Author: Flora Liu, MD
IARS and SOCCA 2026 Annual Meeting coverage
Difficult airway management has traditionally focused on anatomic challenges. However, critically ill patients may have a physiologically difficult airway, in which severe disturbances in oxygenation, circulation, or neurologic function place them at risk of cardiovascular collapse during intubation and the transition to positive-pressure ventilation.
At the 2026 IARS and SOCCA Annual Meeting, experts reviewed the dangers of ICU intubation, strategies to improve preoxygenation and hemodynamic stability, and the need for standardized education across specialties.
Ravindra Alok Gupta, MD, described conditions associated with a physiologically difficult airway, including:
- Severe hypoxemic respiratory failure
- Hemodynamic instability
- Right ventricular dysfunction
- Obesity
- Pregnancy
- Elevated intracranial pressure
Intubation in the ICU is considerably more dangerous than elective intubation in the operating room. The INTUBE study found that 45.2% of critically ill patients experienced at least one major peri-intubation adverse event.
Cardiovascular instability occurred in 42.6%, hypoxemia in 9.3%, and cardiac arrest in 3.1% of patients.
These risks are worsened by limited space, unfamiliar teams, urgent circumstances, and difficulties obtaining equipment or assistance. A structured preintubation checklist involving the airway clinician, ICU team, and bedside nursing staff can identify risks and clarify the plan before medications are administered.
A brief postintubation debrief can also identify complications, confirm stabilization, and improve future team performance. Together, these steps require less than five minutes and may reduce adverse events.
Craig S. Jabaley, MD, FCCM, reviewed methods to prevent severe hypoxemia and cardiovascular collapse. Ventilation-perfusion mismatch and intrapulmonary shunting are major causes of hypoxemia in critically ill patients.
Increasing the inspired oxygen concentration alone may not correct hypoxemia caused by significant shunt physiology. Positive end-expiratory pressure can improve preoxygenation by recruiting collapsed alveoli and increasing the amount of oxygen stored in the lungs before apnea.
The OPTINIV trial found that noninvasive ventilation provided better preoxygenation than high-flow nasal oxygen or conventional oxygen therapy. Noninvasive ventilation may be particularly useful in patients with severe hypoxemia or significant alveolar collapse.
The INTUBE data also demonstrated that mortality increases as the number of intubation attempts rises. Clinicians should therefore prioritize first-pass success by selecting the most experienced operator, appropriate positioning, video laryngoscopy when indicated, and a clearly defined backup plan.
Preventing cardiovascular collapse during induction is equally important. Propofol was identified as one of the most modifiable factors associated with adverse peri-intubation outcomes in critically ill patients because of its potential to cause vasodilation and myocardial depression.
A 2025 randomized trial involving 2,365 critically ill adults found no difference in 28-day mortality between ketamine and etomidate for rapid-sequence intubation. However, ketamine was associated with a slightly higher rate of hemodynamic instability.
The choice of induction medication should therefore be individualized according to the patient’s blood pressure, cardiac function, catecholamine reserve, and underlying disease rather than based on a universal preference.
Mary Jarzebowski, MD, discussed the educational challenges surrounding physiologically difficult airway management. Anesthesiologists, emergency physicians, intensivists, pulmonologists, and surgeons all perform airway management in critically ill patients, but certification standards do not consistently define the necessary physiological competencies.
The CASCADE initiative—Curriculum for Airway Skills in Critically Ill Adults: A Delphi Evaluation—brought together educators from several specialties to identify the core knowledge and skills needed for these cases.
Proposed curriculum areas include:
- Patient-specific physiological risk factors
- Preintubation assessment and optimization
- Oxygenation and ventilation strategies
- Hemodynamic preparation
- Selection of induction medications
- Core and advanced airway skills
- Team communication
- Crisis management
- Competency assessment
The goal is to create a standardized curriculum that can be adapted to different specialties, institutions, and resource environments.
Key Takeaways
A difficult airway is not defined only by challenging anatomy. Severe hypoxemia, shock, right ventricular failure, obesity, pregnancy, and elevated intracranial pressure can make an otherwise straightforward intubation life-threatening.
ICU intubation carries a high incidence of cardiovascular instability, hypoxemia, and cardiac arrest. Clinicians should treat every critically ill airway as a high-risk procedure requiring preparation and team coordination.
Noninvasive ventilation with positive end-expiratory pressure may provide better preoxygenation than conventional oxygen therapy, particularly in patients with significant shunt physiology.
First-pass success is essential because repeated attempts are associated with worse outcomes.
Propofol should be used cautiously in unstable critically ill patients. Ketamine and etomidate have similar mortality outcomes, but the induction medication should be selected according to the patient’s individual physiology.
Brief checklists and team debriefs can improve communication and reduce preventable complications.
Cross-specialty education is necessary so that clinicians learn not only how to place an endotracheal tube but also how to stabilize the patient’s physiology before, during, and after intubation.
Thank you to IARS and SOCCA for allowing us to summarize this important coverage from the 2026 Annual Meeting.