Airways and ICU – SOA25 Updates

So, for the next big topic at SOA25, we have the ICU airway!

Who have we speaking on this then?

Andy Higgs

Andy Higgs, a Professor of Intensive Care Medicine (ICM) and Anaesthesia, is a Consultant at Warrington Hospitals, Cheshire. With training in Liverpool, North West England, and Melbourne, Australia, he has a long-standing interest in airway management, particularly in the ICU setting. His expertise includes extubation strategies and managing difficult airways in critically ill patients. Professor Higgs is a faculty member of the Aintree Difficult Airway Management course and co-authored the Difficult Airway Society (DAS) Extubation Guidelines (2012). He also chairs the joint Royal College of Anaesthetists, Faculty of Intensive Care Medicine, and DAS group working on guidelines for airway management in the critically ill, making him a key contributor to the session’s focus on the DAS/ICS Tracheal Intubation Update 2025 and strategies to prevent unrecognised oesophageal intubation.

Ellen O’Sullivan

Professor Ellen O’Sullivan, an expert in Anaesthesia, brings extensive experience in airway management to the SQA25 Congress. While specific details of her background are not fully outlined in the poster, her title and involvement suggest a deep knowledge of anaesthetic techniques and airway safety in critical care settings. Her participation likely focuses on practical guidance for managing airway trauma and C-spine injuries, areas where anaesthesia plays a critical role in ensuring patient safety during intubation and other procedures.

Guri Sandhu

Professor Guri Sandhu, a specialist in Laryngology and ENT, is a leading figure in airway surgery and voice management. Based on available information about his profile, he has a large practice managing voice problems and receives referrals from the music industry, media, and stage. His honors include Honorary Fellowship of the Royal Academy of Music, ENT Surgeon to The Royal Society of Musicians, and the only British ENT surgeon to be made a fellow of the American Laryngological Association. Professor Sandhu’s expertise is directly relevant to the session’s focus on tracheostomy care and managing airway trauma, as he likely provides insights into surgical techniques and long-term airway management strategies for ICU patients.

Sarah Wallace OBE

Professor Sarah Wallace, a Speech and Language Therapist (SLT), is a renowned expert in communication and dysphagia management in critical care. She works clinically in cardiothoracic, ECMO, and general critical care in Manchester and has over 60 publications, several of which are top-cited and have won awards from the BMJ and ICS. She holds expert advisor roles with the ICS, the National Tracheostomy Safety Project, and the Royal College of Speech and Language Therapists (RCSLT). Professor Wallace has pioneered new treatments for laryngeal recovery in ICU, setting up the first Fibreoptic Endoscopic Evaluation of Swallowing (FEES) service in Asia and the UK. Her expertise directly addresses the session’s emphasis on communication challenges in ICU airway management, particularly for tracheostomy patients, and she likely contributes to strategies for improving patient outcomes through better verbal communication and swallowing rehabilitation.

Fauzia Mir

Fauzia Mir, a Consultant Anaesthetist, brings practical experience in airway management to the SQA25 Congress. While her specific background isn’t detailed in the poster, her role as a consultant suggests expertise in tracheal intubation, managing difficult airways, and ensuring patient safety during critical procedures. Her contribution likely focuses on the practical aspects of the DAS/ICS Tracheal Intubation Update 2025 and strategies to manage airway trauma and C-spine injuries, drawing on her experience in high-stakes ICU environments.

Collectively, these speakers cover a broad spectrum of expertise essential for advancing airway management in the ICU. Andy Higgs and Ellen O’Sullivan provide deep insights into anaesthesia and airway safety, addressing critical topics like unrecognised oesophageal intubation and C-spine injury management. Guri Sandhu’s ENT and laryngology expertise enhances the session’s focus on tracheostomy care and airway trauma. Sarah Wallace’s pioneering work in speech and language therapy directly tackles communication challenges, a vital aspect of ICU care. Fauzia Mir complements the panel with her hands-on anaesthetic experience, ensuring practical guidance for ICU professionals.

Book here!

