The aims of this study were: To describe the prevalence of Emergency Department (ED) airway management failures requiring rescue maneuvers, to describe successful rescue methods used when the primary method chosen is unsuccessful, and to characterize the roles of emergency physicians and other specialists in rescue airway management. A prospective observational study was conducted of ED airway management in 30 hospitals in the USA, Canada, and Singapore participating in the National Emergency Airway Registry (NEAR) database project. Patients were entered in the study if they underwent ED airway management, the first method chosen was not successful in achieving intubation, and a rescue technique was required. Data were collected on a structured data form for entry into a relational database with subsequent search for subjects fulfilling inclusion and exclusion criteria. Descriptive statistics were used for analysis of these data. There were 7,712 patients identified who underwent emergency intubation during the study period from January 1998 to February 2001. A total of 207 (2.7%) patient intubations met the inclusion criteria. Of these, 102 (49%) patients underwent rescue rapid sequence intubation (RSI). RSI was used after failure of oral intubation with sedation alone (n = 29), oral intubation without medications (n = 37), or blind nasotracheal intubation (n = 36). Forty-three (21%) patients underwent rescue cricothyrotomy after failure of RSI (n = 26) or other intubation methods (n = 17). Seventy-nine percent of rescue RSIs and 53% of rescue surgical airways were performed by emergency physicians. In conclusion, a total of 2.7% of emergency intubations required rescue. RSI is the most commonly used first line technique for ED airway management and is also the principal back-up technique when other oral or nasal intubation methods fail. Emergency physicians manage the majority of ED intubations, including those requiring rescue techniques.