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Whats New in Airway Management

Lauren Berkow, MD
Department of Anesthesiology and Critical Care Medicine
Johns Hopkins School of Medicine
Baltimore, Maryland
Learning Objectives:
As a result of completing this activity, the participant
will be able to
Describe some new methods of airway evaluation
Explain current airway devices and algorithms
Discuss how to manage extubation of the difficult
Describe the challenges of airway management
outside the operating room
Enumerate methods of disseminating difficult air-
way information
Author Disclosure Information:
Dr. Berkowhas disclosed that she receives consulting
fees and honoraria from Masimo Corporation and
Teleflex, and consulting fees from Medtronic and
s the condition of patients presenting for anesthesia
and surgery continues to become more complex, so
has airway management. In addition, the number of
patients who require anesthesia and airway management
outside the operating room setting is increasing. New
airway devices continue to be introduced into the market
and clinical practice, making airway management deci-
sions even more challenging. According to the ASA Closed
Claims database, the number of claims involving airway
management, both inside and outside the operating room
setting, is substantial.
This chapter discusses some of the
new evaluation methods and devices, many of the issues
surrounding airway competency, airway management
outside the operating room setting, and the role of
simulation and standardization in airway education and
airway management. In addition, several still-unanswered
questions, such as how to predict airway difficulty, which
airway device to choose, howto assess airway competency,
and how to disseminate difficult airway information to
both medical providers and patients, will be addressed.
According to the ASA Closed Claims database,
the number of claims involving airway
management, both inside and outside the
operating room setting, is substantial.
Even though no single specific test has been proven to ac-
curately predict difficulty with airway management, rou-
tine preoperative tests are still useful to assess and prepare
for challenging situations. Difficulty may be encountered
during mask ventilation, supraglottic airway placement,
or laryngoscopy and intubation (Supplemental Digital
Content 1, Several pre-
operative assessment characteristics have been linked to
both difficulties with mask ventilation and laryngoscopy
(Table 1).
In addition, several disease states have been
associated with difficult airway management (Table 2).
Supplemental digital content is available for this article. Direct URL
citations appear in the printed text and are available in both the HTML
and PDF versions of this article. Links to the digital files are provided in
the HTML and PDF text of this article on the Journals Web site
New Methods of Airway Assessment
Preoperative endoscopic airway examination, used for
many years by otolaryngologists to assess airway anatomy,
is now being used by anesthesiologists preoperatively
to identify airway pathology and to predict potential
difficulty with mask ventilation or supraglottic airway
Ultrasound can also be used to identify the
cricothyroid membrane and to confirm endotracheal tube
placement by identifying bilateral lung movement.
Airway Management of the Obese Patient
The incidence of obesity continues to rise in the United
States and worldwide. According to the Centers for Dis-
ease Control, 20 to 30% of Americans are obese and 65%
are classified as overweight.
Similarly, the World Health
Organization reports that more than 1.4 billion adults are
overweight, and 10% of the worlds adult population is
Obese patients have a very high incidence of ob-
structive sleep apnea, and both conditions have been as-
sociated with difficult mask ventilation and difficult
Obese patients are also at higher risk of
aspiration and arterial desaturation during airway man-
Arterial desaturation can have multiple causes,
including reduced functional residual capacity, chronic
hypoxemia from obstructive sleep apnea or pulmonary
hypertension, and deconditioning.
Proper positioning of the obese patient is an important
component of airway management. Placing the obese pa-
tient in the ramp position by using either pillows and
blankets or specifically designed ramping devices such as
the Troop Elevation Pillow(Mercury Medical, Clearwater,
FL) or Rapid Airway Management Positioner device
(Airpal Inc., Coopersburg, PA) has been shown to improve
success during both mask ventilation and direct laryngos-
The goal of ramping the patient is to align the
sternal notch with the external auditory meatus.
When selecting an airway device, it is
important to identify the one that will give the
best results in each particular patient.
Airway Algorithms/Decision-making
The 2003 ASA practice guidelines for management of the
difficult airway, updated in 2013, recommend an assess-
ment of the patient to include the possibility of difficulty
with both ventilation and intubation.
In addition, the
guidelines encourage the creation and implementation of
multiple airway plans to safely manage the difficult airway,
with the use of alternate airway devices when conventional
methods fail (Supplemental Digital Content 2, http://links.; Supplemental Digital Content 3,; Supplemental Digital
Content 4,; and Supplemen-
tal Digital Content 5,
When creating an airway management plan, several
important questions should be addressed before the deci-
sion is made to performan awake intubation or to intubate
after induction of general anesthesia (Table 3). Which air-
way device is chosen for intubation is less important than
why it is chosen, and the selection should depend on what
is available and what the airway provider is skilled in using
(Supplemental Digital Content 6,
ASA/A344). When selecting an airway device, it is im-
portant to identify the one that will give the best results in
each particular patient. It is also important to have a back-
up plan should the first airway device fail. Providers should
consider becoming proficient in several alternate airway
devices and practice regularly on normal patients.