Advances in Airway Management: Key Updates at SOA25 Congress

Airway management in the intensive care unit (ICU) remains a critical and evolving field, with new evidence, techniques, and technologies shaping safer and more effective practices. The upcoming SOA25 Congress promises to deliver key updates on airway management through collaboration with the Difficult Airway Society (DAS). This session will cover:

• Latest evidence
• Safety updates
• Practical guidance
• DAS/ICS tracheal Intubation Update 2025,
• Strategies for preventing unrecognised oesophageal intubation
• Managing airway trauma and C-spine injuries
• Tracheostomy care
• Communication challenges in the ICU

Advances in Airway Management Techniques and Equipment

Airway management in the ICU has seen significant advancements, focusing on improving safety and outcomes during intubation and tracheostomy procedures. The DAS/ICS Tracheal Intubation Update 2025, to be presented at SOA25, will likely emphasise updated protocols for tracheal intubation, building on previous DAS guidelines.

A key focus is preventing unrecognised oesophageal intubation, a critical error we all know and want to avoid at all costs! Techniques such as capnography remain the gold standard for confirming tube placement, with recent studies reinforcing its importance.

A 2023 paper in Anaesthesia titled “Unrecognised oesophageal intubation: a global challenge” highlighted that despite widespread awareness, this issue persists in 1 in 10,000 intubations globally, underscoring the need for continuous training and adherence to capnography use.

Video laryngoscopy (VL)

We see the debates every day on social media platforms! VL has become a game-changer in ICU airway management. We will approach this in a separate blog shortly.

Devices like the C-MAC and GlideScope have improved first-pass success rates, particularly in patients with difficult airways or C-spine injuries. A 2024 study in Critical Care Medicine titled “Video Laryngoscopy in Critically Ill Patients: A Meta-Analysis” found that VL reduced failed intubation attempts by 30% compared to direct laryngoscopy in ICU settings. These devices provide better visualization of the glottis, which is crucial for patients with limited neck mobility or trauma.

HFNO2

Another advancement is the use of high-flow nasal oxygen (HFNO) for pre-oxygenation and apnoeic oxygenation during intubation. HFNO delivers up to 60 L/min of heated, humidified oxygen, extending safe apnoea time in critically ill patients. A 2024 study in The Lancet Respiratory Medicine titled “High-Flow Nasal Oxygen in ICU Intubation: A Randomised Trial” demonstrated that HFNO reduced the incidence of hypoxaemia during intubation by 15% compared to standard bag-valve-mask ventilation.

• Physiological Benefits of HFNO: theoretical benefits including improved oxygenation, reduced work of breathing, pharyngeal dead space washout, and low-level PEEP, which are particularly beneficial in ITU settings for stabilising patients before or during emergency airway procedures.
• Emergency Airway Management: HFNO’s role in apneic oxygenation (e.g., THRIVE and OPTINIV trials) is critical for extending safe apnea time, reducing desaturation risks during intubation, and supporting difficult airway management in critically ill patients.
• Limitations: Some studies note that HFNO’s benefits may vary by patient population (e.g., immunocompromised or COVID-19 patients) and setting (ICU vs. ED). Careful monitoring is essential to avoid delayed intubation, which can worsen outcomes.

