Guidelines for the management of difficult airway: American Society of Anesthesiologists

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

Recommendations for 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.

Recommendations for 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.
• eidentify 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 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.
• 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.

Recommendations for Unanticipated and Emergency Difficult Airway Management

• Call for help.
• Optimize oxygenation
• When appropriate, refer to an algorithm and/or cognitive aid.
• If an invasive approach to the airway is necessary (i.e., cannot intubate, cannot ventilate), identify a preferred intervention.

Recommendations for Confirmation of Tracheal Intubation

• Confirm tracheal intubation using capnography or end-tidal carbon dioxide monitoring.
• When uncertain about the location of the tracheal tube, determine whether to either remove it and attempt ventilation or use additional techniques to confirm positioning of the tracheal tube.

Recommendations for Extubation of the Difficult Pathway

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

Recommendations for 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.
• 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.

Reference:

Jeffrey L. Apfelbaum, Carin A. Hagberg, Richard T. Connis, Basem B. Abdelmalak, Madhulika Agarkar, Richard P. Dutton, John E. Fiadjoe, Robert Greif, P. Allan Klock, David Mercier, Sheila N. Myatra, Ellen P. O'Sullivan, William H. Rosenblatt, Massimiliano Sorbello, Avery Tung; 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology Newly Published on November 11, 2021. doi: https://doi.org/10.1097/ALN.0000000000004002