Table 1. Preoperative Characteristics Associated
With Difficult Airway Management
Difficult Mask Ventilation Difficult Laryngoscopy
Increased BMI History of prior difficulty
Snoring/obstructive sleep apnea Difficult mask ventilation
Presence of beard Obesity/obstructive sleep apnea
Lack of teeth Airway pathology
Mallampati III or IV Mallampati III or IV
Airway masses/tumors Reduced cervical range of motion
Limited mandibular
protrusion test
Short thyromental distance
Age above 55y
BMI body mass index.
Table 2. Disease States Associated With Difficult
Airway Management
Congenital Acquired
Pierre Robin syndrome Morbid obesity
Treacher Collins syndrome Acromegaly
Goldenhar syndrome Infections involving the airway
(Ludwig angina)
Mucopolysaccharidoses Rheumatoid arthritis
Achondroplasia Obstructive sleep apnea
Micrognathia Ankylosing spondylitis
Down syndrome Tumors involving the airway
Trauma (airway, cervical spine)
32 Ber kow
Airway Devices
In addition to conventional laryngoscopy, many airway
devices are now available to manage ventilation and in-
tubation, including rigid intubating stylets, bougies, video-
laryngoscopes, and fiberoptic bronchoscopes, among oth-
ers. The supraglottic airway was added to the 2003 ASA
Difficult Airway Algorithm for use as both a rescue device
and a conduit for intubation.
Supraglottic airway devices
are now available in a variety of shapes and sizes. In ad-
dition, several second-generation devices now allow
decompression of the stomach, and some were developed
primarily as intubating devices (Supplemental Digital
Content 7,
Videolaryngoscopy devices that are reusable, reusable with
disposable blades, or fully disposable can be obtained. Unlike
conventional laryngoscopy, each of these devices provides
an indirect view of the larynx on a video screen.
laryngoscopy is a two-step process: first the larynx is identi-
fied, then the endotracheal tube is advanced through
the vocal cords. With videolaryngoscopy, tube delivery can be
difficult at times, despite a clear view of the larynx.
laryngoscopy has been demonstrated to provide an improved
view of the glottis in patients with restricted neck mobil-
In the recently revised ASA guidelines for manage-
ment of the difficult airway, video-assisted laryngoscopy was
added as a potential initial approach to intubation.
Cricoid Pressure: Necessary or Ineffective?
The current literature is inconclusive with regard to the
effectiveness of cricoid pressure. Aspiration during in-
duction of anesthesia and intubation is rare but has been
reported to occur despite the use of cricoid pressure.
Often misapplied, it may be used at the wrong time, in the
wrong place, or with the incorrect amount of pressure.
addition, evidence suggests that the application of cricoid
pressure may worsen the view at laryngoscopy and may
make supraglottic airway placement more difficult.
Some studies that used radiological examination have
suggested that cricoid pressure may not always result in
successful occlusion of the esophagus.
Extubation of the Difficult Airway
Extubation, especially in the patient with a difficult air-
way, can be just as challenging as intubation. Extubated
patients who require reintubation pose additional chal-
lenges. Often the airway is edematous, hemodynamic in-
stability may be present, and the environment in which the
airway must be managed may be small. The ASA Closed
Claims data, as well as data from other studies, have
shown a 12%incidence of complications during the period
of extubation.
A variety of factors can lead to compli-
cations during extubation (Table 4). Human factors, such
as decreased availability of equipment, fatigue, time pres-
sure, and distractions from noise or staff movement, also
can contribute to extubation-related complications.
The Difficult Airway Society of the United Kingdom
recently published guidelines for tracheal extubation.
These guidelines suggest that planning for extubation
should begin before induction of anesthesia and propose
two algorithms: a low-risk and a high-risk pathway.
The high-risk algorithm includes the options of using a
supraglottic airway or an airway exchange catheter as a
bridge to extubation or postponement of extubation.
Both the Difficult Airway Society guidelines and other
studies support the use of an airway exchange catheter as a
bridge to extubation.
This technique has several ad-
vantages: the catheter can be left in place for as long as
needed, is well tolerated by patients, and provides a con-
duit for reintubation. Patients should remain in a moni-
tored setting until the airway exchange catheter is removed
and the airway is no longer at risk.