Key Trials on High-Flow Nasal Oxygen in ITU and Emergency Airway Management

1. FLORALI Trial (2015): High-Flow Oxygen vs. Noninvasive Ventilation and Standard Oxygen in Acute Hypoxemic Respiratory Failure
   • Summary: This multicenter, randomized controlled trial (RCT) compared HFNO, noninvasive ventilation (NIV), and standard oxygen therapy in 310 patients with acute hypoxemic respiratory failure in the ICU. HFNO reduced the need for intubation in patients with severe hypoxemia (PaO₂/FiO₂ ≤ 200 mmHg) compared to standard oxygen, though it did not significantly reduce mortality compared to NIV. The trial demonstrated HFNO’s ability to improve oxygenation and reduce respiratory distress, making it relevant for stabilizing patients before emergency airway interventions.
   • Relevance to ITU and Airway Management: HFNO’s ability to provide high FiO₂ and low-level positive end-expiratory pressure (PEEP) makes it a valuable tool for preoxygenation and delaying intubation in emergency airway scenarios, reducing the risk of desaturation during intubation attempts.
2. OPTINIV Trial (2016): HFNO Combined with NIV for Preoxygenation in Hypoxemic Patients
   • Summary: This single-center, blinded RCT investigated the combination of HFNO and NIV for preoxygenation before orotracheal intubation in 50 ICU patients with hypoxemic acute respiratory failure. The trial found that HFNO combined with NIV improved oxygenation and reduced desaturation events during intubation compared to NIV alone, highlighting its utility in emergency airway management.
   • Relevance to ITU and Airway Management: The study underscores HFNO’s role in apneic oxygenation, extending the safe apnea time during intubation, which is critical in critically ill patients with limited oxygen reserves.
3. THRIVE Trial (2015): Transnasal Humidified Rapid-Insufflation Ventilatory Exchange for Airway Management
   • Summary: This RCT compared HFNO (using the THRIVE technique) with facemask preoxygenation in 40 patients undergoing emergency surgery with difficult airways. HFNO significantly extended apnea time (mean 248 seconds vs. 123 seconds) without significant differences in arterial blood gases or laryngoscopy attempts, demonstrating its efficacy in maintaining oxygenation during airway securing procedures.
   • Relevance to ITU and Airway Management: THRIVE’s ability to provide continuous oxygenation during apnea makes it a critical tool for managing difficult airways in the ITU, reducing the risk of hypoxia during intubation.
4. SOHO-COVID Trial (2022): HFNO vs. Standard Oxygen in COVID-19 Respiratory Failure
   • Summary: This RCT, published in JAMA, compared HFNO with conventional oxygen therapy in 711 ICU patients with respiratory failure due to COVID-19. HFNO did not significantly reduce mortality but showed a trend toward lower intubation rates, particularly in patients with higher FiO₂ requirements, suggesting its role in stabilizing patients to avoid invasive ventilation.
   • Relevance to ITU and Airway Management: The trial highlights HFNO’s potential to delay or prevent intubation in severe respiratory failure, which is crucial for managing ICU patients with compromised airways during pandemics or resource-constrained settings.
5. HIGH Trial (2018): HFNO in Immunocompromised Patients with Acute Respiratory Failure
   • Summary: This multicenter RCT evaluated HFNO versus standard oxygen in 776 immunocompromised ICU patients with acute respiratory failure. HFNO did not reduce 28-day mortality but showed a trend toward lower intubation rates, suggesting it may help stabilize patients before definitive airway management.
   • Relevance to ITU and Airway Management: The study supports HFNO as a bridge therapy to improve oxygenation in high-risk immunocompromised patients, potentially reducing the urgency for emergency intubation.
6. HOT-ER Study (2016): HFNO in Emergency Department for Acute Respiratory Distress
   • Summary: This RCT assessed HFNO versus conventional oxygen therapy in 100 emergency department patients with acute respiratory distress. HFNO reduced respiratory rate and improved patient comfort but did not significantly reduce intubation or mortality rates, indicating its role in early stabilization.
   • Relevance to ITU and Airway Management: While conducted in the ED, the findings are applicable to ITU settings, as HFNO can stabilize patients transferred to the ICU, potentially reducing the need for immediate airway intervention.
7. SHINE Trial (2020): HFNO During Neonatal Endotracheal Intubation
   • Summary: This multicenter RCT protocol (results published later) investigated HFNO for stabilization during neonatal endotracheal intubation. While focused on neonates, the study’s principles of apneic oxygenation are relevant to adult ICU settings, where HFNO can support airway management by maintaining oxygenation during intubation attempts.
   • Relevance to ITU and Airway Management: The trial highlights HFNO’s potential to improve procedural safety during intubation, which is critical in emergency airway management in the ITU.

Tracheostomy Care: Innovations and Best Practices

Tracheostomies are a cornerstone of long-term airway management in the ICU, but they come with challenges like infection, tube dislodgement, and communication difficulties. The SOA25 session will explore new insights into tracheostomy care, likely focusing on multidisciplinary approaches involving speech and language therapists, as highlighted by Professor Sarah Wallace OBE’s involvement.

Recent innovations include the use of antimicrobial tracheostomy tubes to reduce ventilator-associated pneumonia (VAP). Silver-coated tubes may reduce VAP rates, but with limited supporting data (20% reduction in VAP rates being reported). Additionally, speaking valves, such as the Passy-Muir valve, have improved communication for tracheostomy patients, enhancing quality of life. Professor Wallace’s expertise in speech and language therapy will likely highlight strategies to integrate these tools effectively.

