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Rev Esp Anestesiol Reanim. 2017;xxx(xx):xxx---xxx

Revista Española de Anestesiología

y Reanimación
www.elsevier.es/redar

CONTINUING EDUCATION

Guidelines and algorithms for managing the difficult

airway夽
M.A. Gómez-Ríos a,b,∗ , L. Gaitini c,e , I. Matter d,e , M. Somri c,d

a
Departamento de Anestesiología y Medicina Perioperativa, Complejo Hospitalario Universitario de A Coruña, La Coruña,
Galicia, Spain
b
Grupo de Anestesiología y Tratamiento del Dolor, Instituto de Investigación Biomédica de A Coruña (INIBIC), La Coruña, Galicia,
Spain
c
Department of Anesthesiology, Bnai Zion Medical Center, Haifa, Israel
d
Department of Surgery, Bnai Zion Medical Center, Haifa, Israel
e
Faculty of Medicine, Technion, Institute of Technology, Haifa, Israel

Received 1 July 2017; accepted 3 July 2017

KEYWORDS Abstract The difficult airway constitutes a continuous challenge for anesthesiologists. Guide-
Guidelines; lines and algorithms are key to preserving patient safety, by recommending specific plans and
Algorithms; strategies that address predicted or unexpected difficult airway. However, there are currently
Airway; no ‘‘gold standard’’ algorithms or universally accepted standards. The aim of this article is
Difficult airway; to present a synthesis of the recommendations of the main guidelines and difficult airway
Anaesthesia algorithms.
© 2017 Sociedad Española de Anestesiologı́a, Reanimación y Terapéutica del Dolor. Published
by Elsevier España, S.L.U. All rights reserved.

PALABRAS CLAVE Guías y algoritmos para el manejo de la vía aérea difícil

Guías;
Resumen La vía aérea difícil constituye un continuo desafío para el anestesiólogo y su
Algoritmos;
tratamiento es una de las tareas de mayor exigencia al representar un riesgo vital. Las guías y
Vía aérea;
algoritmos juegan un papel clave en la preservación de la seguridad del paciente al recomendar
Vía aérea difícil;
planes y estrategias específicos para abordar la vía aérea difícil prevista o inesperada. Sin
Anestesia

夽
Please cite this article as: Gómez-Ríos MA, Gaitini L, Matter I, Somri M. Guías y algoritmos para el manejo de la vía aérea difícil. Rev Esp
Anestesiol Reanim. 2017. https://doi.org/10.1016/j.redar.2017.07.009
∗ Corresponding author.

E-mail address: magoris@hotmail.com (M.A. Gómez-Ríos).

2341-1929/© 2017 Sociedad Española de Anestesiologı́a, Reanimación y Terapéutica del Dolor. Published by Elsevier España, S.L.U. All rights
reserved.

REDARE-853; No. of Pages 8

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2 M.A. Gómez-Ríos et al.

embargo, no existen actualmente algoritmos «de referencia», ni estándares universalmente

aceptados. El objetivo de este artículo es presentar una síntesis de las recomendaciones de las
principales guías y algoritmos de la vía aérea difícil.
© 2017 Sociedad Española de Anestesiologı́a, Reanimación y Terapéutica del Dolor. Publicado
por Elsevier España, S.L.U. Todos los derechos reservados.

