Review Article

iMedPub Journals  Journal of Anaesthesiology

Anaesthesiology and Critical
Critical Care 2018
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Vol.1 No.1:5

Difcult Airway Management during Anesthesia: A Review of the Incidence and

Soluons
Zhiyong Zeng1, Woo C Tay1, Tomoyuki Saito2, Kyu Kyu Thinn3* and Eugene H Liu3
1Department of Anesthesia, Naonal University Hospital, Naonal University Health System, Singapore
2
Department of Anaesthesiology, Dokkyo Medical University Koshigaya Hospital, 2-1-50 Minamikoshigaya, Koshigaya, Saitama 343-8555, Japan
3
Department of Anesthesia, Yong Loo Lin School of Medicine, Naonal University of Singapore, Naonal University Health System, Singapore
*Corresponding author: Kyu Kyu Thinn, Department of Anesthesia, Naonal University Hospital, Naonal University Health System, 5 Lower Kent
Ridge Road, Singapore 119074, Tel: +65-67726965; E-mail: kyu_kyu_thinn@nuhs.edu.sg
Copyright: ©2018 Zeng Z, et al. This is an open-access arcle distributed under the terms of the Creave Commons Aribuon License, which
permits unrestricted use, distribuon, and reproducon in any medium, provided the original author and source are credited
Received date: January 9, 2018; Accepted date: February 9, 2018; Published date: February 16, 2018

Citaon: Zeng Z, Tay WC, Saito T, Thinn KK, Liu EH (2018) Dicult Airway Management during Anesthesia: A Review of the Incidence and Soluons.
J Anaesthesiol Crit Care. Vol 1 No.1:5

Abstract
Objecve:   We determined the incidence and predicve
factors of dicult airway problems, and the devices used to
solve the problems, in paents having general anesthesia.
Methods:  We reviewed reported dicult  airway cases in
37,805 paents  who underwent general anesthesia from
May 2011 to October 2013. Data were obtained from a
procedural audit system implemented in our instute.
Results and conclusion:  There were 885 (2.3%) paents
with dicult  airway problems. The incidence of diculty
encounter with tracheal intubaon,  supragloc  airways and
mask venlaon  were 4.7%, 0.4% and 1.0%, respecvely. Of  airway management method early.
the 805 paents  with dicult tracheal intubaon, tracheal
intubaon  failed in 11 (0.1%) paents  and 3 of these
paents  needed tracheotomy. The main risk factors of a
Introducon
Predicon  of dicult  airway management and the
preparaon  of advanced equipment and the skill to use them
can prevent poor outcomes when dicules are encountered.
Hence we use a standardized preoperave airway assessment
of all paents,  comprising Mallampa  view, neck movement,
thyromental distance, mouth opening and presence of loose
teeth or gaps in denon,  to enable adequate preparaon.
Failure to intubate the trachea is not in itself life threatening,
but repeated aempts  may traumaze the airway, make airway
rescue more dicult,  leading to failed oxygenaon,  and even
mortality [1,2]. We emphasized oxygenaon,  avoiding mulple
aempts   at device inseron,  and changing to an alternave
ear ly.
While the range of available devices is wide, we had idened
in our department four core devices to train our sta   with, for

dicult airway were short thyromental distance (odds rao

11.3 (9.6-13.4)) and limited neck extension (OR 7.0
(5.5-8.8)). Paents  in whom management was ancipated
to be dicult  had a fourfold higher risk of actual diculty
compared to paents  in whom diculty  was not
ancipated.  The negave  predicve  value of this simple
preoperave  evaluaon   was 98.7%. The most frequently
used devices enabling tracheal intubaon  when diculty
was encountered were bougies and videolaryngoscopes,
especially for unancipated  dicules.   Supragloc  airways
enabled venlaon   and oxygenaon   when dicult
intubaon  was encountered, but there was a 0.4%
incidence with dicult  supragloc   airway placement. Our
review supports a pre-anesthesia simple airway evaluaon,
avoiding mulple  aempts  at tracheal intubaon  or
supragloc   airway inseron  when diculty is encountered
and early use of a small and familiar range of alternave
methods.
Keywords: Dicult   airway; Airway obstrucon;  Airway
management; Dicult   intubaon;  Intratracheal; Laryngeal
masks; Laryngoscopes
use in dicult  airway management: bougies, supragloc
airways, videolaryngoscopes and exible bronchoscopes. These
would enable our sta   to cope with most situaons,  including
the rare ‘cannot venlate   - cannot intubate’ situaons,
esmated   at 0.01-0.05% [3,4]. These four devices feature in
most guidelines for dicult  airway management [2].
Cricothyrotomy is in the guidelines, but few anesthesiologists
have real life experience of emergency cricothyrotomy [5,6] and
we are concerned about iatrogenic injury with this method.
In this review, we studied the incidence of dicult  airway
situaons during general anesthesia, the predicon of diculty,
and the methods which enabled safe and successful airway
management.
Materials and Methods
In 2011, we implemented a 100% procedural audit system of 
all anesthesia work in our department. This was mandated by
the hospital and Ministry of Health as part of the connuous
quality improvement and paent  safety for all procedural and

