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Difficult Airway

Difficult Airway

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Published by Steve Johnstone
ASA Difficult Airway Algorithm and Practice Guidelines for Difficult Airway Management
ASA Difficult Airway Algorithm and Practice Guidelines for Difficult Airway Management

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Published by: Steve Johnstone on Jul 03, 2010
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10/23/2012

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SPECIAL ARTICLE
 Anesthesiology 2003; 98:1269–77 © 2003 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.
 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
PRACTICE guidelines are systematically developed rec-ommendations that assist the practitioner and patient inmaking decisions about health care. These recommen-dations may be adopted, modified, or rejected accordingto clinical needs and constraints.Practice guidelines are not intended as standards or absolute requirements. The use of practice guidelinescannot guarantee any specific outcome. Practice guide-lines are subject to revision as warranted by the evolu-tion of medical knowledge, technology, and practice.They provide basic recommendations that are supportedby analysis of the current literature and by a synthesis of expert opinion, open forum commentary, and clinicalfeasibility data.This revision includes data published since the “Prac-tice Guidelines for Management of the Difficult Airway” were adopted by the American Society of Anesthesiolo-gists in 1992; it also includes data and recommendationsfor a wider range of management techniques than waspreviously addressed.
 A. Definition 
 A standard definition of the difficult airway cannot beidentified in the available literature. For these Guide-lines, a
difficult airway
is defined as the clinical situationin which a conventionally trained anesthesiologist expe-riences difficulty with face mask ventilation of the upper airway, difficulty with tracheal intubation, or both.The difficult airway represents a complex interactionbetween patient factors, the clinical setting, and theskills of the practitioner. Analysis of this interactionrequires precise collection and communication of data.The Task Force urges clinicians and investigators to useexplicit descriptions of the difficult airway. Descriptionsthat can be categorized or expressed as numerical valuesare particularly desirable, as this type of informationlends itself to aggregate analysis and cross-study compar-isons. Suggested descriptions include (but are not lim-ited to):1. Difficult face mask ventilation: (a) It is not possiblefor the anesthesiologist to provide adequate facemask ventilation due to one or more of the followingproblems: inadequate mask seal, excessive gas leak,or excessive resistance to the ingress or egress of gas.(b) Signs of inadequate face mask ventilation include(but are not limited to) absent or inadequate chestmovement, absent or inadequate breath sounds, aus-cultatory signs of severe obstruction, cyanosis, gastricair entry or dilatation, decreasing or inadequate oxy-gen saturation (SpO
2
 ), absent or inadequate exhaledcarbon dioxide, absent or inadequate spirometricmeasures of exhaled gas flow, and hemodynamicchanges associated with hypoxemia or hypercarbia
e.g.
, hypertension, tachycardia, arrhythmia).2. Difficult laryngoscopy: (a) It is not possible to visual-ize any portion of the vocal cords after multiple at-tempts at conventional laryngoscopy.3. Difficult tracheal intubation: (a) Tracheal intubationrequires multiple attempts, in the presence or ab-sence of tracheal pathology.4. Failed intubation: (a) Placement of the endotrachealtube fails after multiple intubation attempts.
B. Purpose of the Guidelines for Difficult  Airway Management 
The purpose of these Guidelines is to facilitate themanagement of the difficult airway and to reduce thelikelihood of adverse outcomes. The principal adverseoutcomes associated with the difficult airway include(but are not limited to) death, brain injury, cardiopulmo-nary arrest, unnecessary tracheostomy, airway trauma,and damage to teeth.
 Additional material related to this article can be found on the A 
NESTHESIOLOGY 
Web site. Go to the following address, click onEnhancements Index, and then scroll down to find the appro-priate article and link. http://www.anesthesiology.org
Developed by the American Society of Anesthesiologists Task Force on Diffi-cult Airway Management: Robert A. Caplan, M.D. (Chair), Seattle, Washington; Jonathan L. Benumof, M.D., San Diego, California; Frederic A. Berry, M.D.,Charlottesville, Virginia; Casey D. Blitt, M.D., Tucson, Arizona; Robert H. Bode,M.D., Boston, Massachusetts; Frederick W. Cheney, M.D., Seattle, Washington;Richard T. Connis, Ph.D., Woodinville, Washington; Orin F. Guidry, M.D., Jack-son, Mississippi; David G. Nickinovich, Ph.D., Bellevue, Washington; and An-dranik Ovassapian, M.D., Chicago, Illinois. Submitted for publication October 23,2002. Accepted for publication October 23, 2002. Supported by the AmericanSociety of Anesthesiologists under the direction of James F. Arens, M.D., Chair,Committee on Practice Parameters. A list of the references used to develop theseGuidelines is available by writing to the American Society of Anesthesiologists. Address reprint requests to the American Society of Anesthesiologists: 520North Northwest Highway, Park Ridge, Illinois 60068-2573. Individual PracticeGuidelines may be obtained at no cost through the Journal Web site, www.anesthesiology.org.
 Anesthesiology, V 98, No 5, May 2003
1269
 
