Difficult Airway Management Guidelines

Pre-Intubation Airway Risk Assessment

The American Society of Anesthesiologists (ASA) recommends evaluating demographic information, clinical conditions, diagnostic test findings, patient/family interviews, and questionnaire responses from medical records to assess airway risk 1
The ASA guidelines emphasize assessing facial features including mouth opening, ability to prognath, head and neck mobility, prominent upper incisors, presence of beard, and upper lip bite test to evaluate airway risk 1, 3
The ASA guidelines recommend measuring anatomical landmarks: Mallampati score, thyromental distance, sternomental distance, interincisor distance, neck circumference, hyomental distance, and their ratios to assess airway risk 1, 3
The ASA guidelines suggest considering advanced evaluation with bedside endoscopy, virtual laryngoscopy/bronchoscopy, or three-dimensional printing when available to assess airway risk 1, 3, 4
The ASA guidelines recommend assessing multiple airway features in combination rather than relying on single predictors to evaluate airway risk 1, 3

The ASA guidelines recommend formulating a documented preformulated strategy that addresses four specific scenarios: awake intubation approach, patient who can be adequately ventilated but is difficult to intubate, patient who cannot be ventilated or intubated, and difficulties with emergency invasive airway rescue 1, 3
The ASA guidelines suggest performing awake intubation when one or more of the following apply: difficult ventilation anticipated, increased risk of aspiration, patient likely incapable of tolerating brief apneic episode, or expected difficulty with emergency invasive airway rescue 2

The ASA guidelines recommend ensuring airway management equipment is immediately available in the room 1, 3, 4
The ASA guidelines suggest having a portable storage unit containing specialized difficult airway equipment immediately accessible 1, 3, 4
The ASA guidelines recommend ensuring a skilled individual is present or immediately available to assist when difficult airway is known or suspected 1, 3, 4, 5

The ASA guidelines recommend performing awake intubation when difficult ventilation is anticipated, there is an increased risk of aspiration, the patient is likely incapable of tolerating a brief apneic episode, or there is expected difficulty with emergency invasive airway rescue 2
The ASA guidelines suggest proceeding with airway management after induction of general anesthesia only when benefits outweigh risks, particularly relevant for uncooperative or pediatric patients where awake intubation may not be feasible 2, 3

The ASA guidelines recommend identifying a preferred sequence of noninvasive devices if a noninvasive approach is selected 2
The ASA guidelines suggest considering combination techniques when difficulty is encountered with individual techniques, including direct laryngoscopy with supraglottic airway, bougie, optical stylet, flexible intubation scope, or airway exchange catheter 2, 6

The ASA guidelines recommend maintaining awareness of passage of time, number of attempts, oxygen saturation, and providing and testing mask ventilation after each attempt when feasible 2
The ASA guidelines suggest limiting the number of attempts at tracheal intubation or supraglottic airway placement to avoid injury and complications 2

The ASA guidelines recommend calling for help immediately and calling for invasive access when the emergency pathway is triggered (cannot oxygenate or ventilate) 7
The ASA guidelines suggest attempting alternative intubation approaches while preparing for emergency invasive airway and performing emergency invasive airway if alternative approaches fail or ventilation deteriorates 7

The Difficult Airway Society (DAS) guidelines recommend using second-generation supraglottic airway devices between attempts to reduce aerosol generation due to improved airway seal 8
The DAS guidelines suggest using the scalpel-bougie-tube technique specifically preferred for emergency front-of-neck access in COVID-19 patients due to reduced aerosolization risk 8
The DAS guidelines recommend inflating the tracheal tube cuff immediately after intubation to a measured pressure of 20-30 cmH₂O 8
The DAS guidelines suggest confirming tracheal intubation with continuous waveform capnography rather than auscultation (which risks PPE contamination) 8

The ASA guidelines recommend documenting the nature of airway difficulty encountered and the description of various airway management techniques used, indicating beneficial or detrimental role of each technique 1
The DAS guidelines suggest recording the difficult airway plan prominently and displaying it visibly on the patient's room 8
The DAS guidelines recommend communicating the plan to staff at shift changeovers 8

The ASA guidelines recommend not relying on a single airway assessment tool—multiple features must be assessed in combination for better prediction 1, 3, 9
The DAS guidelines suggest not delaying transition through the algorithm—minimize the number of attempts at each technique 8
The DAS guidelines recommend not proceeding with repeated unsuccessful attempts—this leads to laryngeal edema or hemorrhage that critically compromises airway maintenance 8
The DAS guidelines suggest not deferring mask ventilation initially—consider second-generation supraglottic airway as an alternative between attempts 8