Difficult intubation and extubation in adult anaesthesia

Overview

These guidelines give structured recommendations for anticipating and managing difficult airway situations in adults, from preoperative assessment through to extubation. The aim is to prevent hypoxaemia and airway trauma through planning, preparation and clear algorithms.

Assessment and preparation

Every patient should have an airway assessment before anaesthesia, combining history and several clinical predictors rather than relying on one sign. When difficulty is expected, the team should agree a plan and back-up plans in advance, with the appropriate equipment and skilled help immediately available.

Managing difficult intubation

Thorough preoxygenation and methods to prolong safe apnoea time are recommended. Videolaryngoscopy has a central role, both as a first-line option in predicted difficulty and as a rescue technique. The number of attempts should be limited. If intubation fails, oxygenation takes priority, using a supraglottic airway or facemask. When oxygenation cannot be maintained, emergency front-of-neck access must be performed without delay, and teams should train for it regularly.

Extubation

Extubation is a high-risk phase and should be planned like intubation. Patients at risk should be identified, and strategies such as airway exchange catheters or a delayed extubation used where appropriate.

Organisation

Difficult airway trolleys, team training, documentation of airway difficulties and communication with the patient and future caregivers are all recommended.