C. Focus
The primary focus of these Guidelines is the manage-ment of the dif 
cult airway encountered during admin-istration of anesthesia and tracheal intubation. Someaspects of the Guidelines may be relevant in other clin-ical contexts. The Guidelines do not represent an ex-haustive consideration of all manifestations of the dif 
-cult airway or all possible approaches to management.
D. Application 
The Guidelines are intended for use by anesthesiolo-gists and by individuals who deliver anesthetic care andairway management under the direct supervision of ananesthesiologist. The Guidelines apply to all types of anesthetic care and airway management delivered inanesthetizing locations and is intended for all patients of all ages.
E. Task Force Members and Consultants
The American Society of Anesthesiologists (ASA) ap-pointed a Task Force of 10 members to (1) review thepublished evidence, (2) obtain the opinions of anesthe-siologists selected by the Task Force as consultants, and(3) build consensus within the community of practitio-ners likely to be affected by the Guidelines. The Task Force included anesthesiologists in both private and ac-ademic practices from various geographic areas of theUnited States and consulting methodologists from the ASA Committee on Practice Parameters.These Practice Guidelines update and revise the 1993publication of the ASA 
Guidelines for Management of the Dif 
cult Airway.
* The Task Force revised and up-dated the Guidelines by means of a
 ve-step process.First, original published research studies relevant to therevision and update were reviewed and analyzed. Sec-ond, the panel of expert consultants was asked to (1)participate in a survey related to the effectiveness andsafety of various methods and interventions that mightbe used during management of the dif 
cult airway, and(2) review and comment on draft reports. Third, theTask Force held an open forum at a major nationalanesthesia meeting to solicit input from attendees on adraft of the Guidelines. Fourth, the consultants weresurveyed to assess their opinions on the feasibility and
nancial implications of implementing the Guidelines.Finally, all of the available information was used by theTask Force to
nalize the Guidelines.
F. Availability and Strength of Evidence
Evidence-based guidelines are developed by a rigorousanalytic process (Appendix). To assist the reader, theseGuidelines make use of several descriptive terms that areeasier to understand than the technical terms and datathat are used in the actual analyses. These descriptiveterms are de
ned below.The following terms describe the
strength
of scienti
cdata obtained from the scienti
c literature.
Supportive
: There is suf 
cient quantitative informationfrom adequately designed studies to describe a statis-tically signi
cant relationship ( 
 P 
0.01) between aclinical intervention and a clinical outcome, usingmeta-analysis.
Suggestive
: There is enough information from case re-ports and descriptive studies to provide a directionalassessment of the relationship between a clinical in-tervention and a clinical outcome. This type of quali-tative information does not permit a statistical assess-ment of signi
cance.
 Equivocal 
: Qualitative data have not provided a clear direction for clinical outcomes related to a clinicalintervention, and (1) there is insuf 
cient quantitativeinformation, or (2) aggregated comparative studieshave found no quantitatively signi
cant differencesamong groups or conditions.The following terms describe the
lack
of availablescienti
c evidence in the literature.
 Inconclusive
: Published studies are available, but they cannot be used to assess the relationship between aclinical intervention and a clinical outcome becausethe studies either do not meet prede
ned criteria for content, as de
ned in the
Focus
of these Guidelines,or do not provide a clear causal interpretation of 
ndings because of research design or analyticconcerns.
 Insuf 
  fi
cient 
: There are too few published studies toinvestigate a relationship between a clinical interven-tion and clinical outcome.
Silent 
: No studies that address a relationship of interest were found in the available published literature.The following terms describe survey responses from theconsultants for any speci
ed issue.Responses are assigned a numeric value of agree
1,undecided
0, or disagree
1. The average weighted response represents the mean value for each survey item.
 Agree
: The average weighted response must be equal toor greater than
0.30 (on a scale of 
1 to 1) toindicate agreement.
 Equivocal 
: The average weighted response must be be-tween
0.30 and
0.30 (on a scale of 
1 to 1) toindicate an equivocal response.
* Practice guidelines for the dif 
cult airway: A report by the American Society of Anesthesiologists Task Force on Management of the Dif 
cult Airway. A 
NESTHE
-
SIOLOGY 
1993; 78:597
602
1270
PRACTICE GUIDELINES
 Anesthesiology, V 98, No 5, May 2003
 
