the indications, decision-making process, tools, cognitive aids, and techniques used in airway rescue assist and highlights the importance of training and preparedness in reducing complications.

Indications for airway rescue

Airway rescue is initiated when conventional methods fail or are predicted to fail. The various indications include failed intubation attempts (cannot intubate), inability to ventilate the patient (cannot ventilate), rapid desaturation or impending respiratory arrest, anatomic or traumatic airway distortion, airway obstruction unrelieved by basic manoeuvres, and accidental extubation in the intensive care unit. These scenarios are often captured under the “Can’t Intubate, Can’t Oxygenate” (CICO) framework, which requires immediate intervention.

AIRWAY RESCUE TECHNIQUES [TABLE 1]

Table 1.

Airway rescue tools and equipment

Supraglottic devices Videolaryngoscopes Bougie or introducers Cricothyrotomy kits (scalpel-bougie-tube or commercial kits) Jet ventilators or oxygen insufflation devices Capnography (for confirmation of ventilation and intubation) Tracheal stents Bronchial blockers Sugammadex Ultrasound (an emerging tool to locate the cricothyroid membrane) Extracorporeal membrane oxygenation (ECMO)

The various techniques for airway rescue include:

Bag-Valve-Mask (BVM) Ventilation: BVM remains a first-line rescue method when tracheal intubation fails. Correct technique, adequate mask seal, and appropriate airway adjuncts (e.g. oropharyngeal or nasopharyngeal airways) and suction are essential. Two-person BVM technique significantly improves success.[3]

Supraglottic Airway Devices (SADs): Supraglottic devices, such as the laryngeal mask airway (LMA^TM) or I-gel^TM, offer quick and effective ventilation when tracheal intubation is unsuccessful. They serve as bridge devices for ventilation and tracheal intubation and may be definitive in certain contexts. SADs are incorporated in most airway algorithms.

Videolaryngoscopy (VL): VL has improved the success rate of rescue tracheal intubations by enhancing glottic visualisation. It is particularly useful in anticipated or encountered advanced airways with high complexity. A hyperangulated blade, in combination with a stylet, is often necessary when Macintosh-style blades are ineffective.

Flexible Intubation Rescue: Used in situations where anatomical abnormalities preclude direct or indirect laryngoscopy. It requires training and patient cooperation, often used in awake tracheal intubation protocols. Flexible tracheal intubation can be used in anaesthetised patients, and it can also serve as a rescue technique in patients who have regained spontaneous respiration after failed intubation. The flexible scope can also be used in combination with videolaryngoscopy with the hybrid or dual camera intubation technique. This combination is called VAFI: videolaryngoscopy-assisted flexible intubation.

Emergency Front-of-Neck Access (EFONA): When non-invasive methods fail, emergency cricothyrotomy or tracheostomy may be lifesaving. The various techniques include needle cricothyrotomy (using a large-bore cannula to deliver oxygen (temporary), surgical cricothyrotomy (more definitive; involves a scalpel, bougie, and tube), and percutaneous tracheostomy (rarely used emergently, but can be relevant in intensive care unit contexts).

Paraglossal Straight-Blade Intubation: Paraglossal straight blade intubation is an outdated method that utilises a direct laryngoscope and a Miller-style blade to bypass tumour masses or swelling around the epiglottis.[4] This can also be done with modern videostylets.

Acute complete reversal of neuromuscular blockade: Rocuronium can be acutely reversed with sugammadex. In a simulation study, it was demonstrated that several strategies can enhance speed and efficacy.[5] The total dose of sugammadex required for complete reversal should be calculated prior to the procedure. The dose should be based on the total body weight. The drugs should be immediately available in the operating room environment. When opioids are administered during induction of anaesthesia, it is often necessary to reverse these with naloxone.

Tracheal Stents: When airway obstruction is caused by tracheal lesions or stenosis, this can be treated by placing emergency tracheal stents. This is done in collaboration with head and neck surgeons or interventional pulmonologists.

Bronchial Blockers: These devices can be placed in case of pulmonary bleeding to isolate the bleeding focus from the healthy lung.

