Practice Guidelines For Management of The Difficult Airway 2013

SPECIAL ARTICLES
Practice Guidelines for Management of the Difficult Airway

An Updated Report by the American Society of Anesthesiologists
Task Force on Management of the Difficult Airway
P RACTICE Guidelines are systematically developed

recommendations that assist the practitioner and
patient in making decisions about health care. These recom-
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Updated by the Committee on Standards and Practice Param-

eters: Jeffrey L. Apfelbaum, M.D. (Chair), Chicago, Illinois; Carin A. the Task Force on Difficult Airway Management, adopted
Hagberg, M.D., Houston, Texas; and selected members of the Task
Force on Management of the Difficult Airway: Robert A. Caplan, by the ASA in 2002 and published in 2003.*
M.D. (Chair), Seattle, Washington; Casey D. Blitt, M.D., Coronado,
California; Richard T. Connis, Ph.D., Woodinville, Washington; and
David G. Nickinovich, Ph.D., Bellevue, Washington. The previous
Methodology
update was developed by the American Society of Anesthesiolo- A. Definition of Difficult Airway
gists Task Force on Difficult Airway Management: Robert A. Caplan,
M.D. (Chair), Seattle, Washington; Jonathan L. Benumof, M.D., San
A standard definition of the difficult airway cannot be identi-
Diego, California; Frederic A. Berry, M.D., Charlottesville, Virginia; fied in the available literature. For these Practice Guidelines,
Casey D. Blitt, M.D., Tucson, Arizona; Robert H. Bode, M.D., Bos- a difficult airway is defined as the clinical situation in which a
ton, Massachusetts; Frederick W. Cheney, M.D., Seattle, Washington;
Richard T. Connis, Ph.D., Woodinville, Washington; Orin F. Guidry,
conventionally trained anesthesiologist experiences difficulty
M.D., Jackson, Mississippi; David G. Nickinovich, Ph.D., Bellevue, with facemask ventilation of the upper airway, difficulty with
Washington; and Andranik Ovassapian, M.D., Chicago, Illinois. tracheal intubation, or both. The difficult airway represents
Received from American Society of Anesthesiologists, Park a complex interaction between patient factors, the clinical
Ridge, Illinois. Submitted for publication October 18, 2012. Accepted
for publication October 18, 2012. Supported by the American Soci-
setting, and the skills of the practitioner. Analysis of this
ety of Anesthesiologists and developed under the direction of the interaction requires precise collection and communication
Committee on Standards and Practice Parameters, Jeffrey L. Apfel- of data. The Task Force urges clinicians and investigators to
baum, M.D. (Chair). Approved by the ASA House of Delegates on
October 17, 2012. A complete bibliography used to develop these
use explicit descriptions of the difficult airway. Descriptions
updated Guidelines, arranged alphabetically by author, is available that can be categorized or expressed as numerical values are
as Supplemental Digital Content 1, http://links.lww.com/ALN/A902. particularly desirable, because this type of information lends
Address correspondence to the American Society of Anesthe- itself to aggregate analysis and cross-study comparisons.
siologists: 520 N. Northwest Highway, Park Ridge, Illinois 60068
2573. These Practice Guidelines, and all ASA Practice Parameters,
Suggested descriptions include, but are not limited to:
may be obtained at no cost through the Journal Web site, www.
anesthesiology.org.
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*American Society of Anesthesiologists: Practice guidelines for 63- DJUBUJPOT BQQFBS JO UIF QSJOUFE UFYU BOE BSF BWBJMBCMF JO
management of the difficult airway: An updated report. ANESTHESIOLOGY CPUIUIF)5.-BOE1%'WFSTJPOTPGUIJTBSUJDMF-JOLTUPUIF
2003; 98:12691277. EJHJUBMmMFTBSFQSPWJEFEJOUIF)5.-UFYUPGUIJTBSUJDMFPOUIF
Copyright 2013, the American Society of Anesthesiologists, Inc. Lippincott +PVSOBMT8FCTJUF XXXBOFTUIFTJPMPHZPSH

Williams & Wilkins. Anesthesiology ; 118:XXXX
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Copyright by the American Society of Anesthesiologists. Unauthorized reproduction of this article is prohibited.
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1. Difficult facemask or supraglottic airway (SGA) ven- and airway management delivered in anesthetizing locations
tilation (e.g., laryngeal mask airway [LMA], intubat- and is intended for all patients of all ages.
ing LMA [ILMA], laryngeal tube): It is not possible
for the anesthesiologist to provide adequate ventilation E. Task Force Members and Consultants
because of one or more of the following problems: The original Guidelines and the first update were developed
inadequate mask or SGA seal, excessive gas leak, or by an ASA-appointed Task Force of ten members, consisting
excessive resistance to the ingress or egress of gas. Signs of Anesthesiologists in private and academic practices from
of inadequate ventilation include (but are not limited various geographic areas of the United States and two con-
to) absent or inadequate chest movement, absent or sulting methodologists from the ASA Committee on Stan-
inadequate breath sounds, auscultatory signs of severe dards and Practice Parameters.
obstruction, cyanosis, gastric air entry or dilatation, The original Guidelines and the first update in 2002 were
decreasing or inadequate oxygen saturation (SpO2), developed by means of a seven-step process. First, the Task
absent or inadequate exhaled carbon dioxide, absent or Force reached consensus on the criteria for evidence. Second,
inadequate spirometric measures of exhaled gas flow, original published research studies from peer-reviewed jour-
and hemodynamic changes associated with hypox- nals relevant to difficult airway management were reviewed
emia or hypercarbia (e.g., hypertension, tachycardia, and evaluated. Third, expert consultants were asked to: (1)
arrhythmia). participate in opinion surveys on the effectiveness of vari-
2. Difficult SGA placement: SGA placement requires mul- ous difficult airway management recommendations and (2)
tiple attempts, in the presence or absence of tracheal review and comment on a draft of the Guidelines. Fourth,
pathology. opinions about the Guideline recommendations were solic-
3. Difficult laryngoscopy: It is not possible to visualize any ited from a sample of active members of the ASA. Fifth,
portion of the vocal cords after multiple attempts at opinion-based information obtained during open forums
conventional laryngoscopy. for the original Guidelines, and for the previous updated
4. Difficult tracheal intubation: Tracheal intubation Guidelines, was evaluated. Sixth, the consultants were
requires multiple attempts, in the presence or absence surveyed to assess their opinions on the feasibility of imple-
of tracheal pathology. menting the updated Guidelines. Seventh, all available infor-
5. Failed intubation: Placement of the endotracheal tube mation was used to build consensus to finalize the updated
fails after multiple attempts. Guidelines.
In 2011, the ASA Committee on Standards and Practice
B. Purposes of the Guidelines for Difficult Airway Parameters requested that the updated Guidelines published
Management in 2002 be re-evaluated. This update consists of an evalu-
The purpose of these Guidelines is to facilitate the manage- ation of literature published since completion of the first
ment of the difficult airway and to reduce the likelihood of update, and an evaluation of new survey findings of expert
adverse outcomes. The principal adverse outcomes associ- consultants and ASA members. A summary of recommenda-
ated with the difficult airway include (but are not limited tions can be found in appendix 1.
to) death, brain injury, cardiopulmonary arrest, unnecessary
surgical airway, airway trauma, and damage to the teeth. F. Availability and Strength of Evidence
Preparation of these updated Guidelines followed a rigorous
C. Focus methodological process. Evidence was obtained from two
The primary focus of these Guidelines is the management of the principal sources: scientific evidence and opinion-based
difficult airway encountered during administration of anesthe- evidence.
sia and tracheal intubation. Some aspects of the Guidelines may
be relevant in other clinical contexts. The Guidelines do not Scientific Evidence
represent an exhaustive consideration of all manifestations of Scientific evidence used in the development of these Guide-
the difficult airway or all possible approaches to management. lines is based on findings from literature published in peer-
reviewed journals. Literature citations are obtained from
D. Application
PubMed and other healthcare databases, direct Internet
The Guidelines are intended for use by an Anesthesiologists
searches, Task Force members, liaisons with other orga-
and by individuals who deliver anesthetic care and airway
nizations, and from hand searches of references located in
management under the direct supervision of an anesthesi-
reviewed articles.
ologist. The Guidelines apply to all types of anesthetic care
Findings from the aggregated literature are reported in the
text of the Guidelines by evidence category, level, and direc-
International Anesthesia Research Society 66th Clinical and Sci- tion. Evidence categories refer specifically to the strength
entific Congress, San Francisco, CA, March 15, 1992.
American Society of Anesthesiologists Annual Meeting, Dallas, and quality of the research design of the studies. Category
TX, October 10, 1999. A evidence represents results obtained from randomized
"OFTUIFTJPMPHZ9999 1SBDUJDF(VJEFMJOFT
SPECIAL ARTICLES
controlled trials (RCTs), and Category B evidence repre- Level 3: The literature contains noncomparative observa-
sents observational results obtained from nonrandomized tional studies with descriptive statistics (e.g., frequen-
study designs or RCTs without pertinent controls. When cies, percentages).
available, Category A evidence is given precedence over Cat- Level 4: The literature contains case reports.
egory B evidence in the reporting of results. These evidence
categories are further divided into evidence levels. Evidence Insufficient Evidence
levels refer specifically to the strength and quality of the sum- The lack of sufficient scientific evidence in the literature may
marized study findings (i.e., statistical findings, type of data, occur when the evidence is either unavailable (i.e., no per-
and the number of studies reporting/replicating the find- tinent studies found) or inadequate. Inadequate literature
ings) within the two evidence categories. For this document, cannot be used to assess relationships among clinical inter-
only the highest level of evidence is included in the summary ventions and outcomes, since such literature does not permit
report for each intervention. Finally, a directional designa- a clear interpretation of findings due to methodological con-
tion of benefit, harm, or equivocality for each outcome is cerns (e.g., confounding in study design or implementation)
indicated in the summary report. or does not meet the criteria for content as defined in the
Focus of the Guidelines.
Category A
RCTs report comparative findings between clinical inter-
ventions for specified outcomes. Statistically significant Opinion-based Evidence
(P < 0.01) outcomes are designated as beneficial (B) or All opinion-based evidence (e.g., survey data, open-forum
harmful (H) for the patient; statistically nonsignificant find- testimony, Internet-based comments, letters, and editorials)
ings are designated as equivocal (E). relevant to each topic was considered in the development
of these updated Guidelines. However, only the findings
Level 1: The literature contains a sufficient number of obtained from formal surveys are reported.
RCTs to conduct meta-analysis, and meta-analytic Opinion surveys were developed for this update by the
findings from these aggregated studies are reported as Task Force to address each clinical intervention identified in
evidence. the document. Identical surveys were distributed to expert
Level 2: The literature contains multiple RCTs, but the consultants and ASA members.
number of RCTs is not sufficient to conduct a viable
meta-analysis for the purpose of these Guidelines. Find- Category A: Expert Opinion
ings from these RCTs are reported as evidence. Survey findings from Task Forceappointed expert consultants
Level 3: The literature contains a single RCT, and findings are reported in summary form in the text, with a complete list-
from this study are reported as evidence. ing of survey responses reported in appendix 2.
Category B Category B: Membership Opinion