Introduction Table 1 Limitations of the guidelines and algorithms of

the American Society of Anesthesiologists and the Difficult
In 1990, Dr. Robert Caplan and his colleagues published Airway Society.
‘‘Adverse Respiratory Events in Anesthesiology: A Closed
Claims Analysis’’ in the journal Anesthesiology.1 This article American Society of Anesthesiologists (ASA)
summarised a detailed retrospective analysis of medical-
No specific considerations for paediatric and obstetric
legal litigation over a period of 5 years in the United States.
patients, patients with a full stomach, and patients with
The main causes of most irreversible brain injuries and
glottic or subglottic obstruction
deaths associated with anaesthetic procedures were found
Poorly defined terminology with no definition of attempt,
to be difficult tracheal intubation (TI), oesophageal intuba-
optimal ventilation attempt with a face mask, and
tion and inadequate ventilation.
optimal attempt by conventional laryngoscopy
In the same year, the American Society of Anesthesiolo-
No discussion of the implications of neuromuscular
gists (ASA) established an Expert Working Group on Difficult
relaxants or the role of regional anaesthesia in patients
Airway Management. The outcome of this group was the
with difficult airway
‘‘Practice Guidelines for Management of the Difficult Air-
No discrimination between an obstructed or unobstructed
way’’, published in 1993, with subsequent updates in 2003
airway
and 20132 (Supplementary Figure S1 available online). The
The clinical endpoint is successful tracheal intubation (TI),
UK’s Difficult Airway Society (DAS) issued its own recommen-
but this may not be necessary if ventilation is adequate
dations in 2003, which were revised in 20133 (Supplementary
The algorithm begins with TI failure, but difficulty
Figure S2 available online).
ventilating with an FM or a supraglottic device may have
The inability to successfully manage a difficult air-
been the initial problem. Thus, the algorithm can direct
way (DA) is responsible for 600 deaths annually and 30%
the clinician to interventions that have already proven
of deaths attributable to anesthesia.4 Evidence consis-
ineffective
tently indicates that successful DA management requires
Does not follow a linear decision tree; this limits its
compliance with specific pre-established strategies. Thus,
usefulness in an emergency situation
a number of anaesthesiology societies have developed their
Does not present a flow chart for extubation
own country-specific guidelines and algorithms. All of these
aim to simplify protocols and facilitate the management of Difficult Airway Society (DAS)
DA, and to minimise the incidence of adverse outcomes.
There are currently no universal algorithms or standards, Only addresses the management of unexpected DA
so guidelines serve only as basic recommendations and not Does not list individual techniques in relation to levels of
as standards of care or absolute requirements.5 The updated evidence
versions of the ASA and DAS guidelines are the most widely
used, and have served as a reference for the development
of others. The recommendations are based on scien-
tific evidence, rigorous bibliographic analysis and expert since the limitations of one are supplemented by the other.
opinion.6 All guidelines require periodic updates in light Table 1 presents the main limitations of both guidelines and
of ongoing technological advances and changes in medical algorithms.
knowledge.
Despite the existence of relevant guidelines and algo-
rithms, the National Audit Project 4 (NAP4), developed in Definitions
2011 by the Royal College of Anaesthetists and the DAS,
showed that reliance on inadequate criteria, together with According to Gil et al., 18% of patients are difficult to intu-
poor planning and training, were the main determinants of bate, 5% are difficult to oxygenate and 0.004---0.008% cannot
poor outcomes in DA management.7 Cognitive processing be intubated/oxygenated.9 Determining and comparing the
and motor skills often deteriorate under situations of stress, incidence of difficult airway is hampered by the use of vary-
such as an unpredicted DA.8 In these scenarios, therefore, ing definitions in the literature.
a clear pre-established strategy is necessary.5 This article The use of precise terminology is the key to any guide-
presents a synthesis of the ASA and DAS guidelines and algo- line and algorithm, and enables an adequate progression of
rithms, with the purpose of facilitating decision-making. The strategies. Despite the absence of standard terminology, the
recommendations of these guidelines are complementary, ASA algorithms propose a series of definitions.
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Guidelines and algorithms for managing the difficult airway 3

Difficult airway Table 2 Predictors of difficult airways.

