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Airway Management: From Basic Techniques to Innovative Technologies
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Airway Management: From Basic Techniques to Innovative Technologies

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Intensive Care".

Deadline for manuscript submissions: 25 March 2026 | Viewed by 10512

Special Issue Editors

Dr. Kunal Karamchandani

E-Mail Website
Guest Editor
Division of Critical Care Medicine, Department of Anaesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
Interests: physiologically difficult airway; airway management; critical illness; patient outcomes; perioperative care; substance use disorders
Prof. Dr. Sheila Nainan Myatra

E-Mail Website
Guest Editor
Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
Interests: physiologically difficult airway; airway management; critical illness; hemodynamic monitoring; sepsis and end of life care

Special Issue Information

Dear Colleagues,

Airway management for surgical procedures under general anesthesia as well as in critically ill patients has significant challenges and may be associated with poor patient outcomes. Clinicians involved with airway management have to take into account anatomic, physiological, and/ or logistical challenges during this process. While traditional approaches to airway management have stood the test of times, the advent of new techniques, devices, and technologies in this field is likely to impact patient outcomes in a positive way. Innovations in patient and airway operator optimization, performance of the procedure, and post tracheal intubation care are essential to advancing the field of airway management. The aim of this Special Issue is to provide a comprehensive overview of some of the time-tested basic techniques of airway management, while also discussing some of the newer advances in this field, along with future opportunities for innovation. Therefore, clinicians involved with airway management are encouraged to submit their original research and review articles to this Special Issue.

Dr. Kunal Karamchandani
Prof. Dr. Sheila Nainan Myatra
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 250 words) can be sent to the Editorial Office for assessment.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • airway management
  • physiologically difficult airway
  • videolaryngoscopy
  • esophageal intubation
  • artificial intelligence

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Published Papers (7 papers)

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Research

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13 pages, 1079 KB  
Article
Ultrasound-Measured Skin-to-Epiglottis Distance as a Predictor of Difficult Intubation in Obese Patients: A Prospective Observational Study
by Kazım Ersin Altınsoy and Bahar Uslu Bayhan
J. Clin. Med. 2025, 14(6), 2092; https://doi.org/10.3390/jcm14062092 - 19 Mar 2025
Cited by 4 | Viewed by 1948
Abstract
Background/Objectives: Difficult intubation is a significant clinical issue in emergency medicine as well as anesthesia practice, occurring more frequently in obese patients. Traditional assessment methods may not be sufficient to predict difficult intubation. This study aims to evaluate the ability of ultrasound-measured [...] Read more.
Background/Objectives: Difficult intubation is a significant clinical issue in emergency medicine as well as anesthesia practice, occurring more frequently in obese patients. Traditional assessment methods may not be sufficient to predict difficult intubation. This study aims to evaluate the ability of ultrasound-measured skin-to-epiglottis distance (SED) to predict difficult laryngoscopy in obese patients and investigate its applicability in clinical practice. Methods: This prospective observational study was conducted between February 2024 and January 2025 at Gaziantep City Hospital on obese patients undergoing bariatric surgery. Patients aged 18 years and older with an American Society of Anesthesiologists (ASA) classification of I-II-III were included in the study. Demographic data, standard airway assessment parameters (neck circumference, thyromental distance, sternomental distance, etc.), and ultrasound-measured skin-to-epiglottis distance were recorded. All intubation procedures were performed by a single experienced anesthesiologist following standard protocols, and laryngoscope view was assessed according to the Cormack–Lehane classification. Results: Among the 61 patients included in the study, 16.4% were classified as having a difficult airway, and 13.1% experienced difficult intubation. No significant correlation was found between standard airway assessment parameters and difficult intubation. However, ultrasound-measured skin-to-epiglottis distance (SED) was significantly higher in patients with difficult intubation (p = 0.004), making it a strong predictor. Additionally, modified Mallampati (p < 0.001), modified Cormack–Lehane (p = 0.003), and Wilson scores (p = 0.001) were significant in predicting difficult airway, although Wilson score was not significant for difficult intubation (p = 0.099). Conclusions: Our study suggests that ultrasound-measured skin-to-epiglottis distance may be a valuable predictor of difficult intubation in obese patients. Given the limitations of preoperative assessment methods, incorporating ultrasound into airway evaluation as a complementary tool provides significant benefits. Larger-scale studies in the future are necessary to further assess the clinical efficacy of this method. Full article
(This article belongs to the Special Issue Airway Management: From Basic Techniques to Innovative Technologies)
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Review

