Airway Management For Induction of General Anesthesia - UpToDate

19/12/21 18:40 Airway management for induction of general anesthesia - UpToDate
Author: Lauren Berkow, MD

Section Editor: Carin A Hagberg, MD, FASA
Deputy Editor: Marianna Crowley, MD
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Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2021. | This topic last updated: Sep 16, 2020.
AIRWAY MANAGEMENT FOR PATIENTS WITH COVID-19
In patients with novel coronavirus disease 2019 (COVID-19 or nCoV), there is a high risk of aerosol spread of the virus during airway
management. Procedures designed to minimize infectious risk to care providers and spread of the virus are discussed separately.
(See "COVID-19: Anesthetic concerns, including airway management and infection control".)
INTRODUCTION
Airway management is a crucial skill for the clinical anesthesiologist. It is an integral part of general anesthesia, allowing ventilation
and oxygenation as well as a mode for anesthetic gas delivery. Major complications of airway management in the operating room are
very rare but may be life threatening.
This topic will discuss the formulation of an airway management strategy for general anesthesia, including plans for the use of mask
ventilation, use of supraglottic airway devices (SGA), endotracheal intubation, and the selection of medications for induction of
general anesthesia. Techniques and devices for airway management, rapid sequence induction intubation, and management of the
difficult airway are discussed separately.
● (See "Direct laryngoscopy and endotracheal intubation in adults".)

● (See "Supraglottic devices (including laryngeal mask airways) for airway management for anesthesia in adults".)
● (See "Flexible scope intubation for anesthesia".)
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● (See "Rapid sequence induction and intubation (RSII) for anesthesia".)

● (See "Management of the difficult airway for general anesthesia in adults".)
AIRWAY ASSESSMENT
All patients undergoing general anesthesia should have a complete history and anesthesia-directed physical examination. One goal of
this evaluation is to predict the degree of difficulty with mask ventilation and endotracheal intubation using standard devices. The plan
for airway management follows from this prediction, since in many cases induction of anesthesia will result in airway obstruction and
at least temporarily make the patient apneic. In addition, factors that predispose the patient to aspiration during anesthesia should be
identified.
Airway history — For patients who report problems with anesthesia in the past, every effort should be made to obtain and review
prior anesthesia records for details of airway management.
A number of disease states, both congenital and acquired, have been associated with difficult airway management ( table 1). In
addition, pulmonary problems such as asthma, recent upper respiratory infection, pneumonia, bronchitis, or presence of chronic
obstructive pulmonary disease (COPD) may impact oxygenation and ventilation during induction [1].
Most patients who present for emergency procedures are at increased risk of aspiration during anesthesia, either because of recent
oral intake or because of predisposing conditions ( table 2). In addition, the incidence of difficult intubation is significantly higher in
the emergency room and other areas outside of the operating room. (See "Approach to the anatomically difficult airway in adults
outside the operating room".)
Airway examination — A number of bedside tests and measurements have been developed to evaluate the airway ( table 3).
Though they are and should be routinely used, they are of limited value in predicting difficult mask ventilation and intubation (see
'Prediction of the difficult airway' below):
● First glance assessment – The preoperative first glance assessment provides significant useful information. Obesity, facial
hair, a thick, short neck, and neck collars are immediately apparent and suggest potential difficulty with airway management.

● Mouth opening – Mouth opening is usually assessed in finger breadths. A mouth opening of less than three finger breadths is
considered limited. Patients with temporomandibular joint (TMJ) disease or prior surgery may have very limited mouth opening
or trismus. Radiation of the head and face can also result in trismus or scarring that distorts the anatomy or limits mobility.
Dentition should be assessed, with particular attention to the presence of caps, crowns, implants, veneers, dentures, braces, or
loose teeth. These should be documented and the risk of damage discussed with the patient. Dentures should ordinarily be
removed in the preoperative area before the patient is brought to the operating suite. However, if mask ventilation is planned,
dentures may be left in place to improve mask fit, though they should be removed immediately prior to intubation to prevent
dislodgement or damage. If the patient has braces, the risk of soft tissue injury to the lips during airway management should be
discussed.
● Mallampati class – Mallampati class was first described in 1985 as a test to predict difficult laryngoscopy [2]. The Mallampati
evaluation originally included three classes based on the ability to view the tonsillar pillars, uvula, and palate with the mouth
open and the tongue protruded. The more widely used modified Mallampati class includes a fourth class ( figure 1) [3]:
• Class I: The entire tonsillar pillars, uvula, hard and soft palates are visualized
• Class II: Partial uvula and soft palate are visualized
• Class III: Only the soft palate is visualized
• Class IV: No visualization of any structures beyond the tongue
A Mallampati class 0 has also been described, in which part of the epiglottis can also be seen upon mouth opening in addition to
all the class I structures listed above [4,5].
The Mallampati test was initially described with the patient in the sitting position. Studies comparing performance of the test
supine with sitting have shown conflicting results, with some reporting an increase in Mallampati class in the supine position [6],
some a decrease [7], and some no change [8]. Two single-center studies reported that the score in the supine position improved
the predictive value for difficult intubation [9,10].
The original description of the Mallampati test did not specify whether the patient should phonate during the test. Most studies
have reported that phonation alters the score and reduces the sensitivity of the test (ie, phonation falsely lowers the Mallampati