Clinical situation in which an experienced anaesthesiolo- Predictors Normal

gist with conventional training has difficulty ventilating the Interincisor distance >4 cm
upper airway with a face mask (FM) or TI or both. Mallampati-Samsoon Grade I---II
classification
Difficult insertion of a supraglottic airway (SGA) Neck Elastic and flexible
Thyromental distance >6 cm
The placement of the SGA requires multiple attempts, in the (Patil’s test)
presence or absence of tracheal pathology. Mandibular protrusion Ability to protrude the lower
jaw beyond the upper incisors
Atlanto-occipital joint Cervical extension of 35◦
Difficult ventilation with an FM or SGA Sterno-mental distance >12 cm
History of previous No difficulty or sequelae
Adequate ventilation cannot be provided due to one or intubation
more of the following problems: inadequate FM or SGA
seal, excessive gas leak or excessive resistance to the
ingress or egress of gas. Signs of inadequate ventilation
include: absent or inadequate chest movement or breath
sounds, auscultory signs of severe obstruction, cyanosis, gas- be performed routinely to identify factors that could lead
tric air entry or dilation, decreased or inadequate oxygen to difficulties in ventilation with FM, insertion of an SGA,
saturation, absent or inadequate exhaled carbon dioxide, laryngoscopy, TI, and surgical access.10
absent or inadequate spirometric measures of exhaled gas While there are multiple predictors of DA (Table 2), none
flow, and haemodynamic changes associated with hypox- is totally reliable since they all have low sensitivity, speci-
aemia and hypercapnia (e.g. hypertension, tachycardia, ficity and positive predictive value.11,12 Test combinations
arrhythmias). must therefore be used to increase reliability.10 How-
ever, even in the absence of predictors, a pre-established
Difficult laryngoscopy plan is necessary to overcome any difficulties that may
arise.
No portion of the vocal cords is visible, after multiple Another point that is essential in planning the man-
attempts at conventional laryngoscopy. agement of DA is the assessment of aspiration risk.
Pharmacological measures and preoperative fasting are
important for reducing volume and raising the pH of
Difficult tracheal intubation gastric contents. In patients with an intestinal obstruc-
tion or with slow gastric emptying, a nasogastric
TI requires multiple attempts, in the presence or absence of tube should be inserted to minimise residual gastric
tracheal pathology. volume.13,14