Observational studies or RCTs without pertinent compar- Survey findings from a random sample of active ASA members
ison groups may permit inference of beneficial or harmful are reported in summary form in the text, with a complete listing
relationships among clinical interventions and outcomes. of survey responses reported in appendix 2.
Inferred findings are given a directional designation of Survey responses from expert and membership sources
beneficial (B), harmful (H), or equivocal (E). For studies are recorded using a five-point scale and summarized based
that report statistical findings, the threshold for significance on median values.
is P < 0.01. Strongly Agree: Median score of 5 (At least 50% of the
Level 1: The literature contains observational comparisons responses are 5)
(e.g., cohort, casecontrol research designs) between Agree: Median score of 4 (At least 50% of the responses are
clinical interventions for a specified outcome. 4 or 4 and 5)
Level 2: The literature contains observational studies with Equivocal: Median score of 3 (At least 50% of the responses
associative statistics (e.g., relative risk, correlation, are 3, or no other response category or combination of
sensitivity/specificity). similar categories contain at least 50% of the responses)
Disagree: Median score of 2 (At least 50% of responses are
2 or 1 and 2)
All meta-analyses are conducted by the ASA methodology Strongly Disagree: Median score of 1 (At least 50% of
group. Meta-analyses from other sources are reviewed but not responses are 1)
included as evidence in this document.
When an equal number of categorically distinct responses are Category C: Informal Opinion
obtained, the median value is determined by calculating the arith-
metic mean of the two middle values. Ties are calculated by a pre- Open-forum testimony during development of the previous
determined formula. update, Internet-based comments, letters, and editorials are
1SBDUJDF(VJEFMJOFT
all informally evaluated and discussed during the formula- testing in some patients. Observational studies and case
tion of Guideline recommendations. When warranted, the reports indicate that certain diagnostic tests (e.g., radiogra-
Task Force may add educational information or cautionary phy, computed tomography scans, fluoroscopy) can identify
notes based on this information. a variety of acquired or congenital features in patients with
difficult airways (Category B3-B/B4-B evidence).2233 The lit-
Guidelines erature does not provide a basis for using specific diagnostic
I. Evaluation of the Airway tests as routine screening tools in the evaluation of the dif-
History. Although there is insufficient literature to evalu- ficult airway.
ate the efficacy of conducting a directed medical history or The consultants and ASA members strongly agree that
reviewing previous medical records to identify the presence additional evaluation may be indicated in some patients to
of a difficult airway, the Task Force points out the obvious characterize the likelihood or nature of the anticipated air-
value of these activities. Based on recognized associations way difficulty.
between a difficult airway and a variety of patient character-
istics, some features of a patients medical history or previous
Recommendations for Evaluation of the Airway
medical records may be related to the likelihood of encoun-
tering a difficult airway. History. An airway history should be conducted, whenever
Observational studies of nonselected patients report asso- feasible, before the initiation of anesthetic care and airway
ciations between several preoperative patient characteristics management in all patients. The intent of the airway history
(e.g., age, obesity, obstructive sleep apnea, history of snor- is to detect medical, surgical, and anesthetic factors that may
ing) and difficult laryngoscopy or intubation (Category B2-H indicate the presence of a difficult airway. Examination of
evidence).16 Observational studies report difficult intubation previous anesthetic records, if available in a timely manner,
or extubation occurring in patients with mediastinal masses may yield useful information about airway management.
(Category B3-H evidence).7,8 Physical Examination. An airway physical examination
Case reports of difficult laryngoscopy or intubation should be conducted, whenever feasible, before the initiation
among patients with a variety of acquired or congenital of anesthetic care and airway management in all patients.
disease states (e.g., ankylosis, degenerative osteoarthritis, The intent of this examination is to detect physical charac-
subglottic stenosis, lingual thyroid or tonsillar hypertrophy, teristics that may indicate the presence of a difficult airway.
Treacher-Collins, Pierre Robin or Down syndromes) are also Multiple airway features should be assessed (table 1).
reported (Category B4-H evidence).918 Additional Evaluation. Additional evaluation may be indi-
The consultants and ASA members strongly agree that cated in some patients to characterize the likelihood or nature
an airway history should be conducted, whenever feasible, of the anticipated airway difficulty. The findings of the airway
before the initiation of anesthetic care and airway manage- history and physical examination may be useful in guiding
ment in all patients. the selection of specific diagnostic tests and consultation.
Physical Examination. Observational studies of nonselected
patients report associations between certain anatomical fea-
II. Basic Preparation for Difficult Airway Management
tures (e.g., physical features of head and neck) and the likeli-
Basic preparation for difficult airway management includes:
hood of a difficult airway (Category B2-H evidence).1921 The
(1) availability of equipment for management of a difficult
presence of upper airway pathologies or anatomical anoma-
airway (i.e., portable storage unit), (2) informing the patient
lies may be identified by conducting a pre-procedure physi-
with a known or suspected difficult airway, (3) assigning an
cal examination. There is insufficient published evidence to
individual to provide assistance when a difficult airway is
evaluate the predictive value of multiple features of the air-
encountered, (4) preanesthetic preoxygenation by mask, and
way physical examination versus single features in predicting
(5) administration of supplemental oxygen throughout the
the presence of a difficult airway.
process of difficult airway management.
The consultants and ASA members strongly agree that an
The literature is insufficient to evaluate the benefits of
airway physical examination should be conducted, whenever
the availability of difficult airway management equipment,
feasible, before the initiation of anesthetic care and airway
informing the patient of a known or suspected difficult air-
management in all patients. The consultants and ASA mem-
way, or assigning an individual to provide assistance when a
bers strongly agree that multiple features# should be assessed
difficult airway is encountered.
during a physical examination.
One RCT indicates that preanesthetic preoxygenation
Additional Evaluation. The airway history or physical exam-
by mask maintains higher oxygen saturation values com-
ination may provide indications for additional diagnostic
pared with room air controls (Category A3-B evidence).34
# Including, but not limited to: length of upper incisors, relation Two RCTs indicate that 3 min of preanesthetic preoxygen-
of maxillary and mandibular incisors during normal jaw closure and ation maintains higher oxygen saturation values compared
voluntary protrusion, interincisor distance, visibility of uvula, shape
of palate, compliance of mandibular space, thyromental distance,
with 1 min of preanesthetic preoxygenation (Category A2-B
length and thickness of neck, and range of motion of head and neck. evidence).35,36 Meta-analysis of RCTs indicate that oxygen
SPECIAL ARTICLES
saturation levels after preoxygenation are equivocal when limited to: (1) awake intubation, (2) video-assisted laryngos-
comparing preoxygenation for 3 min with fast-track pre- copy, (3) intubating stylets or tube-changers, (4) SGA for
oxygenation of four maximal breaths in 30 s (Category A1-E ventilation (e.g., LMA, laryngeal tube), (5) SGA for intuba-
evidence).3741 Three RCTs indicate that times to desaturation (e.g., ILMA), (6) rigid laryngoscopic blades of varying
tion thresholds of 9395% oxygen concentration are longer design and size, (7) fiberoptic-guided intubation, and (8)
for 3 min of preoxygenation (Category A2-B evidence).37,41,42 lighted stylets or light wands.
Meta-analysis of RCTs comparing postextubation supple- Awake Intubation. Studies with observational findings
mental oxygen with no supplemental oxygen indicates lower indicate that awake fiberoptic intubation is successful
frequencies of arterial desaturation during transport with in 88100% of difficult airway patients (Category B3-B
supplemental oxygen to or in the postanesthesia care unit evidence).4953 Case reports using other methods for awake
(Category A1-B evidence).4348 Subjects in the above studies intubation (e.g., blind tracheal intubation, intubation
do not exclusively consist of patients with difficult airways. through supraglottic devices, optically guided intubation)
The consultants and ASA members strongly agree that also report success with difficult airway patients (Category
at least one portable storage unit that contains specialized B4-B evidence).12,5461
equipment for difficult airway management should be read- Video-assisted Laryngoscopy. Meta-analyses of RCTs com-
ily available. The consultants and ASA members strongly paring video-assisted laryngoscopy with direct laryngoscopy
agree that if a difficult airway is known or suspected, the in patients with predicted or simulated difficult airways report