score) [7-9].
We routinely perform the Mallampati evaluation in the sitting position, and perform the test in the supine position if the patient is
unable to sit up. We perform the test without phonation.
● Thyromental distance – Thyromental distance (TMD) is the distance between the thyroid cartilage and the mandible,
measured in full extension of the neck. Short TMD has been defined as less than 6 cm. Historically, TMD has been used as a
rough estimate of the submental space, which is the space that must accommodate the tongue during laryngoscopy [11,12].
● Sternomental distance – Sternomental distance is measured between the sternal notch and the mandible, measured in full
neck extension. Short sternomental distance is defined as less than 12 cm. This parameter and TMD may be objective
surrogates for adequacy of neck extension [13].
● Neck range of motion – Both neck flexion and extension should be assessed for limitations. Patients with arthritis of the neck,
cervical spine disease, or previous spine surgery may have limited neck extension. Studies have shown that neck range of
motion decreases with age, and decreased neck extension has been associated with difficulty with airway management [14].
Patients with restricted neck extension may be more difficult to optimally position for induction of anesthesia and intubation.
● Mandibular protrusion – Patients are asked to protrude the lower jaw such that the mandibular teeth are in front of the
maxillary teeth, as a predictor of the ability to sublux the mandible during laryngoscopy. A more objective, similar measurement
is the upper lip bite test (ULBT), which assesses the patient's ability to reach and cover the upper lip with their lower incisors.
ULBT grading includes [15,16]:
• Grade 1: The patient can fully cover the upper lip with lower incisors
• Grade 2: The patient can partially cover the upper lip with lower incisors
• Grade 3: The patient cannot reach the upper lip with lower teeth
Advanced methods of airway assessment — Endoscopy and ultrasound have limited application for routine airway assessment
[11,17]. For patients with known or suspected distortions of airway anatomy, these techniques as well as radiologic imaging may be
useful before airway management is undertaken.

● Preoperative endoscopy – Preoperative airway endoscopy, which has been used by otolaryngologists for many years to
diagnose airway pathology, can also be used for preoperative airway assessment. Endoscopy provides visualization of internal
airway anatomy that cannot be viewed with external tests. Routine preoperative airway endoscopy is not indicated for patients
undergoing elective surgery unless abnormal airway anatomy is suspected [18].
● Ultrasound – With increasing availability of bedside ultrasound in the operating room, ultrasound has been used for airway
assessment. It can allow visualization of the airway from the mouth to mid-trachea, and can also be used to identify the
cricothyroid membrane, visualize the vocal cords, and identify airway pathology [19,20]. The use of ultrasound examination to
predict difficulty with intubation has not been fully studied.
PREDICTION OF THE DIFFICULT AIRWAY
Numerous investigators have attempted to predict difficulty with airway management based on the bedside airway assessment
described above. Single tests are of limited value for predicting the difficult airway [21-24], though combinations of tests add some
diagnostic accuracy [4,17]. At the very least, this preoperative airway assessment forces the clinician to think about potential difficulty
with airway management.
Difficult mask ventilation — The incidence of difficult mask ventilation for anesthesia in the general surgical population is between
0.9 and 5 percent, depending on the definition of difficulty [25-28]. For our purposes, we will define difficult mask ventilation as the
inability of an unassisted anesthesiologist to maintain adequate oxygenation or reverse signs of inadequate ventilation.
Prospective studies have variably identified the following risk factors for difficult mask ventilation ( table 4) [25-27,29,30]:
● Age older than 55

● Body mass index (BMI) >26 or 30 kg/m2 (calculator 1)
● Presence of a beard
● Lack of teeth
● History of snoring/sleep apnea
● Abnormal neck anatomy