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22 pages, 374 KB  
Review
Human Factors in Airway Management: Designing Systems for Safer, Team-Based Care
by Manuel Á. Gómez-Ríos, Pavel Michalek, Tomasz Gaszyński and André A. J. Van Zundert
J. Clin. Med. 2025, 14(24), 8850; https://doi.org/10.3390/jcm14248850 (registering DOI) - 14 Dec 2025
Abstract
The increasing complexity of airway management, particularly in high-stakes or emergency settings, demands a holistic approach that accounts not only for technical skill but also for the systems in which clinicians operate. Advances in airway devices such as videolaryngoscopes, videolaryngeal mask airways, flexible [...] Read more.
The increasing complexity of airway management, particularly in high-stakes or emergency settings, demands a holistic approach that accounts not only for technical skill but also for the systems in which clinicians operate. Advances in airway devices such as videolaryngoscopes, videolaryngeal mask airways, flexible intubation scopes, combined techniques, and single-use technologies offer new opportunities for improving outcomes—but also introduce new challenges. This article explores the intersection of human factors and the implementation of new airway devices, using a systems-based lens informed by the SEIPS 3.0 framework. Drawing on recent guidelines, real-world case studies, and design principles, we examine how technological changes affect team dynamics, decision-making, equipment layout, and cognitive load. We also highlight the importance of standardized processes, training, and environmental design in mitigating risk and enhancing performance. Ultimately, we propose actionable strategies to integrate human factors into airway device adoption to improve both patient safety and clinician well-being. This review underscores the fact that embedding human factor principles into the adoption and use of airway technologies is essential to build safer, more resilient, and team-centered airway management systems. Full article
(This article belongs to the Special Issue Airway Management: From Basic Techniques to Innovative Technologies)
22 pages, 481 KB  
Review
Artificial Intelligence for Predicting Difficult Airways: A Review
by Meruyert Alatau, Johann Bauer and Vitaliy Sazonov
J. Clin. Med. 2025, 14(23), 8600; https://doi.org/10.3390/jcm14238600 - 4 Dec 2025
Viewed by 342
Abstract
Background: Accurately predicting difficult airways is essential to ensuring patient safety in anesthesiology and emergency medicine. However, traditional assessment tools often lack sufficient sensitivity and specificity, particularly in high-pressure or resource-limited settings. Artificial intelligence (AI) and machine learning (ML) have emerged as [...] Read more.
Background: Accurately predicting difficult airways is essential to ensuring patient safety in anesthesiology and emergency medicine. However, traditional assessment tools often lack sufficient sensitivity and specificity, particularly in high-pressure or resource-limited settings. Artificial intelligence (AI) and machine learning (ML) have emerged as promising tools for enhancing airway assessment. Objective: This review evaluates the performance of AI- and ML-based models for predicting difficult airways and compares them with traditional clinical methods. The review also analyzes the models’ methodological robustness, clinical applicability, and ethical considerations. Methods: A comprehensive literature search was conducted across PubMed, Web of Science, and Scopus to identify studies published between 2020 and 2025 that employed AI/ML models to predict difficult airways. Both original research and review articles were included. Key metrics, such as the area under the curve (AUC), sensitivity, and specificity, were extracted and compared. A qualitative analysis was performed to focus on dataset characteristics, validation strategies, model interpretability, and clinical relevance. Results: AI models demonstrated superior performance compared to traditional assessment tools. The MixMatch semi-supervised deep learning (DL) model achieved the highest performance (area under the curve [AUC] of 0.9435, sensitivity of 89.58%, and specificity of 90.13%). Models that used facial imaging combined with deep learning consistently outperformed those that relied solely on clinical parameters. However, methodological heterogeneity, a lack of standardized evaluation metrics, and limited population diversity impeded cross-study comparability. Few studies incorporated interpretability frameworks or addressed ethical challenges related to data privacy and algorithmic bias. Conclusions: AI and ML models have the potential to transform the assessment of difficult airways by improving diagnostic accuracy and enabling real-time clinical decision support. Full article