anesthesiologist should: (1) inform the patient (or respon- improved laryngeal views, a higher frequency of successful
sible person) of the special risks and procedures pertaining to intubations, and a higher frequency of first attempt intuba-
management of the difficult airway, (2) ascertain that there is tions with video-assisted laryngoscopy (Category A1-B evi-
at least one additional individual who is immediately avail- dence); no differences in time to intubation, airway trauma,
able to serve as an assistant in difficult airway management, lip/gum trauma, dental trauma, or sore throat were reported
(3) administer facemask preoxygenation before initiating (Category A1-E evidence).6270 One RCT comparing the
management of a difficult airway, and (4) actively pursue use of video-assisted laryngoscopy with Macintosh-assisted
opportunities to deliver supplemental oxygen throughout intubation reported no significant differences inthe degree of
the process of difficult airway management. cervical spine deviation (Category A3-E evidence).69 A study
with observational findings and four case reports indicate
Recommendations for Basic Preparation that airway injury can occur during intubation with video-
At least one portable storage unit that contains specialized assisted laryngoscopy (Category B3/B4-H evidence).7175
equipment for difficult airway management should be read- Intubating Stylets or Tube-Changers. Observational studies
ily available (table 2). If a difficult airway is known or sus- report successful intubation in 78100% of difficult airway
pected, the following steps are recommended: patients when intubating stylets were used (Category B3-B
Inform the patient (or responsible person) of the special evidence).7681 Reported complications from intubating sty-
risks and procedures pertaining to management of the lets include mild mucosal bleeding and sore throat (Category
difficult airway. B3-H evidence).80 Reported complications after the use of a
Ascertain that there is at least one additional individual tube-changer or airway exchange catheter include lung lac-
who is immediately available to serve as an assistant in eration and gastric perforation (Category B4-H evidence).82,83
difficult airway management. SGAs for Ventilation. RCTs comparing the LMA with face-
Administer facemask preoxygenation before initiating mask for ventilation were only available for nondifficult
management of the difficult airway. The uncoopera- airway patients. Case reports indicate that use of the LMA
tive or pediatric patient may impede opportunities for can maintain or restore ventilation for adult difficult airway
preoxygenation. patients (Category B4-B evidence).8486 Two observational
Actively pursue opportunities to deliver supplemen- studies indicate that desaturation (SpO2 < 90%) frequencies
tal oxygen throughout the process of difficult airway of 06% occur when the LMA is used for pediatric
management. Opportunities for supplemental oxygen difficult airway patients (Category B3-H evidence).87,88 An
administration include (but are not limited to) oxygen observational study reports the LMA providing successful
delivery by nasal cannulae, facemask, or LMA, insuffla- rescue ventilation in 94.1% of patients who cannot be mask
tion; and oxygen delivery by facemask, blow-by, or nasal ventilated or intubated (Category B3-B evidence).89 Reported
cannulae after extubation of the trachea. complications of LMA use with difficult airway patients
include bronchospasm, difficulty in swallowing, respiratory
III. Strategy for Intubation of the Difficult Airway obstruction, laryngeal nerve injury, edema, and hypoglossal
A preplanned preinduction strategy includes the consider- nerve paralysis (Category B4-H evidence).9093 One observa-
ation of various interventions designed to facilitate intubation tional study reports that the laryngeal tube provides ade-
should a difficult airway occur. Noninvasive interventions quate ventilation for 95% of patients with pharyngeal and
intended to manage a difficult airway include, but are not laryngeal tumors.94
1SBDUJDF(VJEFMJOFT
ILMA. RCTs comparing the ILMA with standard laryngo- Recommendations for Strategy for Intubation
scopic intubation were only available for nondifficult airway The anesthesiologist should have a preformulated strategy
patients. Observational studies report successful intubation for intubation of the difficult airway. The algorithm shown
in 71.4100% of difficult airway patients when an ILMA in figure 1 is a recommended strategy. This strategy will
was used (Category B3-B evidence).95100 One observational depend, in part, on the anticipated surgery, the condition
study indicated that when the ILMA is used with a simulated of the patient, and the skills and preferences of the anesthe-
difficult airway using a semirigid collar, 3 of 10 patients were siologist. The recommended strategy for intubation of the
successfully intubated (Category B3-B evidence).101 RCTs difficult airway includes:
comparing the fiberoptic ILMA with standard fiberoptic
An assessment of the likelihood and anticipated clinical
intubation report a higher frequency of first attempt suc-
impact of six basic problems that may occur alone or
cessful intubation for patients with predicted or simulated
in combination: (1) difficulty with patient cooperation
difficult airways (Category A2-B evidence).102,103 Reported
or consent, (2) difficult mask ventilation, (3) difficult
complications from ILMAs include sore throat, hoarseness,
SGA placement, (4) difficult laryngoscopy, (5) difficult
and pharyngeal edema (Category B3-H evidence).99
intubation, and (6) difficult surgical airway access.
Rigid Laryngoscopic Blades of Alternative Design and
A consideration of the relative clinical merits and fea-
Size. Observational studies indicate that the use of rigid
sibility of four basic management choices: (1) awake
laryngoscopic blades of alternative design may improve
intubation versus intubation after induction of general
glottic visualization and facilitate successful intubation for
anesthesia, (2) noninvasive techniques versus invasive
difficult airway patients (Category B3-B evidence).104,105
techniques (i.e., surgical or percutaneous airway) for the
Fiberoptic-guided Intubation. Observational studies report
initial approach to intubation, (3) video-assisted lary-
successful fiberoptic intubation in 87100% of difficult
ngoscopy as an initial approach to intubation, and (4)
airway patients (Category B3-B evidence).106117 Three RCTs
preservation versus ablation of spontaneous ventilation.
comparing rigid fiberscopes (UpsherScopes, WuScopes, and
The identification of a primary or preferred approach
Bullard laryngoscopes) with rigid direct laryngoscopy report
to: (1) awake intubation, (2) the patient who can be
equivocal findings for successful intubation and time to
adequately ventilated but is difficult to intubate, and
intubate; two of these studies used simulated difficult air-
(3) the life-threatening situation in which the patient
ways, and the third contained only patients with Mallampati
cannot be ventilated or intubated.
34 scores (Category A2-E evidence).118120
The identification of alternative approaches that can
Lighted Stylets or Light Wands. Observational studies
be used if the primary approach fails or is not feasible
report successful intubation in 96.8100% of difficult air-
(table 3).
way patients when lighted stylets or light wands were used
(Category B3-B evidence).120125 Two RCTs report equivocal The uncooperative or pediatric patient may restrict
findings when comparing lighted stylets with direct laryn- the options for difficult airway management,
goscopy (Category A2-E evidence).126,127 particularly options that involve awake intuba-
Confirmation of Tracheal Intubation. Studies with obser- tion. Airway management in the uncooperative or
vational findings report that capnography or end-tidal pediatric patient may require an approach (e.g.,
carbon dioxide monitoring confirms tracheal intubation intubation attempts after induction of general an-
in 88.5100% of difficult airway patients (Category B3-B esthesia) that might not be regarded as a primary
evidence).128130 approach in a cooperative patient.
The consultants and ASA members strongly agree that The conduct of surgery using local anesthetic
the anesthesiologist should have a preplanned strategy for infiltration or regional nerve blockade may provide
intubation of the difficult airway. The consultants and ASA an alternative to the direct management of the
members strongly agree that the strategy for intubation of difficult airway, but this approach does not represent a
the difficult airway should include the identification of a pri- definitive solution to the presence of a difficult airway,
mary or preferred approach to: (1) awake intubation, (2) the nor does it obviate the need for a preformulated
patient who can be adequately ventilated but who is difficult strategy for intubation of the difficult airway.
to intubate, and (3) the life-threatening situation in which Confirmation of tracheal intubation using capnography
the patient cannot be ventilated or intubated. The consul- or end-tidal carbon dioxide monitoring.
tants and ASA members strongly agree that the strategy for
intubation of the difficult airway should include the iden- IV. Strategy for Extubation of the Difficult Airway
tification of alternative approaches that can be used if the The literature does not provide a sufficient basis for evaluat-
primary approach fails or is not feasible. The consultants and ing the benefits of an extubation strategy for the difficult
ASA members strongly agree that the strategy for intuba- airway. For purposes of this Guideline, an extubation strat-
tion of the difficult airway should include confirmation of egy is considered to be a logical extension of the intubation
tracheal intubation (e.g., capnography). strategy.
SPECIAL ARTICLES
DIFFICULT AIRWAY ALGORITHM