● Male gender
● Short thyromental distance (TMD) (<6 cm)
● Severely limited mandibular protrusion
● Mallampati class 3 or 4 ( figure 1)
The presence of more than one risk factor significantly increases the chance of difficulty or failure of mask ventilation. Clinicians will
not always be able to predict which patients will have difficult mask ventilation and patients with difficult mask ventilation are often
more difficult to intubate. As an example, in one prospective study, only 17 percent of cases of difficult mask ventilation were predicted
by the anesthesiologist [25]. In another study, intubation was difficult in one-quarter of patients with difficult mask ventilation, while the
overall incidence of difficult intubation was approximately 5 percent [29].
Difficult supraglottic airway device use — Approximately 0.1 to 4.7 percent of attempts to manage the airway with a supraglottic
airway (SGA) device will be unsuccessful [31]. Successful use of the SGA depends on selection of the appropriate sized device, more
so than with the use of an endotracheal tube. The large number of brands and styles of available SGAs complicates the evaluation of
failure. Some factors that may predict difficulty with SGA device placement or use include ( table 5) [32,33]:
● Small mouth opening (<3 finger breadths)

● Neck radiation
● Tonsillar hypertrophy
● Fixed cervical spine flexion deformity
● Applied cricoid pressure
● Obesity
● Poor dentition or large incisors
● Male gender
Difficult intubation — The incidence of difficult direct laryngoscopy in patients with normal anatomy is approximately 5 percent in the
general surgical population [17,34,35]. The incidence of difficult or failed intubation is much less. Individual bedside tests have only
poor to moderate discriminative power in predicting difficult intubation for patients with no airway pathology [22,36-41].

Most commonly, difficult laryngoscopy is defined as a Cormack-Lehane class 3 or 4 view, in which the vocal cords cannot be seen
during laryngoscopy ( figure 2).
Common risk factors for difficult intubation include ( table 6) [17,35] (see 'Airway examination' above):
● Prior difficult intubation

● Small mouth opening (<3 finger breadths)
● Mallampati class 3 or 4 ( figure 1)
● Shortened TMD (<6 cm)
● Shortened sternomental distance (<12 cm)
● Limited neck mobility
● Limited mandibular protrusion or upper lip bite test (ULBT) grade 3
● Thick neck (circumference >40 cm)
Predictors of difficult laryngoscopy and intubation may be less useful or irrelevant when video laryngoscopes (VL) are used. VLs
improve laryngeal view in most patients [42]. Their use achieves a high success rate for intubation of patients with predicted difficult
intubation, and those who have failed direct laryngoscopy. In a study of over 2000 VL intubations, Mallampati score did not correlate
with failed intubation [43]. The strongest predictor of failure was neck pathology, including presence of a surgical scar, radiation
changes, or mass. In another study, risk factors for difficult VL intubation after direct laryngoscopy were Cormack-Lehane grade 3 or 4
view with direct laryngoscopy ( figure 2), short sternothyroid distance, and high upper lip bite test score ( table 7) [44].
Obesity as a risk factor — Obesity is a recognized risk factor for difficulty with airway management [34,35]. An audit of major
complications of airway management from over three million anesthetics in the United Kingdom found twice as many case reports of
major complications in obese patients, especially in the morbidly obese [45]. Among obese patients, there was an increased
frequency of aspiration and other complications with the use of supraglottic airways, difficulty with intubation, and airway obstruction
during emergence or recovery from anesthesia. When rescue devices were required, they failed more often than in nonobese
patients. (See "Anesthesia for the patient with obesity", section on 'Airway management'.)
Difficult mask ventilation is more common in obese patients, particularly in those with obstructive sleep apnea [25,26]. It is less clear
whether obesity increases the risk of difficult laryngoscopy or intubation. Some studies suggest that obesity is a risk factor for both