Key Findings from Early vs. Late Tracheostomy Trials

1. Mortality:
   • Mixed Results on Short-Term Mortality: Some studies suggest early tracheostomy may reduce ICU mortality, while others find no significant difference. However, the TracMan trial (2013) found no significant difference in 30-day mortality between early (≤4 days) and late (≥10 days) tracheostomy groups
   • Long-Term Mortality: Most studies, including a Cochrane review, report no significant difference in long-term mortality (e.g., 1-year follow-up) between early and late tracheostomy
2. Duration of Mechanical Ventilation:
   • Early tracheostomy is often associated with a shorter duration of mechanical ventilation. A 2022 Bayesian meta-analysis reported a 97% posterior probability that early tracheostomy reduces mechanical ventilation duration compared to late tracheostomy Similarly, a 2024 meta-analysis found reduced ventilator days with early tracheostomy (≤7 days)
3. ICU and Hospital Length of Stay:
   • Early tracheostomy is frequently linked to shorter ICU and hospital LOS. A 2018 study by Herritt et al. showed that early tracheostomy significantly reduced ICU LOS and hospital costs, based on a meta-analysis of RCTs. A 2015 meta-analysis also reported a significant reduction in ICU LOS (weighted mean difference, -9.13 days; 95% CI, -17.55 to -0.70)
   • However, some studies, like the TracMan trial, found no significant difference in ICU LOS
4. Ventilator-Associated Pneumonia (VAP):
   • Early tracheostomy may reduce the incidence of VAP. A 2021 meta-analysis found that early tracheostomy (≤7 days) was associated with lower VAP rates. The 2022 Bayesian analysis supported this with a 94% posterior probability of VAP reduction. However, some reviews, such as Hosokawa et al., found no significant reduction in VAP
5. Sedation and Other Benefits:
   • Early tracheostomy is associated with reduced sedation requirements, which can improve patient comfort and facilitate communication. The Herritt et al. study highlighted decreased sedation as a benefit, alongside reduced pain and improved communication.
6. Cost-Effectiveness:
   • Early tracheostomy may reduce hospital costs due to shorter ICU stays. The 2018 Herritt et al. study estimated significant cost savings based on reduced LOS
7. Special Populations:
   • Traumatic Brain Injury (TBI): In TBI patients, early tracheostomy may reduce VAP, ICU LOS, hospital LOS, and mechanical ventilation duration, but it does not consistently reduce mortality and may even increase it in some analyses
   • COVID-19 Patients: Early tracheostomy in COVID-19 patients reduced ICU LOS and mechanical ventilation duration but did not impact mortality
   • Pediatric Patients: In pediatric ICUs, early tracheostomy (≤10 days) reduced VAP incidence and shortened ventilation and PICU stays, but further studies are needed to identify specific patient groups that benefits.

Notable Trials and Reviews

1. TracMan Trial (2013):
   • A multicenter RCT in the UK comparing early (≤4 days) vs. late (≥10 days) tracheostomy in 909 patients. It found no significant difference in 30-day mortality, ICU LOS, or other secondary outcomes. Notably, only 45% of the late group required tracheostomy, suggesting many patients can be extubated without needing the procedure
2. Cochrane Review (2015):
   • Analyzed eight RCTs with 1,977 patients. Found that early tracheostomy (≤10 days) was associated with lower mortality at the longest follow-up (47.1% vs. 53.2%) but no significant difference in 28-day mortality or VAP. Moderate-quality evidence suggested benefits in reducing mechanical ventilation duration and ICU LOS
3. Bayesian Meta-Analysis (2022):
   • Included 19 RCTs with 3,508 patients. Used Bayesian methods to estimate posterior probabilities, finding a 99% probability of benefit for short-term mortality, 94% for VAP reduction, 97% for reduced mechanical ventilation duration, and 97% for shorter ICU LOS with early tracheostomy
4. Siempos et al. (2015):
   • A meta-analysis of 13 RCTs with 2,434 patients reported lower ICU mortality with early tracheostomy but no difference in long-term mortality or VAP. Highlighted the need for further studies on long-term outcomes
5. Herritt et al. (2018):
   • Focused on cost-analysis, finding that early tracheostomy reduced ICU LOS and hospital costs, in addition to clinical benefits like fewer ventilator days and less sedation

Conclusion

The evidence suggests that early tracheostomy (≤10 days) may reduce ICU LOS, mechanical ventilation duration, VAP incidence, and sedation requirements, with potential cost savings. However, its impact on mortality remains inconsistent, with some studies showing a modest reduction in ICU mortality but no long-term benefit. The decision to perform early tracheostomy should be individualized, weighing benefits against risks like procedural complications and unnecessary interventions. Further RCTs with standardized definitions and focus on long-term outcomes are needed to clarify optimal timing. For detailed insights, refer to the linked studies above.