Extracorporeal Membrane Oxygenation (ECMO): In selected cases, ECMO can be used to rescue the airway, for example, in patients with large mediastinal masses that compress the lower airways.[6]

Decision-making and algorithms

Guidelines from societies such as the Difficult Airway Society, the American Society of Anesthesiologists, and the All India Difficult Airway Association emphasise the importance of pre-emptive planning and the need for rapid rescue in managing unanticipated difficult tracheal intubation.[7] Key elements for an appropriate decision include:

• Assessment: use of airway assessment tools (e.g. Mallampati, LEMON, MOANS, and the airway triage application method)

• Preoxygenation and use of high-flow nasal oxygen to increase safe apnoea time

• Escalation planning and transitioning to the airway rescue phase: recognising failure early and moving to the next steps

• Team communication: clear roles, closed-loop communication, and calling for help early

• A standardised airway algorithm or cognitive aids can help decision-making during high-stress situations.

Cognitive aids

The airway rescue phase consists of both a passive and an active phase. This airway rescue assist checklist can be used as a cognitive aid and is available in the airway triage application method, as shown in Figure 1.[8]

Figure 1.

(a) Passive phase of airway rescue assist; (b) Active phase of airway rescue assist

When coming to the rescue, it is very important to listen to what is needed, observe what the team is doing, and realise that there is a strong psychological factor that may influence the situation. After a short passive phase, the active phase is used to rescue the airway and the patient. The rescue team should not jump to conclusions (fixation error) and should refrain from judgment.

Training and simulation

Simulation-based training is crucial for developing competence and confidence in airway rescue techniques. Team-based drills, “can’t intubate, can’t ventilate” scenarios, and surgical airway practice improve response times and reduce adverse outcomes. Airway rescue assist training should become part of the airway management curriculum.[9] The importance of simulation and frequent drills, even for established practitioners of securing the airway, such as anaesthesiologists, emergency medicine doctors, and technicians, is emphasised.

Communication

In time-pressured environments, lifesaving decisions need to be made quickly by the teams. It is essential to switch to closed-loop communication to prevent errors and ensure accuracy.

In the airline industry, pilots use the “my plane – your plane” phrase to indicate which pilot is flying the plane. I propose that we could do that during an airway crisis and use the phrase “my airway – your airway”. It should be clear who is leading the rescue attempt.

More help needed?

The situation may be very complex or life-threatening. The rescue team should quickly decide if more expert assistance or equipment will be needed.

How to call for help?

Every hospital has its unique system. A resuscitation team may be needed, or an airway rescue team, if available, in large academic centres. Phones, pagers, or alarm buttons can be used to activate these teams. Not only are extra hands often needed, but also advanced airway devices or an expert team.

COMPLICATIONS OF AIRWAY RESCUE

The airway rescue can lead to various complications, including:

• Hypoxia and hypoxic brain injury

• Aspiration

• Airway trauma (e.g. laryngeal or tracheal injury)

• Oesophageal intubation

• Subcutaneous emphysema or pneumothorax (needle cricothyrotomy)

• Infection (tracheostomy-related)

• Death

Prompt recognition and mitigation of these concerns are essential to minimise these risks.

Documentation

It is of utmost importance to document events and the clinical situation accurately and precisely. This is a high-risk event, and it may lead to coroner inquests or malpractice investigations, as we have seen in the past.[2]

CONCLUSION

Airway rescue assist is a critical component of emergency and perioperative airway management. Success hinges on early recognition of complexity, familiarity with rescue techniques, and a structured approach to escalation. Regular training, adherence to evidence-based algorithms, and the availability of appropriate equipment and cognitive aids can significantly enhance patient outcomes in airway emergencies. The concept is akin to a code blue situation, with the airway as the primary goal for maintenance of oxygenation. This approach may be viable in areas of less intense expertise in airway management, such as wards and similar settings, or where trainees are working. However, with the loss of airway in different locations, especially for an airway rescue team, responding within a few minutes would mean a hypoxic event is likely to occur.

Conflicts of interest

The author is the creator of Airway Triage Application but has no personal financial benefits.

Disclosure of use of artificial intelligence (AI)-assistive or generative tools

The authors confirm that no AI tools or language models (LLMs) were used in the writing or editing of the manuscript, and no images were manipulated using AI.

Declaration of use of permitted tools

The figures are my own copyright, and it is used in Airway Triage Application.

Authors contributions

JMH: Concept, writing, and editing.

Presentation at conferences/CMEs and abstract publication

Not Applicable.

Study data availability

Not Applicable.

Supplementary material

This article has supplementary material and can be accessed at this link. Supplementary Material at http://links.lww.com/IJOA/A38.

SUPPLEMENTARY MATERIAL

https://vimeopro.com/airwaymanagementacademy/airway-management-academy-multimedia-library/video/820157978

Funding Statement

Nil.