Failed intubation
Pre-induction preparation
Placement of the endotracheal tube fails after several
Optimal patient positioning maximises the probability of
attempts.
success and minimises the number of attempts. The
These definitions have their limitations. For example,
‘‘sniffing’’ position (slight cervical flexion with head in
they do not include specific Cormack---Lehane grades to
hyperextension) is most frequently used. Ramping (hori-
characterise the visualisation of laryngeal structures, they
zontal alignment of the external auditory canal with the
do not mention the use of adjuvants that can facilitate
suprasternal fork) is necessary for obese patients. Both pos-
ventilation, laryngoscopy or TI, and they do not specify
itions optimise airway patency, respiratory mechanics and
the maximum number of attempts. The latter is pivotal
passive oxygenation during apnea.3
in decision-making and helps to avoid the ‘‘cannot intu-
Adequate pre-oxygenation is imperative for all patients
bate, cannot oxygenate’’ (CICO) scenario due to repeated
before proceeding to the induction of general anaesthesia
attempts. Most of these deficiencies are addressed by the
(GA). Increasing oxygen reserve delays the onset of hypoxia,
DAS, which includes descriptions of optimal conditions for
allowing more time for airway management. Apnoea time
ventilation and TI, as well as the definition of a laryngoscopy
without desaturation is limited to 1---2 min in a healthy adult
attempt.
breathing room air; whereas with correct pre-oxygenation,
this is extended to 8 min.15---17
Pre-operative evaluation of the airway Pre-oxygenation can be achieved with the adminis-
tration of 100% oxygen through a well-sealed FM until
Both the ASA and the DAS guides emphasise the importance the expired oxygen fraction is 0.87---0.90. Other methods
of preoperative airway assessment to anticipate poten- include ‘‘apnoeic oxygenation’’, which involves adminis-
tial problems and prepare strategies to reduce adverse tering 15 L/min of oxygen through a nasal cannula, and
outcomes.5 Thus, preoperative airway assessment should positioning the head at a 25◦ angle in the obese patient
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4 M.A. Gómez-Ríos et al.
with continuous positive airway pressure, and prolonging the
duration of apnoea without desaturation.3
Anticipated difficult airway: awake tracheal
intubation
This situation focuses on patients who present with charac-
teristics that predict difficulty or with a previous history of
DA, and is addressed in the ASA guide. In contrast, the DAS
only considers the unanticipated DA.
Awake TI is the technique of choice in anticipated
DA, since preservation of muscle tone maintains air-
way patency and facilitates identification of anatomical
structures. Moreover, spontaneous ventilation is preserved
and prevents the larynx from adopting a more ante-
rior position during anaesthesia induction, thus facilitating
TI.
The choice of technique (a non-invasive technique using
fibreoptic bronchoscopy [FOB], video laryngoscopy [VL] or
an SGA versus an invasive technique such as a surgical
airway, percutaneous airway, jet ventilation, or retro-
grade intubation) will depend on the type of surgery,
the patient’s status and the anaesthesiologist’s skills and
preferences.
Awake TI using FOB is successful in 88---100% of cases.18---20
To achieve such high success rates the patient must be
fully informed about the technique and the risks and care-
fully prepared (e.g. administer antisialagogues, such as
glycopyrrolate, atropine and scopolamine and nasal vaso-
constrictors, such as 5% liquid cocaine and phenylephrine).21
Other considerations, such as supplemental oxygen through-
out the procedure (e.g. nasal cannula, endoscopic mask),22
safe conscious sedation, maintenance of spontaneous ven-
tilation and patient cooperation,21 and suitable topical or
regional anaesthesia that must include oral cavity, orophar-
ynx, larynx and trachea,21,23 are all important to ensure
patient comfort and avoid reflex airway responses, such
as coughing or laryngospasm, or sympathetic cardiovascular
responses.23 If regional anaesthesia is chosen, the nerves to
be blocked are the trigeminal (which innervates the upper
airway mucosa), the glossopharyngeal nerve (innervates the
oropharynx), and the pneumogastric nerve (innervates the
tracheal mucosa).21
Lack of patient cooperation, limited resources and
unskilled operators are among the factors that cause a
given technique to fail. In the case of failure of awake
intubation, an alternative strategy should be selected. If
the patient’s condition allows, the surgery can be can-
celled. This is appropriate in cases where the patient needs
to be fully informed, when the airway mucosa presents
oedema, bleeding or trauma, or different equipment or per-
sonnel are needed. If the surgery cannot be delayed, GA
induction may be possible if ventilation with FM or SGA is
adequate. Another alternative is to perform regional anaes-