Controversies in Airway Management

Supraglottic Airway Devices

One ongoing controversy is the role of supraglottic airway devices (SADs) in ICU settings. While SADs like the i-gel are widely used in operating rooms, their use in critically ill patients is less established due to concerns about aspiration risk. A British Journal of Anaesthesia article discusses their usage on the ICU. Second-generation SADs with gastric drainage ports may reduce aspiration rates by 25% compared to first-generation devices, suggesting a potential role in emergency airway management when intubation fails.

• Summary: A case report explores the uncommon use of the I-gel supraglottic airway device for prolonged mechanical ventilation in the ICU, specifically for up to 27 hours in a 65-year-old patient. It highlights the device’s safety and utility in emergency airway management, particularly in “cannot intubate, cannot oxygenate” scenarios, and suggests that SADs like I-gel should be readily available in ICUs. The study emphasizes monitoring for complications like mucosal damage or aspiration risk during extended use.
• Summary: (NAP4) examines airway management complications in ICU and emergency settings across the UK, with a focus on supraglottic airway devices. It reports that SADs are increasingly used in critical care for rescue ventilation, with a success rate of over 90% in difficult airway scenarios. The study underscores the importance of SADs in managing unanticipated difficult airways and highlights risks like aspiration and airway trauma.
• Summary: This comprehensive review discusses the role of supraglottic airway devices, particularly the laryngeal mask airway (LMA), in managing difficult airways in ICU settings. It highlights the LMA’s rapid placement and high success rate by less experienced operators compared to endotracheal intubation, making it a critical tool in emergencies. The paper also addresses limitations, such as the lack of definitive protection against aspiration.
• Summary: This paper advocates for third-generation SADs with vision-guided systems, which improve placement accuracy in ICU and emergency settings. It discusses their potential to reduce malpositioning (a common issue with blind insertion techniques) and enhance safety for prolonged use in critical care. The study is significant for proposing advancements in SAD technology for ICU applications.
• Summary: While primarily focused on out-of-hospital cardiac arrest, this randomized clinical trial has implications for ICU settings, comparing SADs (specifically I-gel and LMA Supreme) with tracheal intubation. It found that SADs provided faster and more successful ventilation, particularly by less skilled operators, suggesting their utility in critical care emergencies where rapid airway management is crucial.

C-spine injuries

Another debated area is the management of C-spine injuries during intubation. The traditional approach of manual in-line stabilization (MILS) has been challenged by concerns that it may worsen glottic visualization. Video laryngoscopy has emerged as a safer alternative, as noted earlier, but some experts advocate for awake fibreoptic intubation in high-risk cases. The SOA25 session, featuring experts like Professor Guri Sandhu (Laryngology/ENT), will likely address these controversies and provide practical guidance.

Communication Challenges in Airway Management

Effective communication is vital in ICU airway management, particularly for patients with tracheostomies or those on mechanical ventilation. Speech and language therapists play a crucial role in facilitating communication using tools like communication boards and voice restoration techniques. The involvement of Professor Sarah Wallace at SQA25 underscores the importance of this aspect. A study in Critical Care titled “Communication Strategies for Mechanically Ventilated Patients” emphasised that early intervention by speech therapists reduced patient anxiety and improved satisfaction scores by 40%.

Conclusion

The SQA25 Congress will provide a comprehensive update on airway management in the ICU, covering new techniques, equipment, and evidence-based practices. Advances like video laryngoscopy, high-flow nasal oxygen, and antimicrobial tracheostomy tubes are transforming care, while ongoing controversies around supraglottic airways and C-spine management highlight the need for continued research and training. For critical care professionals, staying informed about these developments is essential for improving patient outcomes. To learn more and register for the congress, visit ics.ac.uk/soa.

---

Written by JW