(This article belongs to the Special Issue Airway Management: From Basic Techniques to Innovative Technologies)
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13 pages, 1022 KB  
Review
Preoxygenation in the ICU
by Clément Monet, Mathieu Capdevila, Inès Lakbar, Yassir Aarab, Joris Pensier, Audrey De Jong and Samir Jaber
J. Clin. Med. 2025, 14(20), 7305; https://doi.org/10.3390/jcm14207305 - 16 Oct 2025
Viewed by 2888
Abstract
Tracheal intubation is a frequent and high-risk procedure in the intensive care unit (ICU). Unlike elective intubation in the operating room, ICU intubation is often performed under emergent conditions in physiologically unstable patients, leading to increased technical difficulty and higher complication rates. Among [...] Read more.
Tracheal intubation is a frequent and high-risk procedure in the intensive care unit (ICU). Unlike elective intubation in the operating room, ICU intubation is often performed under emergent conditions in physiologically unstable patients, leading to increased technical difficulty and higher complication rates. Among these, hypoxemia is particularly frequent and represents a major determinant of morbidity and mortality. Optimizing preoxygenation is therefore a cornerstone of safe airway management in critically ill patients. The aim of this review is to explore the advantages and limitations of each preoxygenation strategy and to provide clinicians with clear, practical guidance to optimize airway management in the ICU. Preoxygenation aims to increase oxygen reserves in order to prolong the duration of safe apnea. Conventional methods include high-flow oxygen delivery through a tightly fitted face mask, though efficacy depends on minimizing leaks. More advanced strategies include non-invasive ventilation (NIV), which improves both alveolar oxygen fraction and lung volume, and high-flow nasal cannula (HFNC), which additionally allows apneic oxygenation during intubation. Randomized controlled trials, including the recent PREOXY study, demonstrate the superiority of NIV over facemask preoxygenation in reducing peri-intubation desaturation, particularly in hypoxemic patients. HFNC is valuable when NIV is contraindicated, while combined approaches (NIV plus HFNC) may further enhance efficacy. Beyond technique, structured protocols and team organization are crucial to reduce complications. In conclusion, preoxygenation is an essential, patient-specific intervention that mitigates the risks of ICU intubation. Familiarity with available methods enables clinicians to tailor strategies, optimize oxygenation, and improve patient safety during this high-risk procedure. Full article
(This article belongs to the Special Issue Airway Management: From Basic Techniques to Innovative Technologies)
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10 pages, 1342 KB  
Review
Review of Neurostimulation Therapies for Obstructive Sleep Apnea: Hypoglossal Nerve Stimulation and Beyond
by Patrícia dos Santos Cé, Maria Eduarda Schiestl Melo, Alan Alves Machado, Sarah Eden Ridge and Thomaz Fleury Curado
J. Clin. Med. 2025, 14(15), 5494; https://doi.org/10.3390/jcm14155494 - 4 Aug 2025
Viewed by 3675
Abstract
Obstructive sleep apnea (OSA) is a sleep-related respiratory disorder characterized by partial or complete obstruction of the upper airway, typically resulting in a decrease in arterial oxygen saturation and repeated awakenings from sleep. It is the most common sleep-related respiratory disorder, affecting 9% [...] Read more.
Obstructive sleep apnea (OSA) is a sleep-related respiratory disorder characterized by partial or complete obstruction of the upper airway, typically resulting in a decrease in arterial oxygen saturation and repeated awakenings from sleep. It is the most common sleep-related respiratory disorder, affecting 9% to 38% of adults. OSA is associated with loss of tone, improper contraction of the tongue, and pharyngeal dilator muscles of the upper airway during sleep. The gold-standard treatment for moderate-to-severe OSA is continuous positive airway pressure (CPAP). However, many patients have poor long-term compliance with CPAP. Stimulation of the upper airway with electrical activation of the hypoglossal nerve has emerged as a promising treatment for patients with moderate-to-severe OSA who have failed CPAP therapy. Objectives: The present paper aims to review the literature regarding neurostimulation for the treatment of OSA. Conclusions: Hypoglossal nerve stimulation (HNS) has shown favorable success and low morbidity in the management of moderate-to-severe OSA. Full article
(This article belongs to the Special Issue Airway Management: From Basic Techniques to Innovative Technologies)
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Other