Airway Management Outside the Operating Room
Airway management can be much more challenging out-
side the operating room setting than within it. Airway
history is frequently unknown, additional resources may
be far away, and patients are often hemodynamically un-
stable. Many patients who require airway management in
the intensive care unit setting have recently undergone a
failed extubation attempt, and significant laryngeal edema
may be present. Critically ill patients often have poor
pulmonary reserve, making preoxygenation difficult. A
study by T.C. Mort
showed that preoxygenation of crit-
ically ill patients for 8 minutes did not prevent hypoxemia
during intubation. In addition, the incidence of complica-
tions associated with airway management, such as hypox-
emia, aspiration, and cardiac arrest, is much higher in
remote locations than in the operating room.
Table 3. Airway Management Questions
1. Will the patient be difficult to ventilate by mask?
2. Will supraglottic airway placement be difficult?
3. Will the patients trachea be difficult to intubate?
4. What resources might be needed to manage the patient?
5. Are those resources readily available?
Table 4. Factors That May Contribute to
Complications During Extubation
Reduced airway reflexes (residual neuromuscular blockade, OSA,
Airway edema (surgical causes, positioning, difficult intubation,
fluid overload)
Laryngospasm (secretions, blood, debris)
Human factors (fatigue, time pressure, distractions)
OSA obstructive sleep apnea.
33 Whats New in Airway Management
The Fourth National Audit Project Report
The Fourth National Audit Project was completed and
published in 2011. Researchers collected reports of air-
way-related complications in more than 300 hospitals in
the United Kingdom over a 1-year period. The results re-
vealed that poor airway assessment and planning, failure
to perform awake intubation when needed, and lack of
proper communication and training played a major role in
complications. Researchers also found a 60% failure rate
for cricothyrotomy and a 30% incidence of airway events
during extubation. Moreover, 28% of events occurred
outside the operating room. Sixty-one percent of the air-
way events that occurred in the intensive care unit setting
resulted in death or brain damage. The study revealed
several common themes associated with these events
(Table 5). As a result, members of The Fourth National
Audit Project team recommended the creation of guide-
lines and checklists for airway management, stan-
dardization of equipment, broader use of capnography,
and improved communication and training of personnel.
Airway Management During CPR
The current American Heart Association guidelines for
cardiopulmonary resuscitation published in 2010 included
several changes related to airway management.
phrase Look, listen, and feel was removed from the
guidelines and ABC (Airway, Breathing, Circulation)
was changed to CAB (Compressions, Airway, Breath-
ing). The guidelines now recommend the initiation of res-
cue breathing after completion of a full round of chest
compressions. This change was recommended based on
several studies which showed that survival did not increase
with the addition of ventilation to cardiopulmonary re-
suscitation and that survival decreased with interruptions
to or delays in chest compressions.
Additional rec-
ommendations concerning the use of cricoid pressure,
capnography, and weaning of oxygen levels were also
added to the 2010 guidelines (Table 6).
Standardization, which is common practice in aviation and
industry, is used to improve efficiency and decrease errors.
It has recently been applied to health care and airway
management. Standardization of equipment and proce-
dures, as well as standardized training of personnel, has
been shown to reduce adverse airway events such as
emergency surgical airway
(Supplemental Digital Con-
tent 8, The ASAand The
Fourth National Audit Project report also recommend
the availability of consistent airway equipment both inside
and outside the operating room setting. Standardization of
equipment can ensure that the necessary equipment is
available both when and where it is needed. Standardizing
procedures with algorithms and guidelines can improve
teamwork and communication.
Standardization of equipment and procedures,
as well as standardized training of personnel,
has been shown to reduce adverse airway
events such as emergency surgical airway.
Airway Competency
A current area of controversy is competency in managing
an airway: how should this be defined, and should it be
assessed and documented during residency training? The
number of times an individual must perform an airway
procedure before competency is achieved is currently un-
known, but it most likely varies among providers and be-
tween airway devices. Competency in airway management
should include expertise in both airway skills and decision-
making. Formal airway rotations during residency can
help to ensure that the opportunity exists to achieve com-
petency with a variety of airway techniques and devices. It
is unlikely that airway competency is routinely assessed, as
currently only 49% of anesthesia residency programs in
the United States offer a formal airway rotation.
Several initiatives that could be incorporated into an
anesthesia residency program to assess airway competency
Table 5. Fourth National Audit Project (NAP4)
Prospective study of airway-related adverse events over a 1-y period in
300 hospitals in the United Kingdom
61% of airway events in the ICU resulted in death or brain damage
Common themes
Almost 50% of patients obese
Large number of events occurred in off hours
Lack of capnography, lack of needed equipment
Lack of experienced personnel, inadequate training
Delayed recognition of high-risk patients
Lack of back-up plans for management
ICUintensive care unit.