thesia (neuroaxial or epidural anaesthesia, as appropriate),
if feasible. None of these alternatives involve securing
the airway, so a plan to deal with a difficult TI must be
made. Surgical access of the airway may be the best option
in patients with traumatic or obstructive upper airway
lesions.
Unanticipated difficult airway after induction
of general anesthesia or in an unconscious or
non-cooperative patient
This section includes cases of predicted DA in which awake
TI is not possible (e.g. a paediatric, agitated or uncon-
scious patient), and in which difficult TI is diagnosed after
induction of GA (unanticipated DA). The latter is the most
common situation and is often caused by poor airway
assessment.7 In both situations, the patient may have a full
stomach, so the risk of bronchopulmonary aspiration is con-
siderable.
The decision-making process is influenced by the
patient’s characteristics, the urgency of the surgery, and
the skills of the operator. The fundamental principle must
always be maintaining airway patency, oxygenation, and
minimising the risk of aspiration.
If FM ventilation is adequate, emergency intubation will
not be required. However, if FM ventilation is inadequate,
an emergency non-invasive technique (insertion of an SGA)
is indicated or, failing this, an invasive surgical technique
(surgical, percutaneous airway or jet ventilation). In both
cases, help should be summoned immediately, and the fea-
sibility of restoring spontaneous ventilation and awakening
the patient should be considered.
The possibility of performing ventilation with FM is a key
issue in decision-making. Therefore, early ventilation with
FM using 100% oxygen after induction of GA is always rec-
ommended. This also enables the anaesthetist to assess the
convenience of maintaining spontaneous ventilation before
performing neuromuscular blockade (NMB). TI can be suc-
cessfully achieved without NMB, so it is a valid alternative
in a suspected DA.
Each laryngoscopy and TI attempt can potentially cause
airway trauma and worsen the situation further. Therefore,
they must be performed under optimum conditions from
the start, and the number and duration of attempts should
be limited since the probability of success decreases with
each attempt. Repeated attempts can cause oedema and
bleeding, reduce the likelihood of effective rescue with an
SGA, and increase the risk of progression to a CICO sce-
nario. Therefore, the DAS recommends a maximum of 3
TI attempts; a fourth attempt can only be made by an
experienced anaesthesiologist.3 After a failed attempt, the
same technique should not be repeated, and changes should
be introduced in each additional attempt to improve the
chances of success. This may include changing the position
of the patient, the device or blade, or the depth of NMB,
using adjuncts such as introducers and stylet, and calling in
a more experienced operator. When all attempts fail, the
TI must be declared unsuccessful and the next level of the
algorithm should be attempted. Impaired ventilation should
indicate the early use of an SGA and, if unsuccessful, the
use of surgical access.
Gas exchange during and between TI attempts (ven-
tilation with FM) should be maintained using apnoeic
oxygenation techniques24 and positive pressure ventilation
through an endoscopic mask25,26 or a laryngeal mask airway
(LMA); the latter also serves as a conduit for the FOB.27
All the TI techniques available for an awake patient can
also be used for the unconscious or anesthetised patient.
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Guidelines and algorithms for managing the difficult airway
However, under such conditions, TI with direct laryngoscopy
and FOB is likely to be more difficult, for the reasons
discussed above. The choice of technique determines the
probability of success. VL offers better glottic vision than
conventional direct laryngoscopy, and is currently the first
choice for some anesthesiologists.4,28 FOB or optical stylet
may be the preferred technique for skilled operators. The
use of FOB should be avoided in an emergency due to tech-
nical problems (ventilation, secretions and bleeding), unless
used by an experienced operator. In general, any blind tech-
nique should be avoided due to the high failure rate and
the potential for airway trauma, which can result in fur-
ther deterioration of ventilation. The first and second choice
of laryngoscope will be determined by the experience and
training of the anaesthesiologist.
Besides poor vision of the laryngeal structures, difficulty
in TI may be due to the impossibility of advancing the
ETT through the glottis. Small diameter ETTs are easier to
insert because they enable better visualisation of the pas-
sage between the vocal cords, and cause less trauma. The
advance of the ETT can be impeded by arytenoids, espe-
cially when guided by an introducer or FOB. This problem
can be overcome by counter clockwise rotation of the ETT,
by reducing the gauge difference between the FOB or intro-