difficult mask ventilation and difficult laryngoscopy, while other studies suggest that with proper positioning and preparation, ventilation
and laryngoscopy are not difficult [46-50]. In one large retrospective single center database study, obese patients were more difficult
to intubate than lean patients, but the degree of obesity had no effect on the odds of difficulty [51]. Among approximately 67,700
patients who required intubation, the odds of difficult intubation (defined as more than one attempt) increased in a linear fashion with
increasing BMI up to a BMI of 30 kg/m2, but remained constant for patients with BMI >30 kg/m2.
Distribution of body fat varies among obese patients, even at similar body mass index, which may account for some of the variability
in difficulty with airway management. Oxygen saturation typically falls more quickly with apnea in obese patients, so adequate
preoxygenation is particularly important in these patients. (See 'Preoxygenation' below.)
CREATION OF A STRATEGY FOR AIRWAY MANAGEMENT
General approach — The airway management plan will depend on the medical history of the patient, the type of procedure for which
anesthesia is being given, the surgical conditions required, and the expected degree of difficulty should intubation be necessary. It is
important to recognize that any strategy can unexpectedly fail, and backup plans should always be considered. The American Society
of Anesthesiologists Difficult Airway Algorithm is a tool for organizing the approach to the patient with a potentially difficult airway and
the management of unexpected airway problems ( algorithm 1) [52]. Anesthesiologists should be familiar with the difficult airway
algorithm.
Difficult airway management in patients with trauma is discussed separately, and is shown in an algorithm ( algorithm 2). (See
"Anesthesia for adult trauma patients", section on 'Airway management'.)
The following questions should be considered when formulating an airway management plan:
● What airway devices can be used for patients undergoing this procedure? The choice of airway device may be impacted by the
location and expected length of the surgical procedure, patient position during surgery, and the need for muscle relaxants. (See
'Choice of airway device' below.)
● What airway devices can be used in this patient? This must take into account the risk of aspiration, difficult mask ventilation,
difficult supraglottic airway (SGA) placement, or difficult intubation, as well as the likelihood of difficult ventilation (high PIP, need
for PEEP) once the airway is placed.
● If intubation is planned, what method should be used (direct laryngoscopy, video laryngoscopy, or flexible bronchoscopic
intubation)? Direct laryngoscopy is appropriate for most patients, though video laryngoscopy is becoming more common. (See
'Choice of intubation technique' below.)
● Should induction of general anesthesia occur before or after intubation (asleep versus awake intubation)? If a difficult intubation
is expected, the decision to intubate awake depends upon expected difficulty with mask ventilation and potential risk of
aspiration.
● Should spontaneous ventilation be maintained?
● Is a surgical airway needed? If so, should the surgeon be standing by or should a tracheostomy be performed while the patient
is awake?
● If the initial plan fails, what is plan B (the backup plan)? The equipment and expertise needed for plan B should be arranged
ahead of time.
Management of the difficult airway during induction of anesthesia is discussed more fully elsewhere. (See "Approach to the
anatomically difficult airway in adults outside the operating room" and "Management of the difficult airway for general anesthesia in
adults".)
Choice of airway device
Airway device options — Not all patients undergoing general anesthesia require the placement of an endotracheal tube.
Supraglottic airway devices (SGAs) are rapidly becoming more widespread in use as an alternative to an endotracheal tube,
especially in Europe.
In a review of approximately three million anesthetics in the United Kingdom, an SGA was used for airway management in 56.2
percent of cases, while an endotracheal tube was used in 38.4 percent, and 5.3 percent were managed with mask ventilation alone
[45].

Technique for use and the various types of airway management devices are discussed more fully elsewhere. (See "Devices for
difficult emergency airway management in adults outside the operating room" and "Flexible scope intubation for anesthesia" and
"Supraglottic devices (including laryngeal mask airways) for airway management for anesthesia in adults" and "Direct laryngoscopy
and endotracheal intubation in adults".)
● Facemask – Facemask ventilation is the most basic of airway management techniques. Ventilation by facemask is used most
often in the operating room between induction of anesthesia and placement of an airway device. Airway management with
facemask alone may be used for short cases without the surgical need for muscle relaxation if the anesthesiologist will have full
access to the patient's airway throughout the case. (See "Basic airway management in adults", section on 'Bag-mask
ventilation'.)
● Supraglottic airway (SGA) – SGA is a term used to describe any airway device that is inserted into the oropharynx and has a
ventilation orifice above the glottis. The most common type of SGA is the laryngeal mask airway (LMA), although there are
others. An SGA may be used as the planned airway management device (with either spontaneous or controlled ventilation), as
a conduit for intubation, or as a rescue device when either mask ventilation or intubation are difficult. (See "Supraglottic devices
(including laryngeal mask airways) for airway management for anesthesia in adults".)
● Endotracheal tube (ETT) – The ETT is a single use device which is inserted through the nose or mouth with the distal end in
the mid-trachea. For adults and most pediatric patients beyond the newborn period, a tube with an inflatable cuff is used to
protect against secretions and to create a seal for positive pressure ventilation. For some specific surgical procedures,
specialized endotracheal tubes may be necessary, such as a laser-safe tube for airway laser surgery, or a double-lumen tube for
lung isolation for differential ventilation. (See "Direct laryngoscopy and endotracheal intubation in adults" and "Lung isolation
techniques", section on 'Double-lumen endobronchial tubes' and "Anesthesia for head and neck surgery", section on 'Surgical
considerations'.)
Supraglottic airway versus endotracheal tube — The decision to use a supraglottic airway (SGA) or an endotracheal tube (ETT)
must take into account comorbidities and findings on the preoperative airway assessment, in addition to the type and expected length
of the surgical procedure. In addition, the following device-specific factors may affect the decision to choose one or the other class of
airway device:

● Clinically important features of SGA use:
• Easily placed blindly

• Less hemodynamic response to placement than laryngoscopy and ETT placement
• Lower risk of bronchospasm
• Lower peak inspiratory pressures possible
• Does not protect against aspiration
• Does not protect against laryngospasm
● Clinically important features of ETT use:
• May be difficult to place

• Requires deeper level of anesthesia for placement than SGA
• Stimulus for bronchospasm
• High peak inspiratory pressures possible
• Protects against aspiration
In general, we use SGA for shorter procedures (<3 hours), for patients who are at low risk of aspiration, and for procedures which will
not require a prolonged period of muscle relaxation. The use of SGA for laparoscopy is controversial because of the potential risk of
aspiration and inability to ventilate with increased intraabdominal pressure, but there are several studies and case reports describing
the safe use of an SGA for laparoscopic procedures [53,54]. SGA devices can be used in the prone position for selected patients
having short procedures, such as minor rectal surgeries [55]. (See "Supraglottic devices (including laryngeal mask airways) for airway
management for anesthesia in adults".)
Choice of intubation technique — The choice of intubation technique should be individualized based on the expertise of the
clinician, the availability of airway devices, and the clinical situation. Use of a familiar technique by an experienced clinician is most
likely to succeed. In most cases, endotracheal intubation is performed using direct laryngoscopy. A laryngoscope is used to create a
view of the glottis with direct line of sight. Increasingly, practice is shifting toward the use of indirect laryngoscopy with video
laryngoscopes as a first pass intubation technique. Use of these devices is well established for patients for whom direct laryngoscopy
may be difficult.