Jump to: Research, Review

9 pages, 6757 KB  
Project Report
Airway Proficiency and Efficiency Amongst Anesthesia Providers and Respiratory Therapists: A Comparison Study
by Calleigh G. Brignull, Emily B. Williams, Harper A. Sprouse, Kyle J. Adams, Stephanie L. Tanner, John W. Sykes, Henry Moulder, William R. Hand and Robert R. Morgan, Jr.
J. Clin. Med. 2025, 14(22), 8059; https://doi.org/10.3390/jcm14228059 - 13 Nov 2025
Viewed by 276
Abstract
Background/Objectives: Studies have demonstrated significant morbidity and mortality associated with airway management, especially when provided outside of the operative setting. The goal of this study was to compare baseline measurements of airway management procedures between anesthesia providers (CRNAs and anesthesiologists) and respiratory [...] Read more.
Background/Objectives: Studies have demonstrated significant morbidity and mortality associated with airway management, especially when provided outside of the operative setting. The goal of this study was to compare baseline measurements of airway management procedures between anesthesia providers (CRNAs and anesthesiologists) and respiratory therapists using high-fidelity manikins. Methods: This prospective study assessed anesthesia providers and respiratory therapists performing direct laryngoscopy (DL), video laryngoscopy (VL), and LMA placement. The same Laerdal SimMan high-fidelity manikin (Laerdal, Stavanger, Norway) was used in all assessments, with the detection of end-tidal “carbon dioxide” serving as evidence of success for each procedure. Each procedure was performed twice, once under “Healthy Patient” SimMan settings, and once under the “Limited Cervical Range of Motion (ROM)” (DL), “Pharyngeal Obstruction” (VL), and “Full Tongue Edema” (LMA) settings, respectively, to simulate a moderately difficult airway. The order in which the techniques were performed was randomized for each participant. Completion time and number of attempts were recorded for each procedure and compared between the groups. Results: Sixty-two providers (30 anesthesia providers and 32 respiratory therapists) were enrolled. There were no significant differences in average time to completion for any procedure, except respiratory therapists took longer than anesthesia providers in VL with simulated pharyngeal obstruction (p = 0.0004). There were no differences in number of attempts needed for successful completion. Conclusions: This study demonstrates that while completion times for DL and LMA placement were similar amongst provider groups, average time to completion of VL for respiratory therapists was longer under difficult simulated settings. These results reflect potential areas of improvement for other provider groups that may have airway privileges at their respective institutions. Full article
(This article belongs to the Special Issue Airway Management: From Basic Techniques to Innovative Technologies)
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17 pages, 1427 KB  
Systematic Review
Suction-Assisted Laryngoscopy and Airway Decontamination (SALAD) for Emergency Airway Management: A Systematic Review of Evidence and Implementation
by Saniyah Shaikh, Hamad Hejazi, Safwaan Shaikh, Adeeba Sajid, Rida Shahab, Ayesha Deed, Rida Afnan, Anam Hashmi, Raiyan Ehtesham Ahmed Sharieff, Asfiya Naureen and Marcelo A. F. Ribeiro, Jr.
J. Clin. Med. 2025, 14(20), 7430; https://doi.org/10.3390/jcm14207430 - 21 Oct 2025
Viewed by 744
Abstract
Background: Emergency airway management is a crucial and complex procedure frequently performed in the emergency department (ED). Airway contamination usually caused by blood, secretions, and emesis impairs ventilation, reduces successful intubation, and increases the complication rates, leading to difficult laryngoscopy, delayed intubation, [...] Read more.
Background: Emergency airway management is a crucial and complex procedure frequently performed in the emergency department (ED). Airway contamination usually caused by blood, secretions, and emesis impairs ventilation, reduces successful intubation, and increases the complication rates, leading to difficult laryngoscopy, delayed intubation, and increased mortality rates. One technique employed to decontaminate these airways when standard approaches fail is Suction-Assisted Laryngoscopy and Airway Decontamination (SALAD). Methods: A comprehensive literature search was conducted across PubMed, Cochrane, and Science direct databases following a specific search strategy. All search results were screened in a two-stage process (title–abstract and full-text screening) in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 guidelines. Data from finalized articles were extracted using a standardized excel file developed a priori. Lastly, quality and risk of bias were assessed using appropriate tools according to respective study designs, and data were narratively synthesized. Results: A total of 224 records were identified. Upon screening, seven studies were included consisting of five simulation-based studies and two clinical case reports. Simulation studies reported that SALAD training significantly improved first-pass intubation success (53.7–90.2%), reduced time to intubation (up to 30 s), and enhanced airway visualization. Clinical cases further reported successful first-pass intubation in patients with massive airway contamination without complications. Overall, across both study types, the SALAD technique improved airway management performance, provider confidence, and airway contamination control compared to standard suction techniques. Conclusions: This systematic review highlights the benefits of the SALAD technique by enhancing airway visualization, reinforcing it as a significant tool for contaminated airway management. Trainees who underwent SALAD training demonstrated improved first-pass intubation success, reduced intubation time, and increased operator confidence. While data from the included studies seems promising, most studies are small simulation-based studies with limited clinical outcome data. Given its clinical relevance and educational value, future studies must prioritize high-quality research in clinical environments to establish SALAD’s efficacy and to define its role in integration into prehospital protocols. Full article
(This article belongs to the Special Issue Airway Management: From Basic Techniques to Innovative Technologies)
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