1. Assess the likelihood and clinical impact of basic management problems:
= Difficulty with patient cooperation or consent
= Difficult mask ventilation
= Difficult supraglottic airway placement
= Difficult laryngoscopy
= Difficult intubation
= Difficult surgical airway access
2. Actively pursue opportunities to deliver supplemental oxygen throughout the process of difficult airway
management.
3. Consider the relative merits and feasibility of basic management choices:
= Awake intubation vs. intubation after induction of general anesthesia
= Non-invasive technique vs. invasive techniques for the initial approach to intubation
= Video-assisted laryngoscopy as an initial approach to intubation
= Preservation vs. ablation of spontaneous ventilation
4. Develop primary and alternative strategies:

AWAKE INTUBATION INTUBATION AFTER
INDUCTION OF GENERAL ANESTHESIA
Airway approached by
Invasive Airway Access(b)*
Noninvasive intubation Initial intubation Initial intubation
attempts successful* Attempts UNSUCCESSFUL
FROM THIS POINT ONW ARDS

Succeed* FAIL CONSIDER:
1. Calling for help.
2. Returning to
spontaneous ventilation.
Cancel Consider feasibility Invasive 3. Awakening the patient.
(a) (b)*
Case of other options airway access
FACE MASK VENTILATION ADEQUATE FACE MASK VENTILATION NOT ADEQUATE
CONSIDER/ATTEMPT SGA
SGA ADEQUATE* SGA NOT ADEQUATE

OR NOT FEASIBLE
NONEMERGENCY PATHWAY EMERGENCY PATHWAY
Ventilation adequate, intubation unsuccessful Ventilation not adequate, intubation unsuccessful
IF BOTH
Alternative approaches FACE MASK Call for help
to intubation(c) AND SGA
(e)
VENTILATION Emergency noninvasive airway ventilation
BECOME
INADEQUATE
Successful FAIL after
Intubation* multiple attempts Successful ventilation* FAIL
Emergency
Invasive Consider feasibility Awaken invasive airway
(b)* (d) (b)*
airway access of other options(a) patient access
*Confirm ventilation, tracheal intubation, or SGA placement with exhaled CO2.