For patients who require awake intubation, a flexible intubating scope is commonly used. (See "Flexible scope intubation for
anesthesia" and "Video laryngoscopes and optical stylets for airway management for anesthesia in adults".)
Choice of medications for induction and intubation — Plans for airway management and the choice of anesthesia induction
agents are interdependent. Induction must achieve a level of anesthesia deep enough to allow successful placement of the chosen
airway device without physiologic response (eg, hypertension, tachycardia, cough). Endotracheal intubation requires a deeper level of
anesthesia than supraglottic airway placement. In most cases, a combination of medications is used. Intravenous induction is most
common; inhalation induction is occasionally used in adult patients. (See "Induction of general anesthesia: Overview".)
Patients who have not fasted or are at high risk for aspiration should undergo rapid sequence induction. (See "Rapid sequence
induction and intubation (RSII) for anesthesia".)
Intravenous induction — The most common induction agents used to achieve unconsciousness and apnea are propofol, ketamine,
and etomidate. Methohexital (1 to 2 mg/kg IV), a short-acting barbiturate, may be used in selected circumstances (eg, patients with
egg allergy, for anesthesia for electroconvulsive therapy). Thiopental, once the most common anesthesia induction agent, is no longer
available in the United States. In many cases, a combination of medications is used when placement of an airway device is planned,
so that less of each individual agent is necessary.
The selection of intravenous induction agents, opioids, and neuromuscular blocking agents during induction of anesthesia, as well as
adjuvant medications, are discussed separately. (See "General anesthesia: Intravenous induction agents".)
Inhalation induction — Induction of anesthesia can be performed with inhalation of a volatile anesthetic. This technique is
commonly used in pediatric patients to avoid needle placement for intravenous (IV) induction. It is rarely used in adults; though, it is
useful in cases with difficult IV access or when maintenance of spontaneous ventilation is preferred. (See "Induction of general
anesthesia: Overview", section on 'Inhalation anesthetic induction'.)
SECURING THE AIRWAY
Once the plan for induction and airway management is established and a backup plan determined, the patient is positioned and
preoxygenated.
Preparation for induction of anesthesia — Prior to induction of anesthesia, an assortment of standard and alternative airway
devices should be immediately available, including small, medium, and large facemasks; several sizes and types of laryngoscopes;
oral and nasal airways; several sizes of supraglottic airway, and a bougie. Alternative devices for laryngoscopy, including a video
laryngoscope and flexible intubating scope, as well as other emergency airway equipment should be accessible quickly, and present
in the operating room or anesthetizing location if difficult airway is suspected ( table 8). (See 'Prediction of the difficult airway'
above.)
Patient positioning — Before induction of anesthesia, the patient's head should be placed in the sniffing position (atlanto-occipital
extension with head elevation of 3 to 7 cm), supported so that the neck is flexed and the head extended. Though this may not be the
optimal final position for airway management in a specific patient, it should be the starting point, with modification made as necessary.
Obese patients may require a ramped position to open the space between the chin and the chest, and to align the sternal notch with
the external auditory meatus ( figure 3) [46].
Preoxygenation — All patients presenting for general anesthesia should be preoxygenated with 100 percent oxygen to increase
oxygen reserve and provide additional time to secure the airway. Since the supine position reduces functional residual capacity
(FRC), preoxygenation can be performed in the semi-upright position and is especially useful for those with characteristics associated
with oxygenation difficulty (eg, the obese patient, the pregnant patient, patients with poor pulmonary reserve) [56].
Preoxygenation is administered for three minutes of normal tidal volume breathing, for eight deep breaths over one minute, or until the
fraction of expired oxygen is over 90 percent [57]. Ultimately, the time to desaturation with apnea will depend on the length of
preoxygenation as well as the patient's oxygen consumption and FRC. Desaturation may occur more quickly with apnea despite
adequate preoxygenation in patients with poor pulmonary reserve (eg, those with COPD, pulmonary hypertension, severe asthma,
lung cancer, obesity, obstructive sleep apnea) or increased oxygen consumption (eg, pregnancy).
The use of nasal cannula for passive apneic oxygenation during laryngoscopy can prolong the time to desaturation in high-risk
patients during airway management [58-61]. We suggest the administration of oxygen by nasal cannula at 10 L/minute in addition to
facemask oxygen in those patients who are at high risk for difficult laryngoscopy and intubation. (See 'Difficult intubation' above.)
Several devices (eg, Optiflow and SuperNOV2A) that deliver humidified high flow nasal oxygen can be used for supplemental
oxygenation during airway management [62]. (See "Preoxygenation and apneic oxygenation for airway management for anesthesia".)

Mask ventilation — After preoxygenation and induction of anesthesia, if a rapid sequence intubation is not planned, mask ventilation
should be established using 100 percent oxygen. We close and cover the patient's eyes with tape or a transparent dressing as soon
as he or she is unconscious to avoid injury during airway manipulation. Technical aspects of mask ventilation are discussed
elsewhere. (See "Basic airway management in adults", section on 'Bag-mask ventilation'.)
Administration of neuromuscular blocking agents — When endotracheal intubation is planned after induction of anesthesia, a
neuromuscular blocking agent (NMBA) is routinely administered during induction, to improve intubating conditions and reduce the risk
of upper airway injury [63]. (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Endotracheal intubation'.)
Timing of administration — Mask ventilation is often established prior to the administration of neuromuscular blocking agents
(NMBAs). This sequence allows the clinician to prove his or her ability to ventilate the patient before removing the patient's ability to
ventilate on his or her own, while maintaining the option to awaken the patient should attempts at airway control fail.
The need to withhold NMBAs until mask ventilation is established has been questioned, partly because muscle relaxation may
improve mask ventilation [64-67]. Administration of an NMBA along with induction agents may also shorten the time to endotracheal
intubation. In a randomized trial that compared administration of rocuronium immediately after administration of propofol with
administration after checking mask ventilation in 114 patients with normal airways, the mean time to intubation was shorter in patients
who received NMBA early (116 versus 195 seconds) [67]. In addition, average tidal volume during mask ventilation was greater in
patients who received rocuronium early (550 versus 390 mL per breath).
However, muscle relaxation can make mask ventilation worse or impossible in some patients. Assessment of the ability to mask
ventilate prior to administration of NMBA may allow for a change in plan; for example, the use of succinylcholine rather than a longer
acting NMBA if mask ventilation is a struggle, or awakening the patient if possible. Thus the timing of NMBA administration should be
individualized based on the expected difficulty with airway management, unless a rapid sequence intubation is being performed. For
rapid sequence induction and intubation, the NMBA is typically administered at the same time as the induction agent, without mask
ventilation. (See "Rapid sequence induction and intubation (RSII) for anesthesia".)
For patients with anticipated difficulty with mask ventilation or intubation, it is reasonable to withhold the administration of a muscle
relaxant until after mask ventilation is confirmed, or consider an awake technique or inhalational induction. If difficulty with airway

