American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway

Key points

• These guidelines, developed by an international task force representing anesthesiology and airway organizations, replace the 2013 ASA difficult airway guidelines and add new algorithms for adults and children.
• Before anesthetic care or airway management, an airway risk assessment and airway physical examination should be performed, assessing multiple airway features.
• Awake intubation is advised, when appropriate, if difficult intubation is suspected together with difficult face mask or supraglottic ventilation, increased aspiration risk, inability to tolerate a brief apnoea, or expected difficulty with emergency invasive airway rescue.
• During difficult airway management, be aware of the passage of time, the number of attempts and oxygen saturation, test mask ventilation after each attempt and limit the number of intubation or supraglottic airway attempts.
• Supplemental oxygen should be given before and throughout difficult airway management, including extubation, and tracheal intubation should be confirmed with capnography or end-tidal carbon dioxide monitoring.

Overview

A difficult airway is a situation in which a physician trained in anesthesia care experiences anticipated or unanticipated difficulty or failure with face mask ventilation, laryngoscopy, supraglottic airway ventilation, tracheal intubation, extubation or an invasive airway. The guidelines combine literature evidence with surveys of expert consultants, ASA members and participating organizations, and do not address education or certification requirements.

Preparation and anticipated difficult airway

Airway equipment and a portable storage unit with specialised difficult airway equipment should be available, and monitoring should meet ASA standards. Have a preformulated strategy covering awake intubation, the patient who can be ventilated but is difficult to intubate, the patient who cannot be ventilated or intubated, and difficulty with emergency invasive rescue. Uncooperative or paediatric patients may restrict awake options. Combination techniques may be used when individual techniques fail.

Unanticipated and emergency difficult airway

Call for help, optimise oxygenation (for example with low- or high-flow nasal oxygen), use an algorithm or cognitive aid, and consider waking the patient or restoring spontaneous breathing. If an invasive airway is needed in a cannot-intubate, cannot-ventilate situation, it should be performed as rapidly as possible by a trained individual, for example surgical cricothyrotomy with a scalpel-bougie technique; ECMO may be initiated when appropriate and available. In observational studies, capnography confirmed tracheal intubation in 88.5% to 100% of difficult airway patients.

Extubation and follow-up

Have a preformulated extubation strategy, assess readiness, ensure a skilled assistant, choose an appropriate time and place, weigh elective tracheostomy and awake versus deep extubation, and consider postextubation steroids and/or racemic epinephrine when appropriate. Inform the patient of the airway difficulty, document it in the record and, when feasible, advise registration with an emergency notification service.

FAQ

When should awake intubation be chosen?

When difficult intubation is suspected and there is also difficult ventilation, increased aspiration risk, poor tolerance of apnoea, or expected difficulty with emergency invasive airway rescue.

How many intubation attempts are acceptable?

The guidelines do not set a number, but advise limiting attempts to avoid injury and complications while tracking time, attempts and oxygen saturation.

How should tracheal intubation be confirmed?

With capnography or end-tidal carbon dioxide monitoring; if the tube position is uncertain, either remove it and ventilate or confirm placement with additional techniques.

Source

Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2022;136(1):31-81. DOI: 10.1097/ALN.0000000000004002. Copyright © 2021, the American Society of Anesthesiologists. All Rights Reserved. Summary prepared by Medpresso from the original publication; it is not a substitute for the full text or for medical advice.