ducer and the ETT, and by using flexible ETTs with a silicone
distal end and centre hole. A preconfigured stylet can facil-
itate TI in grade 2 or grade 3 Cormack---Lehane view. Blind
insertion in grades 3b and 4 is not recommended because of
the high risk of airway trauma. The use of a stylet is neces-
sary when using a VL with an angled blade without a guide
channel.
Once TI has been achieved, correct placement should
be ascertained by visual confirmation of ETT between the
vocal cords, bilateral and symmetrical thoracic expansion,
auscultation, and capnography. Availability of the latter is
necessary, since this is the gold standard for confirmation
of pulmonary ventilation. The utility of ultrasound has also
been demonstrated.29
If all TI attempts are unsuccessful, the following should
be considered: (1) Awakening the patient. This is the safest
option if the intervention can be deferred, and requires
complete reversal of NMB. In the case of NMB with rocuro-
nium or vecuronium, reversal is reliably achieved with the
administration of sugammadex.30,31 Surgery may be post-
poned or performed using awake TI or regional anaesthesia;
(2) Attempting TI with FOB via an SGA. This is an option if the
clinical condition is stable, oxygenation is possible through
an SGA, and the anaesthesiologist is experienced in the
technique. As a basic principle, the number of airway inter-
ventions should be minimised; thus, repeated attempts are
inappropriate. Blind techniques are discouraged because of
the frequent need for repeated attempts and the potential
complications; (3) Proceeding with surgery using an FM or
SGA. If awakening the patient is not an option, for example,
in the case of emergent surgery (e.g. caesarean section).
This is a high-risk technique and therefore may only be
used in life-threatening situations. Ventilation through these
devices may be impaired by device malpositioning, regur-
gitation, airway oedema, or surgical factors; (4) Securing
the airway by surgical access (tracheotomy or cricothy-
roidotomy) before losing ventilation capacity with FM
or SGA.
5
Failure of TI and ventilation with FM, without life-
threatening hypoxaemia, require insertion of an SGA to
maintain oxygenation. The LMA, the Combitube and the
laryngeal tube have demonstrated effectiveness in emer-
gency airway rescue in this scenario.2 An observational study
found that LMA provided effective rescue ventilation in
94.1% of patients who could not be ventilated with FM or
intubated.32 The DAS algorithm includes this step after fail-
ure of TI, regardless of whether FM ventilation is feasible.
After insertion, correct ventilation should be confirmed by
means of clinical examination and capnography, and the sur-
gical team should stop and think in order to decide how best
to proceed.
Although the guidelines do not clarify a particular order
of selection, the type of rescue SGA must be selected before
anaesthesia induction. Factors to consider are the clinical
situation, availability of the device, its risks and bene-
fits, and operator experience. The ideal features of an SGA
for airway rescue are: easy insertion at the first attempt,
high oropharyngeal sealing pressure, isolation of the gas-
trointestinal and the respiratory tract, and FOB-guided TI
compatibility. Second-generation SGAs are more effective
and safer than first-generation ones, as they provide bet-
ter sealing and offer greater protection against aspiration;
therefore, they should be available in all centers.3
Cricoid pressure reduces the hypopharyngeal space, and
can prevent insertion of the SGA. If cricoid pressure is
used during fast sequence induction, it must be released
during insertion of the device. Importantly, SGAs are not
useful in patients with glottic or subglottic obstruction.
In such cases, the use of the rigid bronchoscope enables
ventilation by establishing a permeable airway beyond the
obstruction.
The Combitube, when correctly placed, enables ventila-
tion with a higher sealing pressure than the traditional LMA,
protects against regurgitation, and allows TI with FOB, while
the oesophageal cuff protects the airway.33
Repeated attempts at SGA insertion increase the risks of
airway injury, decrease the likelihood of success, and delay
the decision to accept failure and to switch to an alternative
technique to maintain oxygenation. The DAS recommends a
maximum of 3 SGA insertion attempts: 2 with the preferred
second generation device, and the third with an alternative
SGA. Changing the size of the device is considered a new
attempt.3
‘‘Can’t intubate, can’t oxygenate’’ (CICO)
scenario
If ventilation through FM and SGA is not achieved, or
becomes inadequate, invasive airway access should be
performed promptly (surgical, percutaneous airway, or
transtracheal jet ventilation). Incidence of CICO, a poten-
tially fatal situation that requires immediate action, will
vary depending on the setting, patient characteristics and
the experience of the physician. Thus, the number of cases