management is not anticipated, it is reasonable to administer a muscle relaxant prior to confirming mask ventilation. (See
"Management of the difficult airway for general anesthesia in adults", section on 'Timing of administration'.)
Choice of neuromuscular blocking agent — The selection of the appropriate NMBA depends on the clinical application and
patient factors, as discussed separately. (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Selection of
neuromuscular blocking agents'.)
Rocuronium can be relatively quickly reversed with sugammadex if necessary during surgery, or in cases of unexpected difficulty with
airway management. However, rapid reversal of neuromuscular block should not be relied upon as a rescue strategy in a possible or
actual cannot intubate, cannot ventilate scenario. Sugammadex can reverse an intubating dose of rocuronium more rapidly than an
intubating dose of succinylcholine would resolve, but reversal may still take up to six minutes [68]. The primary factors that determine
return of spontaneous ventilation after induction of anesthesia are the depth of anesthesia and respiratory depression from the
induction agents, not the reversal of neuromuscular blockade [69]. In the event of a cannot intubate, cannot ventilate scenario, efforts
should focus on restoring oxygenation and ventilation.
Reversal of NMBAs is discussed in detail separately. (See "Clinical use of neuromuscular blocking agents in anesthesia", section on
'Sugammadex' and "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Reversal of neuromuscular block'.)
Airway placement — Techniques for placement of supraglottic airway (SGA) and endotracheal intubation, flexible scope intubation,
and rapid sequence induction are discussed separately. (See "Flexible scope intubation for anesthesia" and "Direct laryngoscopy and
endotracheal intubation in adults".)
If the use of a SGA is planned, after flaccidity is achieved, as assessed by masseter muscle tone (ie, laxity of the jaw with no
resistance to mouth opening), the clinician can proceed with SGA placement.
Laryngoscopy is performed once a deep enough level of anesthesia has been achieved and, in most cases, when the muscle relaxant
is fully effective. There is significant variation in the time to maximal muscle relaxation with different agents. For routine induction,
relaxation with succinylcholine (1 mg/kg IV) occurs in 45 to 60 seconds, and after approximately three minutes for an intubating dose
of rocuronium (0.45 to 0.6 mg/kg IV), vecuronium (0.08 to 0.1 mg/kg IV), or cisatracurium (0.15 to 0.2 mg/kg IV) ( table 9).

A peripheral nerve stimulator can be used to assess paralysis during induction and throughout the anesthetic. The stimulating
electrodes are placed on the skin along the path of a peripheral nerve, most commonly the ulnar nerve at the wrist. The device
applies a sequence of four electrical stimuli over two seconds, and the contraction of the innervated muscle is monitored. As paralysis
deepens after administration of a muscle relaxant, the twitches fade and ultimately disappear. For optimal intubating conditions, the
twitches should be obliterated. (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Endotracheal
intubation' and "Monitoring neuromuscular blockade", section on 'Train-of-four'.)
If a twitch monitor is not used, laryngoscopy is performed at approximately three minutes after induction, or when a significant
improvement in compliance with mask ventilation is felt as a sign of paralysis.
Confirmation of airway placement — Once an airway device is placed, correct placement must be confirmed with the following:
● Effective manual ventilation.

● Symmetrical chest rise.
● Visible condensation in mask or tube of airway device.
● End-tidal CO2 waveform on gas analyzer.
● If endotracheal tube placed, right mainstem bronchus intubation and esophageal intubation must be ruled out with bilateral
breath sounds and lack of sounds of air entry into stomach, and CO2 wave form detection. Especially in thin patients, air entry
into the stomach may be heard in the chest and mistaken for breath sounds.
● Ultrasound can also be used to confirm endotracheal tube placement. A probe placed over the lateral intercostal spaces
bilaterally will detect movement of the pleura against the lung if ventilation is present ("lung sliding sign") [20].
● If a SGA is used, air leak should occur at high enough peak pressure to allow adequate tidal volume, 18 to 20 cm H2O.
If confirmation is not possible, the airway device should be adjusted or replaced.
EXTUBATION
Any patient who was at particular risk for difficult airway management at the beginning of anesthesia should be considered at risk for
airway compromise at the end of the anesthetic, and a plan should be in place for safe extubation. Risk stratification for difficult