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 Journal of Anaesthesiology and Critical Care 2018

Vol.1 No.1:5

surgical speciales.  The Domain Specic  Review Board was
informed of our audit work and advised that consent from
paents was not required for such audit work. The audit system
recorded the paent’s  characteriscs,  anesthesia techniques,
problems and dicules  encountered and crical  and adverse
incidents.
extension, short thyromental distance, limited mouth opening,
poor denon  and Mallampa   IV oropharyngeal view. We
calculated the sensivity   and specicity  of these factors in
predicng diculty  and also the posive and negave  predicve
values of the presence of these factors.

In this review, we studied all the reported cases of dicult Results

airway management among 37,805 general anesthesia cases in
During the study period, there were 37,805 paents who had
the period May 2011 to October 2013. Addional  informaon
general anesthesia and airway intervenon.  We note the
was obtained from the case notes, and where necessary from
dicult  airway management cases in Table 1. Supragloc
communicaon with the anaesthests  involved in the cases. We
airways were the most common airway
air way technique.
noted the rates of dicult  SGA venlaon,   dicult  tracheal
intubaon,  dicult  mask venlaon,   failed SGA inseron,  and Table 1 Incidence of dicult airway management cases.
failed tracheal intubaon.  Dicult mask venlaon was dened
as inability to maintain adequate mask venlaon  or mask Difficulty
Failed
venlaon  requiring two anaesthests.  Dicult SGA venlaon Airway Number of  encountered
was dened as inability to provide adequate venlaon  because Management cases
Number % Number %
of one or more of the following problems: inadequate SGA seal,
excessive resistance to the ingress or egress of gas. In our Tracheal
  17292 805 4.7 11 0 .1
Intubation
instuon, commonly used SGA are LMA Proseal, LMA Supreme
and I-gel. Dicult  tracheal intubaon  was dened  as Cormack Supraglottic
  18805 63 0.4 34 0 .2
and Lehane grade III or IV by convenonal laryngoscopy and/or  Airway used

the need
We notedforthe methods
addional  devices to achieve tracheal intubaon.
used to solve the dicult  airway
Mask Ventilation 1708 17 1 0 0

Total 37805 885 2.3 - -

problems, the success of airway management, and any
complicaons that occurred during airway management.
Standardized pre anesthesia evaluaon included evaluaon of  incidence of 2.3%. There were no mortalies   or hypoxic brain
Mallampa  view, neck movement, thyromental distance, mouth
opening and presence of loose teeth or gaps in denon.
Thyromental distance was considered abnormal if it was less
than the “three ngers’ breadth” of the paent.  We considered
the Mallampa class I, II and III predicve of low risk of dicult
airway, and Mallampa   class IV as high risk. The presence of 
condions  such as diabetes, obesity (body mass index >27.5
kg/m2), obstrucve sleep apnoea, and whether the paent  was
at risk of aspiraon  were noted. A summary evaluaon  was
made: dicult airway ‘ancipated’ or ‘not ancipated’. Whether
A total of 885 paents  had dicult  airway situaons,  an
damage in any of these paents.  Transient hypoxia with
oxygenaon  <80% occurred in 22 paents,   and was rapidly
corrected by mask venlaon  in between airway
instrumentaon  aempts.   We note the incidence of adverse
outcomes in paents of dicult airway in Table 2.
Table 2 Adverse outcomes in paents with dicult airway.
Adverse Outcome Number %
Hypoxia, transient 22 2.5

a dicult  “me
inducon airway is ancipated
  out”,   is the
during which checked again
identy at the
  of the pre-
paent, Bronchospasm 15 1.7
history of allergies, funconing of monitors, and ancipaon  of 
Laryngospasm 10 1.1
blood loss are also checked. Subsequent preparaon   of a
bougie, videolaryngoscope or other device for dicult  airway Dental trauma 6 0.7

situaons, or no preparaon of addional devices, was based on Pulmonary aspiration 5 0.6

these evaluaons.
Hypercapnia 5 0.6
In our instuon,  all anesthesia inducons  involve an
 Airway trauma 4 0.5
anesthesiologist of at least 3 years’ experience, assisted by an
anesthesia nurse. When a more junior resident carries out
inducon  of anesthesia, a more senior anesthesiologist is also Difcult tracheal intubaon
present in the operang room to supervise the junior doctor.
There were 805 paents  with dicult  tracheal intubaon;
these paents  had a poor laryngoscopy grade or could not be
Stascal Analysis intubated with the inial   device of choice. In 704 of these
paents, a Macintosh laryngoscope was inially  used and failed
theWerisk
calculated
factors the
for odds raos
dicult   (95% condence
  airway, including  limited
intervals)neck
for to achieve tracheal intubaon.  An addional  device was

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required, and the success rates of these are in Table 3. Bougies

and videolaryngoscopes were most commonly used.