Table 6. Airway Management Recommendations
During Cardiopulmonary Resuscitation
Initiate chest compressions before ventilation
Initiate rescue breathing after first round of compressions completed
Routine use of cricoid pressure not recommended
Avoid interruptions in chest compressions
Continuous capnography recommended to confirm tube placement
Titration of oxygen concentration after ROSC to maintain oxygen
saturations of 494%
ROSCreturn of spontaneous circulation.
34 Ber kow
include: a formal airway rotation, checklists and airway
workshops for airway procedures, routine practice of al-
ternate airway devices on normal patients, and use of
simulation to teach decision-making and communication
As additional airway devices are introduced, continuing
education and practice with them is essential for safe
airway management. Along with acquiring competence
in use of these devices, it is equally important to develop
the ability to create and implement a variety of intu-
bation plans. Requiring specific airway rotations during
residency training can provide opportunities for ex-
posure to and adequate experience in a variety of airway
Simulation has long been used in aviation for teamwork
training and standardization of practice, with documented
reduction in errors.
It has been introduced into the
medical environment and is now widely used to teach
decision-making and promote teamwork. Simulation pro-
vides a safe environment in which to teach airway skills,
increase familiarity with new airway devices, and foster
teamwork and communication during complicated man-
agement scenarios. It allows trainees to practice airway
skills and decision-making simultaneously. It offers addi-
tional advantages, including the opportunity to reviewand
debrief events immediately and the ability to simulate rare
clinical events.
Simulation can also be used to assess
airway competency and is now required for Maintenance
of Certification in Anesthesia.
Additional Educational Resources
Several airway simulators are currently available to teach
bronchoscopy and airway management, some of which op-
erate via a laptop computer to allow portability (e.g., Orsim
Bronchoscopy Simulator, Tele-
medicine has also recently been applied to airway manage-
ment. Both fiberoptic intubation and videolaryngoscopy can
be taught to anesthesia providers, intensivists, and emer-
gency airway providers via telemedicine.
Many airway
education websites are accessible and free via the internet
Also, an iPhone application was recently introduced to the
market that provides fiberoptic intubation instruction via a
smartphone (
Dissemination of difficult airway information among
providers and between institutions continues to be a chal-
lenge. Although many institutions and some countries
maintain databases of patients identified as having a
difficult airway, no system currently exists to share this
information. In the United States, the Medic Alert Registry
provides a method to collect and disseminate critical
information about a variety of medical conditions, in-
cluding difficult airway, but it requires a subscription by
the patient and encouragement from medical providers
to enroll.
Alert bracelets are used widely throughout hospitals for
allergy alerts and can also be used for difficult airway
alerts, but these bracelets only function in an individual
hospital environment. Alert bracelets have the advantage
of travelling with patients as they move throughout the
Electronic patient records also provide an opportunity
to document difficult airway information and disseminate
it to all hospital providers. Airway alert signs can be posted
above the patients bed to disseminate important in-
formation during emergent airway management.
Information about difficult airway management needs
to reach the patient, the medical providers caring for the
patient, and the patients primary medical provider. Edu-
cational material given to the patient at discharge or
mailed to the patients residence can provide a written
document to share with future providers. Such documents
should be written in language that is easy to understand
and should provide clear instructions for sharing the in-
formation with medical providers.
The Society for Airway Management (http://www. currently recommends the following steps for
disseminating airway management information: place-
ment of a difficult airway alert bracelet; verbal discussion
with the patient and family; documentation in the patient
record; a letter sent to the patient, surgeon, and primary
care provider; and enrollment in a national registry such as
Medic Alert.
Accurately predicting which patients will have a difficult
airway remains a challenge despite several preoperative
airway examination tests. The number of alternate airway
devices continues to increase, and airway providers should
be competent with several different types. If difficulty
with airway management is anticipated based on history or
examination, multiple airway plans and devices should
be immediately available. Extubation often receives in-
adequate attention, but it is just as important as intubation.
The incidence of respiratory-related complications and dis-
tractions is greater during the extubation period than during
Airway management outside the operating room setting
is often more challenging than in the operating room and
carries a higher risk of complications. Standardization of
airway equipment and procedures can potentially improve
outcomes both inside and outside the operating room en-
vironment. And finally, disseminating information about
35 Whats New in Airway Management
difficult airway management to both patients and medical
care providers is a vital part of perioperative care.
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37 Whats New in Airway Management