a. Other options include (but are not limited to): surgery c. Alternative difficult intubation approaches include (but
utilizing face mask or supraglottic airway (SGA) anesthesia are not limited to): video-assisted laryngoscopy, alternative
(e.g., LMA, ILMA, laryngeal tube), local anesthesia infiltra- laryngoscope blades, SGA (e.g., LMA or ILMA) as an intuba-
tion or regional nerve blockade. Pursuit of these options tion conduit (with or without fiberoptic guidance), fiberoptic
usually implies that mask ventilation will not be problem- intubation, intubating stylet or tube changer, light wand, and
atic. Therefore, these options may be of limited value if this blind oral or nasal intubation.
step in the algorithm has been reached via the Emergency d. Consider re-preparation of the patient for awake intuba-
Pathway. tion or canceling surgery.
b. Invasive airway access includes surgical or percutaneous e. Emergency non-invasive airway ventilation consists of a
airway, jet ventilation, and retrograde intubation. SGA.
Fig. 1. Difficult Airway Algorithm.
1SBDUJDF(VJEFMJOFT
The consultants and ASA members strongly agree with life-threatening complications of difficult airway
that the preformulated extubation strategy should include management.
consideration of: (1) the relative merits of awake extuba-
tion versus extubation before the return of consciousness, Recommendations for Follow-up Care
(2) general clinical factors that may produce an adverse The anesthesiologist should document the presence and
impact on ventilation after the patient has been extubated, nature of the airway difficulty in the medical record. The
and (3) an airway management plan that can be implemented intent of this documentation is to guide and facilitate the
if the patient is not able to maintain adequate ventilation delivery of future care. Aspects of documentation that may
after extubation. The ASA members agree and the consul- prove helpful include:
tants strongly agree that the preformulated extubation strat-
A description of the airway difficulties that were en-
egy should include consideration of the short-term use of a
countered. The description should distinguish between
device that can serve as a guide for expedited reintubation.
difficulties encountered in facemask or SGA ventilation
Recommendations for Extubation and difficulties encountered in tracheal intubation.
The anesthesiologist should have a preformulated strategy for A description of the various airway management
extubation of the difficult airway. This strategy will depend, techniques that were used. The description should indi-
in part, on the surgery, the condition of the patient, and the cate the extent to which each of the techniques served
skills and preferences of the anesthesiologist. a beneficial or detrimental role in management of the
The recommended strategy for extubation of the difficult difficult airway.
airway includes consideration of: The anesthesiologist should inform the patient (or
The relative merits of awake extubation versus extuba- responsible person) of the airway difficulty that was encoun-
tion before the return of consciousness. tered. The intent of this communication is to provide the
General clinical factors that may produce an adverse im- patient (or responsible person) with a role in guiding and
pact on ventilation after the patient has been extubated. facilitating the delivery of future care. The information
An airway management plan that can be implemented conveyed may include (but is not limited to) the presence
if the patient is not able to maintain adequate ventila- of a difficult airway, the apparent reasons for difficulty, how
tion after extubation. the intubation was accomplished, and the implications for
Short-term use of a device that can serve as a guide for future care. Notification systems, such as a written report or
expedited reintubation. This type of device can be a sty- letter to the patient, a written report in the medical chart,
let (intubating bougie) or conduit. Stylets or intubating communication with the patients surgeon or primary care-
bougies are usually inserted through the lumen of the giver, a notification bracelet or equivalent identification
tracheal tube and into the trachea before the tracheal device, or chart flags, may be considered.
tube is removed. Stylets or intubating bougies mayin- The anesthesiologist should evaluate and follow-up with
clude a hollow core that can be used to provide a tem- the patient for potential complications of difficult airway
porary means of oxygenation and ventilation. Conduits management. These complications include (but are not lim-
are usually inserted through the mouth and can be used ited to) edema, bleeding, tracheal and esophageal perforation,
for supraglottic ventilation and intubation. The ILMA pneumothorax, and aspiration. The patient should be advised
and LMA are examples of conduits. of the potential clinical signs and symptoms associated with
life-threatening complications of difficult airway manage-
V. Follow-up Care ment. These signs and symptoms include (but are not limited
Follow-up care includes: (1) documentation of difficult air- to) sore throat, pain or swelling of the face and neck, chest
way and management and (2) informing and advising the pain, subcutaneous emphysema, and difficulty swallowing.
patient (or responsible person) of the occurrence and poten-
tial complications associated with the difficult airway. The Appendix 1: Summary of Recommendations
literature is insufficient to evaluate the benefits of follow-up
I. Evaluation of the Airway
care for difficult airway patients.
An airway history should be conducted, whenever
The consultants and ASA members strongly agree that
feasible, before the initiation of anesthetic care and
the anesthesiologist should: (1) document the presence
airway management in all patients.
and nature of the airway difficulty in the medical record,
(2) inform the patient or responsible person of the airway The intent of the airway history is to detect
difficulty that was encountered, and (3) evaluate and medical, surgical, and anesthetic factors that may
follow-up with the patient for potential complications of indicate the presence of a difficult airway.
difficult airway management. The consultants and ASA Examination of previous anesthetic records, if
members strongly agree that the patient should be advised available in a timely manner, may yield useful in-
of the potential clinical signs and symptoms associated formation about airway management.
SPECIAL ARTICLES
An airway physical examination should be conducted, patient cooperation or consent, (2) difficult mask
whenever feasible, before the initiation of anesthetic ventilation, (3) difficult supraglottic airway place-
care and airway management in all patients. ment, (4) difficult laryngoscopy, (5) difficult intu-
bation, and (6) difficult surgical airway access.
The intent of the physical examination is to detect
A consideration of the relative clinical merits and
physical characteristics that may indicate the pres-
feasibility of four basic management choices: (1)
ence of a difficult airway.
awake intubation versus intubation after induc-
Multiple airway features should be assessed.
tion of general anesthesia, (2) noninvasive tech-
Additional evaluation may be indicated in some niques versus invasive techniques (i.e., surgical
patients to characterize the likelihood or nature of the or percutaneous surgical airway) for the initial
anticipated airway difficulty. approach to intubation, (3) video-assisted laryn-
The findings of the airway history and physical exami- goscopy as an initial approach to intubation, and
nation may be useful in guiding the selection of specific (4) preservation versus ablation of spontaneous
diagnostic tests and consultation. ventilation.
The identification of a primary or preferred ap-
II. Basic Preparation for Difficult Airway Management proach to: (1) awake intubation, (2) the patient who
At least one portable storage unit that contains special- can be adequately ventilated but is difficult to intu-
ized equipment for difficult airway management should bate, and (3) the life-threatening situation in which
be readily available. the patient cannot be ventilated or intubated.
If a difficult airway is known or suspected, the following
The identification of alternative approaches that can be
steps are recommended:
used if the primary approach fails or is not feasible.
Inform the patient (or responsible person) of the The uncooperative or pediatric patient may restrict
special risks and procedures pertaining to manage- the options for difficult airway management, par-
ment of the difficult airway. ticularly options that involve awake intubation.
Ascertain that there is at least one additional Airway management in the uncooperative or
individual who is immediately available to serve as pediatric patient may require an approach (e.g.,
an assistant in difficult airway management. intubation attempts after induction of general
Administer facemask preoxygenation before anesthesia) that might not be regarded as a primary
initiating management of the difficult airway. The approach in a cooperative patient.
uncooperative or pediatric patient may impede The conduct of surgery using local anesthetic in-
opportunities for preoxygenation. filtration or regional nerve blockade may provide
Actively pursue opportunities to deliver supple- an alternative to the direct management of the
mental oxygen throughout the process of difficult difficult airway, but this approach does not rep-
airway management. resent a definitive solution to the presence of a
Opportunities for supplemental oxygen difficult airway, nor does it obviate the need for a
administration include (but are not limited to) preformulated strategy for intubation of the dif-
oxygen delivery by nasal cannulae, facemask ficult airway.
or laryngeal mask airway, insufflation; and
oxygen delivery by facemask, blow-by, or nasal Confirmation of tracheal intubation with capnography
cannulae after extubation of the trachea. or end-tidal carbon dioxide monitoring.
IV. Strategy for Extubation of the

