2026 FSA Podium and Poster Abstracts

Background: The American Society of Anesthesiologists (ASA) Difficult Airway Algorithm currently lacks sufficient evidence to formally incorporate Extracorporeal Membrane Oxygenation (ECMO) for anticipated difficult airways. Traditionally, Veno-Venous (V-V) ECMO is utilized as a "crash" rescue therapy. However, in cases of severe mechanical obstruction—such as ACE inhibitor-induced angioedema—standard anticipated difficult airway technique escalation to surgical airways may be anatomically impossible or high-risk, and elective V-V ECMO can be an invaluable tool.

Case Description: An 86-year-old male presented with rapidly progressing ACE inhibitor-induced angioedema, characterized by a massively enlarged tongue and bloody oropharyngeal secretions. Due to the high risk of a "cannot intubate, cannot oxygenate" (CICO) scenario and the failure of pharmacological interventions, a multidisciplinary team elected for pre-induction V-V ECMO. Cannulation was performed under local anesthesia while the patient remained awake. Following the initiation of ECMO, which stabilized oxygenation (SaO_2 100%) and reduced work of breathing, a definitive airway was secured via GlideScope and fiberoptic bronchoscopy under controlled sedation. The patient was successfully decannulated 31 hours later and extubated after three days following the resolution of edema.

Discussion: This case illustrates that elective V-V ECMO provides a critical "physiological safety net," transforming a high-stakes emergency into a stable, controlled procedure. While the ASA guidelines prioritize awake fiberoptic or surgical airways, these are often untenable in the presence of massive distorted anatomy and hemorrhage. By establishing gas exchange independent of the upper airway prior to induction, clinicians bypass the risks of rapid desaturation and hypoxic brain injury.

Conclusion: As the data pool for elective ECMO grows, its role should be re-evaluated within the standard difficult airway algorithm. For select patients where traditional and surgical access are deemed unsafe, elective V-V ECMO serves as an efficacious and life-saving bridge to airway security.