increases from 0.002% at the intrahospital level3 to 2% in
emergency services.34
In this scenario, the risks associated with an invasive
rescue technique should be weighed against the risks of
hypoxic brain injury or death. Various surgical techniques
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6 M.A. Gómez-Ríos et al.
and devices have been described, but the evidence does
not confirm the superiority of any particular approach.35,36
In an emergency setting in which cognitive processes and
psychomotor coordination are limited, the ideal rescue
technique should entail a simple and familiar procedure.37
DAS recommends cricothyroidotomy with a scalpel as the
method of choice,3 since this is the fastest and most reliable
instrument to secure the airway, and the necessary equip-
ment is available in any location. The technique involves the
following: neck extension, identification of the cricothyroid
membrane with the index finger, previous stabilisation of
the larynx with the non-dominant hand, transverse incision
with a number 10 blade scalpel through the skin and the
cricothyroid membrane (make a transverse incision with the
cutting edge of the blade facing towards you and turn it
90◦ so that the sharp edge points caudally), gentle inser-
tion of up 10---15 cm of an elastic bougie with angled tip
through the incision before withdrawing the scalpel blade
and railroading a lubricated size 6.0 mm cuffed tracheal
tube over the bougie into the trachea. The procedure should
only be attempted with complete neuromuscular blockade
and oxygen (100%) delivered to the upper airway using
an SGA, well-adjusted FM, or nasal insufflation. In cases
where the cricothyroid membrane is not palpable (e.g. an
obese patient), a previous caudocephalic central incision of
8---10 cm and a digital dissection of the adipose tissue are
recommended to identify laryngeal structures.3
The foregoing technique has several advantages: it pro-
tects the airway from aspiration, and enables normal
minute ventilation with low pressure and end-tidal CO2
monitoring. However, most anaesthesiologists do not feel
competent to perform it.7 In the case of an unexpected DA,
a properly trained surgeon may not be immediately avail-
able. Anesthesiologists must therefore learn to perform a
cricothyroidotomy with a scalpel and maintain their compe-
tence in the technique with periodic refresher training.
Transtracheal jet ventilation is another relatively easy-
to-perform invasive technique that can save lives and
provide the time needed to secure a definitive airway.
However, this approach has significant limitations, since it
involves inserting a small-calibre cannula (<4 mm) into the
cricothyroid membrane using the Seldinger technique (the
cannula can become kinked or displaced) and requires a
high-pressure oxygen source of 20---50 psi. Transtracheal jet
ventilation is associated with significant morbidity and a high
risk of complications, such as subcutaneous emphysema and
barotrauma.38,39 Moreover, it cannot be used in patients with
upper airway obstruction, because it could produce tension
®
pneumothorax. Ravussin cannulas (VBM, Sulz, Germany)
and various types of devices for jet ventilation are available
®
on the market, the Manujet (VBM, Sulz, Germany) being
the most popular.
Extubation and postoperative care
Approximately one-third of complications occur during extu-
bation or in the postoperative period.40
Current evidence does not provide sufficient basis for
assessing the benefits of any specific DA extubation strategy.
Nonetheless, a safe, carefully considered strategy should
be followed, taking into account the type of surgery, the
patient’s condition, and the clinician’s abilities and pre-
ferences. The ideal method of extubation is gradual, step
by step, and reversible at any time. The ASA recommends
weighing up the relative merits of awake extubation ver-
sus extubation before the return of consciousness, assessing
the presence of clinical factors that may impair ventila-
tion after extubation (e.g. altered mental status, abnormal
gas exchange, airway oedema, an inability to eliminate sec-
retions, and inadequate return of neuromuscular function),
putting in place a pre-established airway management plan
in the event that spontaneous ventilation is ineffective after
extubation (for example, the equipment necessary to deal
with a DA), and considering the short-term use of an ETT
exchanger or a jet stylet that serves as a ventilation and
guidance device for TI.
Postoperative surveillance is essential for diagnosing and
treating possible adverse effects which could otherwise
go unnoticed. Any instrumentation and manipulation of a
DA can cause trauma or complications, such as oedema,
haemorrhage, oesophageal or tracheal perforation, pneu-
mothorax or pulmonary aspiration. Airway complications
have been reported after the use of VL, second generation
SGAs, and FOB.41---43
Pharyngeal and oesophageal lesions are the most fre-