Table 3 Success rates of rescue devices aer failed inial intubaon aempts  using a Macintosh laryngoscope.

Devices Number (%) Success Failed Success Rate (%)

Bougie 605 (85.9) 600 5 99.2

Videolaryngoscope 52 (7.4) 40 12 76.9

McCoy laryngoscope 33 (4.7) 16 17 48.5

Supraglottic airway (interim) 8 (1.1) 6 2 75

Fiber-optic bronchoscope 2 (0.3) 1 1 50

LMA Fastrach 2 (0.3) 2 0 100

Tracheostomy 1 (0.1) 1 0 100

Face Mask 1 (0.1) 1 0 100

In 605 cases where the rst  aempt with direct laryngoscopy
was unsuccessful, bougies were the rst  addional device used.
In these paents,  some poron  of the laryngeal inlet could be
seen and there was successful intubaon  in 600 cases (99.2%).
Bougies were also used with other laryngoscopes, and overall,
enabled successful intubaon in 686 (85.2%) of cases when used
with a Macintosh laryngoscope, McCoy laryngoscope or
videolarnygoscope. Videolaryngoscopes were the next most
common technique used aer  diculty  with the Macintosh
laryngoscope and intubaon  was successful in 76.9%.
Videolaryngoscopes were used as the rst device, instead of the
Macintosh laryngoscope, for tracheal intubaon  in 37 paents
and was successful in 29 paents (78.4%).
The LMA Fastrach was used for tracheal intubaon  in seven
paents,   all successfully. Flexible bronchoscopy was used in six
paents  as a planned awake procedure prior to inducon  of  used to overcome the diculty in 9 paents, tracheal intubaon
anesthesia. In two paents,  exible  bronchoscopy was used
aer failure with direct
di rect laryngoscopy and videolaryngoscopy
videolar yngoscopy..
In 11 paents  (0.06%), failed intubaon  was diagnosed aer
aempts  with addional devices failed, and further aempts at
tracheal intubaon  were stopped. Three of these 11 paents
required urgent tracheotomy,
tracheotomy, during which mask venlaon was
maintained. In eight paents,   SGAs were successfully used to
maintain oxygenaon.  In one of these 11 paents,   the airway
was maintained with mask venlaon  throughout anesthesia,
aer  intubaon  aempts  failed. In 2 paents,   decisions were
subsequently made to stop anesthesia, awaken the paents, and
postpone surgery. Transient hypoxia had occurred aer  dicult
intubaon  in four paents,  but no paents had severe hypoxia
that resulted in neurological injury.
i njury.
Difcult supragloc airway placement
Among paents for whom SGAs were the planned method of 
paents.  Failed SGA placement occurred in 34 (0.2%) paents,
where further aempts were stopped, and the paents’ airways
were managed with mask venlaon   or tracheal intubaon.
There was concurrent dicult  tracheal intubaon  in 9 of these
paents. When faced with a dicult SGA placement, a dierent
SGA type was aempted   in 21 of these paents  and only 11
(52.4%) were successful.
Difcult mask venlaon
Among paents  for whom mask venlaon  was the planned
method of airway management, there was dicult  mask
venlaon  in 17 (1.0%) paents, requiring the assistant to help
and the use of addional devices. While there were no paents
with impossible mask venlaon,   the anesthesiologists did not
connue  struggling with dicult  mask venlaon.  SGAs were
in 6 paents and exible bronchoscopic intubaon in 2 paents.
Among the 885 paents,   dicult  airway management had
been ancipated   in 524 (59.2%) paents  aer  pre anesthesia
evaluaon.   These 524 paents  were 5.1% of the 9684 paents
in whom diculty  had been ancipated. This incidence was four
fold higher than in paents  for whom diculty  was not
ancipated.
The sensivity,  specicity  and predicve  values of the
indicators used in pre-anesthesia evaluaon  are noted in Table
4. The posive  predicve  values were low, while the negave
predicve  values were high. All the indicators: high Mallampa
class, short thyromental distance, limited neck movement,
limited mouth opening, poor denon, high BMI, increased the
risk of dicult airway management. The magnitude of increased
risk was greatest with short thyromental distance and limited
neck movement.

airway management, there was dicult placement in 63 (0.4%)

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Table 4 Predictors of dicult airway.