extubation, creation of a strategy for extubation, and management of extubation are discussed in detail separately. (See "Extubation
following anesthesia".)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately.
(See "Society guideline links: COVID-19 – Index of guideline topics" and "Society guideline links: COVID-19 – Resources for patients"
and "Society guideline links: Airway management in adults".)
SUMMARY AND RECOMMENDATIONS
● The preoperative airway assessment should review outcomes with prior anesthesia exposure and record mouth opening and
dentition, Mallampati class ( figure 1), thyromental distance (TMD), neck range of motion, and mandibular protrusion. Some
disease states, bedside airway examination tests, and patient characteristics may predict difficulty with airway management.
(See 'Prediction of the difficult airway' above.)
● The strategy for airway management for general anesthesia depends on the requirements for the planned surgical or diagnostic
procedure, patient characteristics that affect airway management, predicted degree of difficulty with airway management, and
risk of aspiration. (See 'Creation of a strategy for airway management' above.)
● The primary plan must determine the preferred airway device and intubation technique. There should always be a backup plan,
with the equipment and expertise readily available to implement an emergency airway algorithm ( algorithm 1). (See 'General
approach' above.)
● The choice between endotracheal tube (ETT) placement and the use of a supraglottic airway (SGA) depends upon both patient
and surgical factors. (See 'Choice of airway device' above.)
• In general, we use SGA for shorter procedures (<3 hours), for patients who are at low risk of aspiration, and for procedures
which will not require a prolonged period of muscle relaxation.
• ETT is preferred in patients at high risk for aspiration, those that require high inspiratory pressures, and for longer cases
requiring muscle relaxation.
• Airway management with facemask alone may be used for short cases without the surgical need for muscle relaxation if the
anesthesiologist will have full access to the patient's airway throughout the case.
● A combination of medications is usually used to achieve the depth of anesthesia necessary for induction of anesthesia and
airway management. Endotracheal intubation requires a deeper level of anesthesia than supraglottic airway placement. (See
'Choice of medications for induction and intubation' above.)
● The patient should be positioned for optimal airway management (eg, "sniffing position" with ramp, if necessary) and
preoxygenated with 100 percent oxygen delivered by mask for three minutes of normal tidal volume breathing, for eight deep
breaths over one minute, or until the fraction of expired oxygen is over 90 percent. (See 'Preparation for induction of anesthesia'
above.)
● Other than for rapid sequence induction and intubation, the timing of administration of neuromuscular blocking agents relative to
establishing mask ventilation should be individualized, based on the expected difficulty with airway management. For patients
with anticipated difficulty with mask ventilation or intubation, it is reasonable to withhold administration of an NMBA until after
mask ventilation is confirmed, or consider an awake or inhalation induction. For patients without anticipated difficulty with mask
ventilation or intubation, it is reasonable to administer NMBAs prior to proving the ability to ventilate by mask. (See
'Administration of neuromuscular blocking agents' above.)
● After placement of an airway device, proper position must be confirmed by auscultation of the chest and the presence of an end-
tidal CO2 waveform. If confirmation is not possible, the airway device should be adjusted or replaced. (See 'Confirmation of
airway placement' above.)
● Any patient who was at particular risk for difficult airway management at the beginning of anesthesia should be considered at
risk for airway compromise at the end of the anesthetic. Airway management should include a plan for safe emergence and
extubation. (See 'Extubation' above.)

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Author: Lauren Berkow, MD

AIRWAY MANAGEMENT FOR PATIENTS WITH COVID-19

● (See "Direct laryngoscopy and endotracheal intubation in adults".)

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● (See "Rapid sequence induction and intubation (RSII) for anesthesia".)

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PREDICTION OF THE DIFFICULT AIRWAY

● Age older than 55

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● Small mouth opening (<3 finger breadths)

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● Prior difficult intubation

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CREATION OF A STRATEGY FOR AIRWAY MANAGEMENT

for PEEP) once the airway is placed.

● Should spontaneous ventilation be maintained?

Choice of airway device

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● Clinically important features of SGA use:

• Easily placed blindly

● Clinically important features of ETT use:

• May be difficult to place

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SECURING THE AIRWAY

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● Effective manual ventilation.

If confirmation is not possible, the airway device should be adjusted or replaced.

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SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

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45. http://www.rcoa.ac.uk/nap4 (Accessed on November 10, 2014).

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