III. Strategy for Intubation of the Difficult Airway
Difficult Airway The anesthesiologist should have a preformulated
The anesthesiologist should have a preformulated strat- strategy for extubation of the difficult airway.
egy for intubation of the difficult airway. The algorithm
shown in figure 1 is a recommended strategy. This strategy will depend, in part, on the surgery,
the condition of the patient, and the skills and
This strategy will depend, in part, on the antici- preferences of the anesthesiologist.
pated surgery, the condition of the patient, and the
skills and preferences of the anesthesiologist. The recommended strategy for extubation of the
difficult airway includes consideration of:
The recommended strategy for intubation of the diffi- The relative merits of awake extubation versus
cult airway includes: extubation before the return of consciousness.
An assessment of the likelihood and anticipated General clinical factors that may produce an
clinical impact of six basic problems that may oc- adverse impact on ventilation after the patient
cur alone or in combination: (1) difficulty with has been extubated.
1SBDUJDF(VJEFMJOFT
An airway management plan that can be im- The anesthesiologist should evaluate and follow-up with
plemented if the patient is not able to main- the patient for potential complications of difficult air-
tain adequate ventilation after extubation. way management.
Short-term use of a device that can serve as a
These complications include (but are not limited
guide for expedited reintubation. This type of
to) edema, bleeding, tracheal and esophageal per-
device can be a stylet (intubating bougie) or con-
foration, pneumothorax, and aspiration.
duit. Stylets or intubating bougies are usually
The patient should be advised of the potential clinical
inserted through the lumen of the tracheal
signs and symptoms associated with life-threatening
tube and into the trachea before the tracheal
complications of difficult airway management.
tube is removed. Stylets or intubating bougies
These signs and symptoms include (but are not
may include a hollow core that can be used
limited to) sore throat, pain or swelling of the face
to provide a temporary means of oxygenation
and neck, chest pain, subcutaneous emphysema,
and ventilation. Conduits are usually inserted
and difficulty swallowing.
through the mouth and can be used for su-
praglottic ventilation and intubation. The in-
tubating laryngeal mask airway and laryngeal Appendix 2: Methods and Analyses
mask airway are examples of conduits. A. State of the Literature.
For these updated Guidelines, a review of studies used in
V. Follow-up Care the development of the previous update was combined
The anesthesiologist should document the presence with new studies published from 20022012. The scientific
and nature of the airway difficulty in the medical assessment of these Guidelines was based on evidence linkages
record. The intent of this documentation is to guide or statements regarding potential relationships between
and facilitate the delivery of future care. Aspects of clinical interventions and outcomes. The interventions listed
documentation that may prove helpful include (but are below were examined to assess their relationship to a variety
not limited to): of outcomes related to difficult airway management.
A description of the airway difficulties that were
encountered. The description should distinguish Evaluation of the Airway:
between difficulties encountered in facemask or A directed patient history
supraglottic airway ventilation and difficulties en- A directed airway physical examination
countered in tracheal intubation. Diagnostic tests (e.g., radiography)
A description of the various airway management
techniques that were used. The description should Basic Preparation for Difficult Airway Management:
indicate the extent to which each of the techniques Informing the patient with a known or suspected difficult
served a beneficial or detrimental role in manage- airway
ment of the difficult airway. Availability of equipment for management of a difficult air-
way (i.e., a portable storage unit)
The anesthesiologist should inform the patient (or re- Availability of an assigned individual to provide assistance
sponsible person) of the airway difficulty that was en- when a difficult airway is encountered
countered. Preanesthetic preoxygenation by facemask before induction
The intent of this communication is to provide the of anesthesia
patient (or responsible person) with a role in guid-
ing and facilitating the delivery of future care. Strategies for Intubation and Ventilation:
The information conveyed may include (but is not Awake intubation
limited to) the presence of a difficult airway, the ap- Adequate facemask ventilation after induction:
parent reasons for difficulty, how the intubation was Videolaryngoscopy
accomplished, and the implications for future care. Intubating stylet, tube-changer, or gum elastic
Notification systems, such as a written report or bougie
letter to the patient, a written report in the medi-
cal chart, communication with the patients sur- Laryngeal mask airway:
geon or primary caregiver, a notification bracelet or Laryngeal mask airway versus facemask
equivalent identification device, or chart flags, may Laryngeal mask airway versus tracheal intubation
be considered. Laryngeal mask airway versus oropharyngeal airway
American Society of Anesthesiologists: Practice Guidelines for
Management of the Difficult Airway: An Updated Report. ANESTHESI- Intubating laryngeal mask airway or the laryngeal mask air-
OLOGY 2003; 98:12691277. way as an intubation conduit
SPECIAL ARTICLES
Rigid laryngoscopic blades of alternative design or size for dichotomous outcome measures. Two combined
Fiberoptic-guided intubation probability tests were used as follows: (1) the Fisher
A lighted stylet or light wand combined test, producing chi-square values based on
logarithmic transformations of the reported P values from
Inadequate Facemask Ventilation After the independent studies, and (2) the Stouffer combined
InductionCannot Intubate: test, providing weighted representation of the studies by
Laryngeal mask airway for emergency ventilation weighting each of the standard normal deviates by the
Rigid bronchoscope size of the sample. An odds ratio procedure based on the
Confirmation of tracheal intubation with capnography or MantelHaenszel method for combining study results using
end-tidal carbon dioxide monitoring 2 2 tables was used with outcome frequency information.
Awake extubation An acceptable significance level was set at P < 0.01 (one-
Supplemental oxygen: tailed). Tests for heterogeneity of the independent studies
Supplemental oxygen delivery before induction by face- were conducted to ensure consistency among the study
mask or insufflation results. DerSimonianLaird random-effects odds ratios were
Supplemental oxygen delivery after extubation by face- obtained when significant heterogeneity was found (P <
mask, blow-by, or nasal cannulae of the trachea 0.01). To control for potential publishing bias, a fail-safe
n value was calculated. No search for unpublished studies
Follow-up Care: was conducted, and no reliability tests for locating research
Postextubation care and counseling results were performed. To be accepted as significant findings,
Documentation of a difficult airway and its management MantelHaenszel odds ratios must agree with combined
Registration with an emergency notification service test results whenever both types of data are assessed. In the
For the literature review, potentially relevant clinical stud- absence of MantelHaenszel odds ratios, findings from both
ies were identified via electronic and manual searches of the the Fisher and weighted Stouffer combined tests must agree
literature. The updated electronic search covered an 11-yr with each other to be acceptable as significant.
period from 2002 through 2012. The manual search covered New meta-analytic findings were obtained for the follow-
a 16-yr period from 1997 through 2012. Over 400 citations ing evidence linkages: (1) preoxygenation for 3-5 min versus
that addressed topics related to the evidence linkages were 4 deep breaths, (2) videolaryngoscope versus direct laryngos-
identified. These articles were reviewed and combined with copy, and (3) supplemental oxygen after extubation (table 4).
pre-2002 articles used in the original Guidelines, resulting In the original Guidelines, interobserver agreement
in a total of 693 articles that contained airway management among Task Force members and two methodologists was
data. Of these, 253 contained data pertaining specifically to established by interrater reliability testing. Agreement levels
difficult airway management. The remaining 440 articles using a kappa () statistic for two-rater agreement pairs were
used nondifficult airway patients or an inseparable mix of dif- as follows: (1) type of study design, = 0.640.78; (2) type
ficult and nondifficult airway patients as subjects, and find- of analysis, = 0.780.85; (3) evidence linkage assignment,
ings from these articles are not considered direct evidence. A = 0.890.95; and (4) literature inclusion for database,
complete bibliography used to develop these updated Guide- = 0.621.00. Three-rater chance-corrected agreement val-
lines, organized by section, is available as Supplemental Digi- ues were: (1) study design, Sav = 0.73, Var (Sav) = 0.008; (2)
tal Content 2, http://links.lww.com/ALN/A903. type of analysis, Sav = 0.80, Var (Sav) = 0.008; (3) linkage
Initially, each pertinent study finding was classified and assignment, Sav = 0.93, Var (Sav) = 0.003; (4) literature
summarized to determine meta-analysis potential. The origi- database inclusion, Sav = 0.80, Var (Sav) = 0.032. These val-
nal Guidelines reported literature pertaining to seven clinical ues represent moderate to high levels of agreement. For the
interventions that contained enough studies with well-defined updated Guidelines, the same two methodologists involved
experimental designs and statistical information to conduct in the original Guidelines conducted the literature review.
formal meta-analyses. New literature pertaining to two clini-
cal interventions contained enough studies with well-defined B. Consensus-Based Evidence
experimental designs and statistical information sufficient for Consensus was obtained from multiple sources, including:
meta-analyses. These interventions were: (1) preoxygenation: (1) survey opinion from consultants who were selected based
35 min of breathing oxygen versus four maximal breaths, on their knowledge or expertise in difficult airway manage-
and (2) postextubation supplemental oxygen: delivery by ment, (2) survey opinions solicited from active members of
mask, blow-by, or nasal cannulae versus room air. the American Society of Anesthesiologists, (3) testimony
General variance-based effect-size estimates or combined for the previous update from attendees of a publicly held
probability tests were obtained for continuous outcome open-forum at a major national anesthesia meeting, (4)
measures, and MantelHaenszel odds ratios were obtained Internet commentary, and (5) Task Force opinion and inter-
American Society of Anesthesiologists Annual Meeting, Dallas, pretation. The survey rate of return was 63% (n = 66 of
TX, October, 1999. 105) for the consultants (table 5), and 302 surveys were
"OFTUIFTJPMPHZ9999 11 1SBDUJDF(VJEFMJOFT
1SBDUJDF(VJEFMJOFT
received from active American Society of Anesthesiologists strategy =64% and follow-up care = 72%. Eighty-eight
members (table 6). percent of the respondents indicated that the Guidelines
An additional survey was sent to the expert consultants would have no effect on the amount of time spent on a
asking them to indicate which, if any, of the evidence link- typical case, and 12% indicated that there would be an
ages would change their clinical practices if the Guideline increase of the amount of time spent on a typical case
update was instituted. The rate of return was 24% (n = 25 with the implementation of these Guidelines. Hundred
of 105). The percent of responding consultants expecting percent indicated that new equipment, supplies, or train-
no change associated with each linkage were as follows: ing would not be needed to implement the Guidelines,
(1) airway history = 84%, (2) airway physical examina- and 100% indicated that implementation of the Guide-
tion =88%, (3) preparation of patient and equipment = lines would not require changes in practice that would
80%, and (4) difficult airway strategy = 80%, extubation affect costs.
Table 1. Components of the Preoperative Airway Physical Examination
Airway Examination Component Nonreassuring Findings
Length of upper incisors Relatively long

