When air meets uncertainty, judgment matters most. We dig into the evolving landscape of airway management where video laryngoscopy, supraglottic devices, and even ECMO promise better outcomes, yet cognitive errors and non‑OR settings still account for many of the most devastating events. Drawing on recent studies, malpractice claims, and national audits, we map the pressure points that turn a difficult intubation into a crisis and show how to defuse them with clearer plans, tighter teamwork, and sharper skills.

We start with three high‑yield rules that change outcomes fast: cap the number of attempts, anticipate physiologic crashes, and switch early to rescue strategies. From there, we unpack the INTUBE findings on hypoxemia and cardiovascular instability, plus data showing how repeated attempts compound failure. Video laryngoscopy gets a balanced look: why it lifts first‑pass success across ED and ICU intubations, and how overreliance can silently erode direct laryngoscopy and awake fiberoptic competence. Expect practical strategies to preserve breadth: intentional DL reps, awake FOI workshops, and shared mental models that define time limits and bailout triggers.

We also tackle unsettled ground. Aspiration risk reduction remains murky; cricoid pressure under general anesthesia has not delivered clear benefits, and robust trials comparing asleep rapid‑sequence to awake, topicalized methods in high‑risk patients are missing. We offer a decision lens to tailor approach by anatomy, physiology, and available expertise. For extreme airways—think massive goiter or tracheal compression—we explore where ECMO fits: preemptive, standby, or rescue. You’ll hear how activation criteria, cannulation readiness, and interprofessional rehearsal turn a complex tool into a safety net rather than a new hazard.

By the end, you’ll have a cleaner playbook: plan A–D that you can execute under stress, a review of device trade‑offs, and concrete ways to reduce cognitive traps that drive harm. If this conversation sharpens your next airway, share it with a colleague, subscribe for future episodes, and leave a quick review to help others find the show.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/294-from-video-laryngoscopy-to-ecmo-what-keeps-airway-management-safe/

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