quent complications after difficult TI. They usually manifest
clinically in the postoperative period; however, they are
difficult to diagnose. Pneumothorax, pneumomediastinum,
and emphysema are only present in 50% of cases. Post-
perforation mediastinitis of the airway has a high mortality
risk, therefore, the patient should be closely monitored in
order to rule out the clinical triad of pain (deep cervical
pain, chest pain, and dysphagia), fever, and crepitation.
Likewise, patients should also be warned of possible signs
and symptoms associated with complications that result
from the treatment of DA. If late symptoms appear, they
should seek medical attention immediately.44
In the postoperative period, it is essential to document
in detail the difficulty encountered in ventilation and TI,
and to describe the techniques used, indicating their success
or failure.45 Informing the patient and adding notifications,
medical alerts, or registering the event in a DA database is
useful.45
Algorithms developed by other
anesthesiological societies
Several countries have published their own algorithms
through their respective anaesthesiology societies. Follow-
ing the first algorithm published by the ASA, France (in
1996), Canada46,47 (in 2013), Italy48 (in 2005) and Germany49
(in 2015) developed their own.
All these algorithms, like the ASA and DAS, emphasise the
importance of predicting a difficult airway and the need for
a pre-formulated strategy to increase safety, limit trauma,
and prioritise oxygenation/ventilation, the use of various
devices and techniques, and the need to develop skills and
maintain competence.50 They also they indicate that all air-
way material should be correctly classified, transportable,
and immediately and easily accessible in order to facilitate
quick resolution of difficult cases. Most of the relevant doc-
uments currently available present recommendations based
+Model
ARTICLE IN PRESS
Guidelines and algorithms for managing the difficult airway
on systematic reviews, with levels of evidence regarding
the prediction of DA, the treatment of anticipated an unex-
pected DA, CICO scenario and extubation of DA. Like the
ASA algorithm, the Italian, German and French guidelines
incorporate all the scenarios into a single document. In con-
trast, the Canadian Society developed separate guidelines
for each situation, comparable to the DAS. Likewise, the
guidelines consider awake TI as the strategy of choice for
predicted DA; the FOB as the gold standard for DA in the
awake, sedated, or anesthetised patient, and for control-
ling ETT positioning; VL as a superior alternative to direct
laryngoscopy for the primary management of DA, and as an
excellent rescue device after DA failure; and the SGA as
a non-invasive rescue method when FM ventilation is not
possible.
The guidelines differ mainly in specific details, such
as algorithm organisation, the number of suggested TI
attempts, alternative devices, and recommended surgical
access techniques. Thus, unlike the ASA and DAS, which
focus on cricothyroidotomy, the German and Canadian
guidelines recommend the transtracheal airway approach,
and the French and Italian guidelines recommend the per-
cutaneous approach, which is guided by the Seldinger
technique. Nonetheless, there is no clear evidence of the
superiority of any particular technique. Interestingly, the
ASA remains the only guideline that takes into account
emergency tracheotomy, which other guidelines consider
too risky and time-consuming, especially when compared to
surgical cricothyroidotomy.
Conclusion
The first algorithm, the ‘‘Practice Guidelines for Manage-
ment of the Difficult Airway’’, issued by the ASA in 1993,
together with later versions issued in 2003 and 2013, marked
a turning point in airway management. Since then, numerous
anaesthesiology societies have developed their own algo-
rithms, one of the most important being the DAS, which was
updated in 2015.
All guidelines and algorithms on this subject are impor-
tant insofar as they have changed clinical practice by
encouraging professionals to plan specific strategies to
address DA. However, in the absence of a universally
accepted protocol, available guidelines are intended only
as basic recommendations and not as standards of care or
absolute requirements, and thus should not replace local
institutional policies. Guidelines should be adapted to the
specific skills and individual judgement of anaesthesiolo-
gists, to the availability of devices in each centre, and to
patient characteristics. Practitioners should develop their
own individual strategies, based on their knowledge and
clinical experience. Techniques selected should be routinely
applied prior to their application in a real-life DA. This
assures the best means of facing the challenges of DA man-
agement.
Conflict of interest
The authors declare no conflict of interest.
7
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at doi:10.1016/j.redare.
2017.11.010.
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