 Disagree
: The average weighted response must be equalto or less than
0.30 (on a scale of 
1 to 1) to indicatedisagreement.
Guidelines
 I. Evaluation of the Airway
1. History.
There is insuf 
cient published evidence toevaluate the effect of a bedside medical history on pre-dicting the presence of a dif 
cult airway. Similarly, thereis insuf 
cient evidence to evaluate the effect of review-ing prior medical records on predicting the presence of a dif 
cult airway. There is suggestive evidence that somefeatures of a patient
s medical history or prior medicalrecords may be related to the likelihood of encounteringa dif 
cult airway. This support is based on recognizedassociations between a dif 
cult airway and a variety of congenital, acquired, or traumatic disease states. In ad-dition, the Task Force believes that the description of adif 
cult airway on a previous anesthesia record or anes-thesia document offers clinically suggestive evidencethat dif 
culty may recur. The consultants and Task Forceagree that a focused bedside medical history and a fo-cused review of medical records may improve the de-tection of a dif 
cult airway.
 Recommendations.
An airway history should be con-ducted, whenever feasible, prior to the initiation of an-esthetic care and airway management in all patients. Theintent of the airway history is to detect medical, surgical,and anesthetic factors that may indicate the presence of a dif 
cult airway. Examination of previous anestheticrecords, if available in a timely manner, may yield usefulinformation about airway management.
 II. Physical Examination
In patients with no gross upper airway pathology or anatomical anomaly, there is insuf 
cient published evi-dence to evaluate the effect of a physical examination onpredicting the presence of a dif 
cult airway. However,there are suggestive data that
ndings obtained from anairway physical examination may be related to the pres-ence of a di
cult airway. This support is based onrecognized associations between the dif 
cult airway anda variety of airway characteristics. The consultants andTask Force agree that an airway physical examinationmay improve the detection of a dif 
cult airway.Speci
c features of the airway physical examinationhave been incorporated into rating systems intended topredict the likelihood of a dif 
cult airway. Existing ratingsystems have been shown to exhibit modest sensitivity and speci
city. The speci
c effect of the airway physicalexamination on outcome has not been clearly de
ned inthe literature.There is insuf 
cient published evidence to evaluatethe predictive value of single features of the airwaphysical examination
versus
multiple features in predict-ing the presence of a dif 
cult airway. The consultantsand Task Force agree that prediction of a dif 
cult airway may be improved by the assessment of multiple features.The Task Force does not regard any rating system asfail-safe.
 Recommendations.
An airway physical examinationshould be conducted, whenever feasible, prior to theinitiation of anesthetic care and airway management inall patients. The intent of this examination is to detectphysical characteristics that may indicate the presenceof a dif 
cult airway. Multiple airway features should beassessed (table 1).
 III. Additional Evaluation
The airway history or physical examination may pro- vide indications for additional diagnostic testing in somepatients. The literature suggests that certain diagnostictests may identify features associated with a di
cult
 Table 1. Components of the Preoperative Airway Physical Examination 
 Airway Examination Component Nonreassuring Findings
1. Length of upper incisors Relatively long2. Relation of maxillary and mandibular incisors duringnormal jaw closureProminent “overbite” (maxillary incisors anterior to mandibularincisors)3. Relation of maxillary and mandibular incisors duringvoluntary protrusion of cannot bringPatient mandibular incisors anterior to (in mandible front of)maxillary incisors4. Interincisor distance Less than 3 cm5. Visibility of uvula Not visible when tongue is protruded with patient in sittingposition ( 
e.g.,
Mallampati class greater than II)6. Shape of palate Highly arched or very narrow7. Compliance of mandibular space Stiff, indurated, occupied by mass, or nonresilient8. Thyromental distance Less than three ordinary nger breadths9. Length of neck Short10. Thickness of neck Thick11. 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 orall of the airway components shown in this table depends on the clinical context and judgment of the practitioner. The table is not intended as a mandatory orexhaustive list of the components of an airway examination. The order of presentation in this table follows the “line of sight” that occurs during conventional orallaryngoscopy.
1271
PRACTICE GUIDELINES
 Anesthesiology, V 98, No 5, May 2003

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