Relationship of maxillary and mandibular incisors Prominent overbite (maxillary incisors anterior to mandibu-
during normal jaw closure lar incisors)
Relationship of maxillary and mandibular incisors Patient cannot bring mandibular incisors anterior to (in front
during voluntary protrusion of mandible of) maxillary incisors
Interincisor distance Less than 3 cm
Visibility of uvula Not visible when tongue is protruded with patient in sitting
position (e.g., Mallampati class >2)
Shape of palate Highly arched or very narrow
Compliance of mandibular space Stiff, indurated, occupied by mass, or nonresilient
Thyromental distance Less than three ordinary finger breadths
Length of neck Short
Thickness of neck Thick
Range of motion of head and neck Patient cannot touch tip of chin to chest or cannot
extend neck
This table displays some findings of the airway physical examination that may suggest the presence of a difficult intubation. The decision
to examine some or all of the airway components shown on this table is dependent on the clinical context and judgment of the practi-
tioner. The table is not intended as a mandatory or exhaustive list of the components of an airway examination. The order of presentation
in this table follows the line of sight that occurs during conventional oral laryngoscopy.
Table 2. Suggested Contents of the Portable Storage Table 3. Techniques for Difficult Airway Management
Unit for Difficult Airway Management
Techniques for Difficult Techniques for Difficult
Rigid laryngoscope blades of alternate design and Intubation Ventilation
size from those routinely used; this may include a rigid
fiberoptic laryngoscope. Awake intubation Intratracheal jet stylet
Videolaryngoscope. Blind intubation (oral or nasal) Invasive airway access
Tracheal tubes of assorted sizes. Fiberoptic intubation Supraglottic airway
Tracheal tube guides. Examples include (but are not Intubating stylet or Oral and nasopharyn-
limited to) semirigid stylets, ventilating tube-changer, tube-changer geal airways
light wands, and forceps designed to manipulate the Supraglottic airway as an Rigid ventilating
distal portion of the tracheal tube. intubating conduit bronchoscope
Supraglottic airways (e.g., LMA or ILMA of assorted Laryngoscope blades of Two-person mask
sizes for noninvasive airway ventilation/intubation). varying design and size ventilation
Flexible fiberoptic intubation equipment. Light wand
Equipment suitable for emergency invasive airway Videolaryngoscope
access.
An exhaled carbon dioxide detector. This table displays commonly cited techniques. It is not a
comprehensive list. The order of presentation is alphabeti-
The items listed in this table represent suggestions. The contents cal and does not imply preference for a given technique or
of the portable storage unit should be customized to meet the sequence of use. Combinations of techniques may be used.
specific needs, preferences, and skills of the practitioner and The techniques chosen by the practitioner in a particular case
healthcare facility. will depend on specific needs, preferences, skills, and clinical
ILMA = intubating LMA; LMA = laryngeal mask airway. constraints.
SPECIAL ARTICLES
Table 4. Meta-analysis Summary
Heterogeneity
Fisher Weighted
Chi- Stouffer Effect Odds Effect
Evidence Linkages N Square P Zc P Size Ratio CI P Size
Preoxygenation for 35 min vs.

4 deep breaths
Oxygen saturation after 5 41.17 0.001 0.46 0.323 0.31 0.001 0.001
preoxygenation
Videolaryngoscope vs. direct
laryngoscopy
Laryngeal view grade 1 7 7.11* 2.5810.72 0.001
Laryngeal view grades 1 and 2 7 5.29 3.368.33 0.414
Successful intubation 9 3.24 1.596.61 0.745
Successful first attempt intubation 6 3.10 1.665.81 0.247
Time to intubation 7 72.86 0.001 2.23 0.013 0.05 0.001 0.001
Supplemental oxygen after
extubation
Hypoxemia 6 0.18 0.100.32 0.486
* Random effects odds ratio.
CI = 99% confidence interval.
Table 5. Consultant Survey Responses
Percent Responding to Each Item
Strongly Strongly
N Agree Agree Equivocal Disagree Disagree
1. The likelihood and clinical impact of the following basic

management problems should be assessed:
Difficulty with patient cooperation or consent 66 60.6* 33.3 3.0 3.0 0.0
Difficult mask ventilation 66 93.9* 6.1 0.0 0.0 0.0
Difficult supraglottic placement 66 75.8* 21.2 1.5 1.5 0.0
Difficult laryngoscopy 66 84.8* 10.6 4.6 0.0 0.0
Difficult intubation 66 89.4* 9.1 1.5 0.0 0.0
Difficult surgical airway access 66 71.2* 24.2 4.6 0.0 0.0
2. Opportunities to deliver supplemental oxygen should be 66 86.4* 10.6 1.5 1.5 0.0
actively pursued throughout the process of difficult airway
management.
3. The relative merits and feasibility of the following basic
management choices should be considered:
Awake intubation vs. intubation after induction of general 66 78.8* 19.7 1.5 3.0 0.0
anesthesia.
Noninvasive technique vs. invasive technique for initial 66 54.5* 34.8 9.1 1.5 0.0
approach to intubation.
Preservation of spontaneous ventilation vs. ablation of 66 74.2* 21.2 1.5 1.5 1.5
Use of video-assisted laryngoscopy vs. rigid laryngoscopic 66 48.5 25.8* 16.7 7.6 1.5
blades as an initial approach to intubation.
4. The following airway devices should be options for emergency
noninvasive airway ventilation:
Rigid bronchoscope 66 13.6 33.3 16.7* 30.3 6.1
Fiberoptic bronchoscope 66 69.7* 12.1 3.0 12.1 3.0
Supraglottic airway 66 92.4* 7.6 0.0 0.0 0.0
(continued)
1SBDUJDF(VJEFMJOFT
Table 5. (Continued )
Strongly Strongly
5. A videolaryngoscope should be included in the portable 66 71.2* 18.2 7.6 3.0 0.0
storage unit for difficult airway management.
6. Transtracheal jet ventilation should be considered an 66
example of: (check one)
Invasive airway ventilation 95.4%
Noninvasive airway ventilation 4.6%
7. An airway history should be conducted, whenever feasible, 66 90.9* 6.1 3.0 0.0 0.0
before the initiation of anesthetic care and airway
management in all patients.
8. An airway physical examination should be conducted, 66 92.4* 7.6 0.0 0.0 0.0
whenever feasible, before the initiation of anesthetic care
and airway management in all patients.
9. Multiple airway features should be assessed 66 80.3* 10.6 6.1 3.0 0.0
10. Additional evaluation may be indicated in some patients to 66 51.5* 39.4 6.1 1.5 1.5
characterize the likelihood or nature of anticipated airway
difficulty.
11. At least one portable storage unit that contains specialized 66 92.4* 6.1 1.5 0.0 0.0
equipment for difficult airway management should be
readily available.
12. If a difficult airway is known or suspected, the anesthesiolo- 66 78.8* 19.7 1.5 0.0 0.0
gist should inform the patient (or responsible person) of the
special risks and procedures pertaining to management of
the difficult airway.
13. If a difficult airway is known or suspected, the 66 65.2* 25.7 9.1 0.0 0.0
anesthesiologist should ascertain that there is at least one
additional individual who is immediately available to serve as
an assistant in difficult airway management.
14. If a difficult airway is known or suspected, the anesthesi- 66 71.2* 15.1 6.1 7.6 0.0
ologist should administer facemask preoxygenation before
initiating management of the difficult airway.
15. If a difficult airway is known or suspected, the 66 86.4* 13.6 0.0 0.0 0.0
anesthesiologist should actively pursue opportunities to
deliver supplemental oxygen throughout the process of
difficult airway management.
16. The anesthesiologist should have a preformulated strategy 66 95.5* 3.0 1.5 0.0 0.0
for intubation of the difficult airway.
17. The strategy for intubation of the difficult airway should
include consideration of the relative clinical merits and
feasibility of four basic management choices:
anesthesia.
Noninvasive techniques for the initial approach to intubation 66 71.2* 25.8 3.0 0.0 0.0
vs. invasive techniques (i.e., surgical or percutaneous airway).
Video-assisted laryngoscopy as an initial approach to intubation. 66 48.5 22.7* 16.7 10.6 1.5
Preservation vs. ablation of spontaneous ventilation. 66 80.3* 12.1 6.1 0.0 1.5
18. The strategy for intubation of the difficult airway should include
the identification of a primary or preferred approach to:
Awake intubation. 66 71.2* 24.2 3.0 0.0 1.5
The patient who can be adequately ventilated but who is 66 77.3* 19.7 3.0 0.0 0.0
difficult to intubate.
The life-threatening situation in which the patient cannot 66 93.9* 6.1 0.0 0.0 0.0
be ventilated or intubated.
19. The strategy for intubation of the difficult airway should 66 98.5* 1.5 0.0 0.0 0.0
include the identification of alternative approaches that can
be used if the primary approach fails or is not feasible.
(continued)
SPECIAL ARTICLES
Strongly Strongly
20. The strategy for intubation of the difficult airway should include 66 98.5* 1.5 0.0 0.0 0.0
confirmation of tracheal intubation (e.g., capnography).
21. The preformulated extubation strategy should include
consideration of:
The relative merits of awake extubation vs. extubation 66 72.7* 21.2 3.0 1.5 1.5
before the return of consciousness.
General clinical factors that may produce an adverse 66 84.8* 15.2 0.0 0.0 0.0
impact on ventilation after the patient has been extubated.
An airway management plan that can be implemented if 66 89.4* 9.1 1.5 0.0 0.0
the patient is not able to maintain adequate ventilation
after extubation.
Short-term use of a device that can serve as a guide for 66 63.6* 28.8 7.6 0.0 0.0
expedited reintubation.
22. The anesthesiologist should document the presence and 66 95.5* 4.5 0.0 0.0 0.0
nature of the airway difficulty in the medical record.
23. The anesthesiologist should inform the patient (or responsi- 66 87.9* 12.1 0.0 0.0 0.0
ble person) of the airway difficulty that was encountered.
24. The anesthesiologist should evaluate and follow-up with 66 77.3* 19.7 3.0 0.0 0.0
the patient for potential complications of difficult airway
management.
25. The patient should be advised of the potential clinical signs 66 65.1* 25.8 7.6 1.5 0.0
and symptoms associated with life-threatening
complications of difficult airway management.
*Median; N = number of consultants who responded to each item. An asterisk beside a percentage score indicates the median.
Including, but not limited to, length of upper incisors, relation of maxillary and mandibular incisors during normal jaw closure and volun-
tary protrusion, interincisor distance, visibility of uvula, shape of palate, compliance of mandibular space, thyromental distance, length
and thickness of neck, and range of motion of the head and neck.
Table 6. ASA Members Survey Responses
Strongly Strongly
1. The likelihood and clinical impact of the following basic

