24: Plan E: Veno-Venous Extracorporeal Membrane Oxygenation as a Rescue Strategy for Airway Management: A Single-Center Experience

Introduction: Airway emergencies such as severe tracheal trauma, obstructing airway tumors, and complex anatomical deformities can make intubation or surgical airway difficult, resulting in catastrophic hypoxemia. Conventional difficult-airway algorithms (Plans A–D) may not be feasible in these situations. Veno-venous extracorporeal membrane oxygenation (VV ECMO) offers a “Plan E” strategy by providing extracorporeal oxygenation independent of airway patency, creating a safe bridge for definitive airway, surgical management or recovery. Methods: We retrospectively reviewed all patients supported with extracorporeal life support (ECLS) for airway compromise in the Adan Hospital ICU between 2016 and 2025. Data collected included demographics, airway indication, surgical intervention, ECLS modality (VV ECMO or ECCO2R), and in-hospital survival. Institutional ethical approval was obtained. Results: Six patients required ECLS for airway emergencies. Indications were tracheal injury (n = 3), tracheal mass with failed intubation (n = 1), tracheal stenosis (n = 1), and advanced kyphoscoliosis with difficult intubation (n = 1). VV ECMO was used in four patients, and ECCO2R in two. Surgical intervention was performed in four cases. Overall survival was 83 % (5/6). One patient with extensive tracheal injury did not survive. No major ECLS-related complications were observed. Limitations: This single-center, retrospective case series is limited by small sample size, lack of a comparison group, and limited long-term follow-up. Selection bias may affect generalizability. Conclusions: VV ECMO served as a safe and effective “Plan E” rescue option when conventional airway strategies failed. Early multidisciplinary planning and timely initiation were critical for success. Broader adoption of structured “Plan E” protocols and multicenter collaboration are warranted to refine indications and optimize outcomes. Keywords: Airway management; Extracorporeal membrane oxygenation; Veno-venous ECMO; Difficult airway; Tracheal injury; Airway obstruction; Rescue oxygenation.