Evolution of Emergency Airway Management From Anatomical Prediction to a Systems-Based Resuscitative Approach in the Emergency Department: A Narrative Review.

Airway management in the emergency department (ED) is one of the most critical and time-pressured procedures in acute care medicine. Patients frequently present with severe physiological compromise, including severe hypoxia, hemodynamic instability, shock, altered mental status, trauma, or cardiac arrest, leaving clinicians with minimal preparation time and incomplete clinical information. While anatomical predictors of laryngoscopic difficulty have traditionally guided pre-intubation assessment, growing evidence suggests that the greatest threats during emergency airway management are often physiological rather than anatomical. Conditions such as profound hypoxemia, hemodynamic instability, metabolic acidosis, and severe respiratory failure significantly increase the risk of peri-intubation complications, including cardiovascular collapse and cardiac arrest, regardless of airway anatomy. PubMed, Google Scholar, and Scopus were searched from January 2000 through December 2025 using structured Boolean search terms, supplemented by hand-searching reference lists and relevant society guidelines. Relevant studies were selected according to predefined eligibility criteria and synthesized narratively. Among the included studies, physiological instability, particularly hypoxemia, metabolic acidosis, and circulatory shock, was consistently associated with an increased risk of peri-intubation cardiac arrest and appeared to be at least as important as bedside anatomical findings in emergency airway risk assessment. Current evidence supports a structured approach to emergency airway management that includes physiological optimization before laryngoscopy, use of the HEAVEN criteria for airway risk stratification, individualized drug selection based on the patient's hemodynamic status, structured airway bundles, video laryngoscopy as the preferred primary intubation device in appropriate emergency airway settings, and team-based cognitive tools such as the Vortex Approach. The DEVICE randomized trial demonstrated a 14.3-percentage-point improvement in first-pass success with video laryngoscopy versus direct laryngoscopy in critically ill adults. Prospective validation of these approaches in lower-resource settings, with neurological recovery rather than intubation success alone as the primary outcome, remains an important research priority.