management problems should be assessed:
Difficulty with patient cooperation or consent 302 49.7 36.4* 8.6 4.0 1.3
Difficult mask ventilation 302 81.8* 15.9 1.0 1.3 0.0
Difficult supraglottic placement 302 64.5* 28.5 5.0 2.0 0.0
Difficult laryngoscopy 302 84.4* 14.6 0.3 0.7 0.0
Difficult intubation 302 87.7* 12.3 0.0 0.0 0.0
Difficult surgical airway access 302 54.6* 32.5 11.3 1.3 0.3
2. Opportunities to deliver supplemental oxygen should be actively 302 79.8* 16.9 3.0 0.3 0.0
pursued throughout the process of difficult airway management.
(continued
1SBDUJDF(VJEFMJOFT
Table 6. (Continued)
Strongly Strongly
3. The relative merits and feasibility of the following basic
management choices should be considered:
anesthesia.
Noninvasive technique vs. invasive technique for initial 302 52.0* 37.1 9.6 1.3 0.0
approach to intubation.
Preservation of spontaneous ventilation vs. ablation of 302 65.2* 28.5 5.3 1.0 0.0
Use of video-assisted laryngoscopy vs. rigid laryngoscopic 302 53.0* 29.5 12.9 4.6 0.0
blades as an initial approach to intubation.
4. The following airway devices should be options for emergency
noninvasive airway ventilation:
Rigid bronchoscope 302 6.3 21.5 33.7* 31.5 7.0
Fiberoptic bronchoscope 302 64.2* 19.2 4.6 8.9 3.0
Supraglottic airway 302 91.4* 8.3 0.3 0.0 0.0
5. A videolaryngoscope should be included in the portable 302 69.5* 20.5 6.6 3.3 0.0
storage unit for difficult airway management.
6. Transtracheal jet ventilation should be considered an example 302
of: (check one)
Invasive airway ventilation 95.7%
Noninvasive airway ventilation 4.3%
7. An airway history should be conducted, whenever feasible, 302 87.1* 10.9 0.7 1.3 0.0
before the initiation of anesthetic care and airway management
in all patients.
8. An airway physical examination should be conducted, 302 91.1* 7.9 0.7 0.3 0.0
whenever feasible, before the initiation of anesthetic care and
airway management in all patients.
9. Multiple airway features should be assessed. 302 71.8* 22.5 2.6 2.0 1.0
10. Additional evaluation may be indicated in some patients to char- 302 55.6* 35.1 7.6 1.3 0.3
acterize the likelihood or nature of anticipated airway difficulty.
11. At least one portable storage unit that contains specialized 302 85.8* 12.2 2.0 0.0 0.0
equipment for difficult airway management should be readily
available.
12. If a difficult airway is known or suspected, the anesthesiologist 302 73.8* 24.2 1.7 0.0 0.3
should inform the patient (or responsible person) of the special
risks and procedures pertaining to management of the difficult
airway.
should ascertain that there is at least one additional individual
who is immediately available to serve as an assistant in difficult
airway management.
should administer facemask preoxygenation before initiating
management of the difficult airway.
should actively pursue opportunities to deliver supplemental
oxygen throughout the process of difficult airway management.
16. The anesthesiologist should have a preformulated strategy for 302 84.4* 14.9 0.7 0.0 0.0
intubation of the difficult airway.
consideration of the relative clinical merits and feasibility of
four basic management choices:
anesthesia.
Noninvasive techniques for the initial approach to intubation 302 62.2* 34.8 2.3 0.7 0.0
vs. invasive techniques (i.e., surgical or percutaneous airway).
continued
SPECIAL ARTICLES
Strongly Strongly
Q Video-assisted laryngoscopy as an initial approach to intubation. 302 53.6* 33.1 8.6 3.3 1.3
Q Preservation vs. ablation of spontaneous ventilation. 302 62.6* 29.1 6.3 2.0 0.0
the identification of a primary or preferred approach to:
Awake intubation. 302 61.9* 31.5 5.6 1.0 0.0
The patient who can be adequately ventilated but who is 302 62.2* 35.1 2.0 0.7 0.0
difficult to intubate.
The life-threatening situation in which the patient cannot be 302 85.1* 13.9 1.0 0.0 0.0
ventilated or intubated.
the identification of alternative approaches that can be used if
the primary approach fails or is not feasible.
confirmation of tracheal intubation (e.g., capnography).
21. The preformulated extubation strategy should include 302 76.2* 18.2 2.6 1.7 1.3
consideration of:
The relative merits of awake extubation vs. extubation
before the return of consciousness.
General clinical factors that may produce an adverse impact 302 73.8* 22.8 3.0 0.3 0.0
on ventilation after the patient has been extubated.
An airway management plan that can be implemented if the 302 75.5* 23.2 1.0 0.3 0.0
patient is not able to maintain adequate ventilation after
extubation.
Short-term use of a device that can serve as a guide for 302 45.4 36.7* 14.5 2.0 1.3
expedited reintubation.
22. The anesthesiologist should document the presence and 302 90.7* 8.6 0.7 0.0 0.0
nature of the airway difficulty in the medical record.
23. The anesthesiologist should inform the patient (or responsible 302 85.7* 13.6 0.7 0.0 0.0
person) of the airway difficulty that was encountered.
24. The anesthesiologist should evaluate and follow-up with the 302 55.3* 37.7 6.6 0.0 0.3
patient for potential complications of difficult airway management.
25. The patient should be advised of the potential clinical signs 302 56.0* 32.1 10.6 1.0 0.3
and symptoms associated with life-threatening complications
of difficult airway management.
N = number of ASA members who responded to each item. An asterisk beside a percentage score indicates the median. Including, but not
limited to, length of upper incisors, relation of maxillary and mandibular incisors during normal jaw closure and voluntary protrusion, inter-
incisor distance, visibility of uvula, shape of palate, compliance of mandibular space, thyromental distance, length and thickness of neck, and
range of motion of the head and neck.
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Practice Guidelines For Management of The Difficult Airway 2013

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Practice Guidelines For Management of The Difficult Airway 2013

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SPECIAL ARTICLES

Practice Guidelines for Management of the Difficult Airway

P RACTICE Guidelines are systematically developed

Updated by the Committee on Standards and Practice Param-

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Category B Category B: Membership Opinion

DIFFICULT AIRWAY ALGORITHM

4. Develop primary and alternative strategies:

FROM THIS POINT ONW ARDS

FACE MASK VENTILATION ADEQUATE FACE MASK VENTILATION NOT ADEQUATE

SGA ADEQUATE* SGA NOT ADEQUATE

*Confirm ventilation, tracheal intubation, or SGA placement with exhaled CO2.

IV. Strategy for Extubation of the

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Table 1. Components of the Preoperative Airway Physical Examination

Airway Examination Component Nonreassuring Findings

Length of upper incisors Relatively long

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Table 4. Meta-analysis Summary

Preoxygenation for 35 min vs.

Table 5. Consultant Survey Responses

Percent Responding to Each Item

1. The likelihood and clinical impact of the following basic

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Table 6. ASA Members Survey Responses

Percent Responding to Each Item

1. The likelihood and clinical impact of the following basic

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