Last updated December 21, 2021

Management of the Difficult Airway

Evaluation of the Airway

  • Before the initiation of anesthetic care or airway management, ensure that an airway risk assessment is performed by the person(s) responsible for airway management whenever feasible to identify patient, medical, surgical, environmental, and anesthetic factors (e.g., risk of aspiration) that may indicate the potential for a difficult airway.

    • When available in the patient’s medical records, evaluate demographic information, clinical conditions, diagnostic test findings, patient/family interviews, and questionnaire responses.

    • Assess multiple demographic and clinical characteristics to determine a patient’s potential for a difficult airway or aspiration.

  • Before the initiation of anesthetic care or airway management, conduct an airway physical examination to further identify physical characteristics that may indicate the potential for a difficult airway.

    • The physical examination may include assessment of facial features and assessment of anatomical measurements and landmarks.

    • Additional evaluation to characterize the likelihood or nature of the anticipated airway difficulty may include bedside endoscopy, virtual laryngoscopy/bronchoscopy, or three-dimensional printing.

  • Assess multiple airway features to determine a patient’s potential for a difficult airway or aspiration.

Preparation for Difficult Airway Management

  • Ensure that airway management equipment is available in the room.

  • Ensure that a portable storage unit that contains specialized equipment for difficult airway management is immediately available.

  • If a difficult airway is known or suspected:

    • Ensure that a skilled individual is present or immediately available to assist with airway management when feasible.

    • Inform the patient or responsible person of the special risks and procedures pertaining to management of the difficult airway.

    • Properly position the patient, administer supplemental oxygen before initiating management of the difficult airway, and continue to deliver supplemental oxygen whenever feasible throughout the process of difficult airway management, including extubation.

  • Ensure that, at a minimum, monitoring according to the ASA Standards for Basic Anesthesia Monitoring are followed immediately before, during, and after airway management of all patients.

Anticipated Difficult Airway Management

  • Have a preformulated strategy for management of the anticipated difficult airway.

    • This strategy will depend, in part, on the anticipated surgery, the condition of the patient, patient cooperation/consent, the age of the patient, and the skills and preferences of the anesthesiologist.

    • Identify a strategy for: (1) awake intubation, (2) the patient who can be adequately ventilated but is difficult to intubate, (3) the patient who cannot be ventilated or intubated, and (4) difficulty with emergency invasive airway rescue.

    • When appropriate, perform awake intubation if the patient is suspected to be a difficult intubation and one or more of the following apply: (1) difficult ventilation (face mask/supraglottic airway), (2) increased risk of aspiration, (3) the patient is likely incapable of tolerating a brief apneic episode, or (4) there is expected difficulty with emergency invasive airway rescue.

    • The uncooperative or pediatric patient may restrict the options for difficult airway management, particularly options that involve awake intubation. Airway management in the uncooperative or pediatric patient may require an approach (e.g., intubation attempts after induction of general anesthesia) that might not be regarded as a primary approach in a cooperative patient.

    • Proceed with airway management after induction of general anesthesia when the benefits are judged to outweigh the risks.

    • For either awake or anesthetized intubation, airway maneuver(s) may be attempted to facilitate intubation.

    • Before attempting intubation of the anticipated difficult airway, determine the benefit of a noninvasive versus invasive approach to airway management.

      • If a noninvasive approach is selected, identify a preferred sequence of noninvasive devices to use for airway management.

  • If difficulty is encountered with individual techniques, combination techniques may be performed.

  • Be aware of the passage of time, the number of attempts, and oxygen saturation.

  • Provide and test mask ventilation after each attempt, when feasible.

  • Limit the number of attempts at tracheal intubation or supraglottic airway placement to avoid potential injury and complications.

    • If an elective invasive approach to the airway is selected, identify a preferred intervention.

  • Ensure that an invasive airway is performed by an individual trained in invasive airway techniques, whenever possible.

  • If the selected approach fails or is not feasible, identify an alternative invasive intervention.

    • Initiate ECMO when/if appropriate and available.

Unanticipated and Emergency Difficult Airway Management

  • Call for help.

  • Optimize oxygenation.

  • When appropriate, refer to an algorithm and/or cognitive aid.

  • Upon encountering an unanticipated difficult airway:

    • Determine the benefit of waking and/or restoring spontaneous breathing.

    • Determine the benefit of a noninvasive versus invasive approach to airway management.

    • If a noninvasive approach is selected, identify a preferred sequence of noninvasive devices to use for airway management.

      • If difficulty is encountered with individual techniques, combination techniques may be performed.

      • Be aware of the passage of time, the number of attempts, and oxygen saturation.

      • Provide and test mask ventilation after each attempt, when feasible.

      • Limit the number of attempts at tracheal intubation or supraglottic airway placement to avoid potential injury and complications.

    • If an invasive approach to the airway is necessary (i.e., cannot intubate, cannot ventilate), identify a preferred intervention.

    • Ensure that an invasive airway is performed by an individual trained in invasive airway techniques, whenever possible.

    • Ensure that an invasive airway is performed as rapidly as possible.

    • If the selected invasive approach fails or is not feasible, identify an alternative invasive intervention.

      • Initiate ECMO when/if appropriate and available.

Extubation of the Difficult Airway

  • Have a preformulated strategy for extubation and subsequent airway management.

    • This strategy will depend, in part, on the surgery/procedure, other perioperative circumstances, the condition of the patient, and the skills and preferences of the clinician.

  • Assess patient readiness for extubation.

  • Ensure that a skilled individual is present to assist with extubation when feasible.

  • Select an appropriate time and location for extubation when possible.

  • Assess the relative clinical merits and feasibility of the short-term use of an airway exchange catheter and/or supraglottic airway that can serve as a guide for expedited reintubation.

    • Minimize the use of an airway exchange catheter with pediatric patients.

  • Before attempting extubation, evaluate the risks and benefits of elective surgical tracheostomy.

  • Evaluate the risks and benefits of awake extubation versus extubation before the return to consciousness.

  • When feasible, use supplemental oxygen throughout the extubation process.

  • Assess the clinical factors that may produce an adverse impact on ventilation after the patient has been extubated.

Follow-Up Care

  • Use postextubation steroids and/or racemic epinephrine when appropriate.

  • Inform the patient or a responsible person of the airway difficulty that was encountered to provide the patient (or responsible person) with a role in guiding and facilitating the delivery of future care.

    • The information conveyed may include (but is not limited to) the presence of a difficult airway, the apparent reasons for difficulty, how the intubation was accomplished, and the implications for future care.

  • Document the presence and nature of the airway difficulty in the medical record to guide and facilitate the delivery of future care.

  • Instruct the patient to register with an emergency notification service when appropriate and feasible.

Recommendation Grading

Overview

Title

Management of the Difficult Airway

Authoring Organization

Publication Month/Year

November 8, 2021

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The management of the difficult airway and to reduce the likelihood of adverse outcomes.

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Emergency care, Hospital, Outpatient

Intended Users

Dentist, medical assistant

Scope

Management, Prevention

Diseases/Conditions (MeSH)

D060666 - Airway Extubation, D000403 - Airway Resistance, D058109 - Airway Management

Keywords

anesthesia, Anesthesiology, airway restriction, difficult airway, airway management

Source Citation

Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, Fiadjoe JE, Greif R, Klock PA, Mercier D, Myatra SN, O'Sullivan EP, Rosenblatt WH, Sorbello M, Tung A. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2022 Jan 1;136(1):31-81. doi: 10.1097/ALN.0000000000004002. PMID: 34762729.