Negative
Non difficult Positive Predictive Predictive Value
Difficult airway (n) airway (n) Odds Ratio (95% CI) S ensitivity (%) Specificity (%) Value (%) (%)

Anticipated difficult airway

Yes 524 9684 4.1 (3.6-4.7) 59.2 73.8 5 .1 98.7

No 361 27236 - - - - -

Body mass index>27.5 kg/m2

Yes 101 2464 1.8 (1.5-2.2) 11.4 93.3 3 .9 97.8

No 784 34456 - - - - -

Obstructive sleep apnea

Yes 44 680 2.8 (2.0-3.8) 5 98.2 6 .1 97.7

No 841 36240 - - - - -

Mallampati classification

VI 47 330 6.2 (4.5-8.5) 5.3 99.1 12.5 97.8

I, II, III 839 36589 - - - - -

Thyromental distance

Short 213 1005 11.3 (9.6-13.4) 24.1 97.3 17.5 98.2

Normal 67
672 35915 - - - - -

Mouth opening

Limited 76 777 4.4 (3.4-5.6) 8.6 97.9 8 .9 97.8

Normal 80
809 36143 - - - - -

Neck extension

Limited 92 606 7.0 (5.5-8.8) 10.4 98.4 13.2 97.9

Normal 79
793 36314 - - - - -

Teeth

Loose 127 1675 3.5 (2.9-4.3) 14.4 95.5 7 .1 97.9

Normal 75
758 35245 - - - - -

Discussion were used in only a very small proporon of cases. Diculty was

minimized or prevented in some paents  by immediate use of 
Our review found an incidence of dicult  airways of 2.3% in bougies and videolaryngoscopes at the start, or by using SGAs
general anesthesia paents,   most of these involved dicult instead of tracheal intubaon. While much preparaon may not
intubaon  [7,8]. The 4.7% rate of dicult  intubaon  among have been necessary, we suggest that it is beer  to over
paents  needing tracheal intubaon  is comparable to that of  prepare, to reduce unexpected dicules [11].
5.8% in a meta-analysis [9] and the 0.06% incidence of failed
Videolaryngoscopes have several advantages over the
tracheal intubaon  is comparable to earlier data of 0.05% in a
convenonal  direct laryngoscopes [8,12,13]. In parcular,  their
non-obstetric populaon [10].
use requires less extension and exion  of the head and neck,
Most of the dicult  intubaon  situaons  were safely and pressure on the neck, and distoron  of the upper airway.
successfully managed using a small range of devices. When Videolaryngoscopes enable both operator and assistant to
some poron of the laryngeal inlet could be seen, bougies were simultaneously view the airway. Adequate mouth opening is sll
most commonly used rst  with a very high success rate. When required to use a videolaryngoscope and there can be diculty
the laryngeal inlet could not be seen at all, videolaryngoscopes inserng  the tracheal tube despite a good view of the larynx,
were then used. Our review suggests that the availability of and and this can cause airway trauma. In some paents,  bougies
experience with videolaryngoscopes helped reduce the rate of  were used to guide the tracheal tube during videolaryngoscopy.
failed intubaon.  Flexible bronchoscopy and the LMA Fastrach We suggest that when convenonal  laryngoscopy has failed, a

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 Journal of Anaesthesiology and Critical Care
videolaryngoscope should be used early and that bougies be
used together with the videolaryngoscope in “can see cannot
intubate situaons”.  In our audit, there was no airway trauma
caused by the videolaryngoscopes, but we should also avoid
mulple  aempts  with videolaryngoscopes, to prevent swelling
and bleeding in the airway [14].
In our paents,  the rate of dicult  SGA inseron  was much
lower than that of dicult tracheal intubaon. It is possible that
many dicult  intubaon  situaons were avoided by using SGAs
instead. SGAs now feature in all dicult  airway algorithms, to
enable oxygenaon and venlaon [15,16]. While SGAs may not
provide the same level of protecon  against aspiraon  of  We suggest that tests not only be directed at dicult
regurgitated stomach contents, SGAs such as the LMA Proseal
and Igel have channels for inseron of gastric tubes that enable
drainage and reducon  of the volume of stomach contents.
However, we cauon  against over reliance on SGAs, as dicult
SGA inseron   can also occur in paents  in whom intubaon  is
dicult.  An earlier review found the rate of dicult  venlaon
with an SGA to be 0.5% [17]. The failed SGA inseron  cases in
our review mostly involved inadequate venlaon   due to gas
leaks. SGA inseron  was abandoned and tracheal intubaon
used instead, but a substanal  proporon  of these also had
dicult  tracheal intubaon  requiring the use of bougies and
videolaryngoscopes. We suggest that it is also important to
avoid mulple  aempts at SGA inseron, as these aempts  can
traumaze   the airway, making subsequent mask venlaon,
tracheal intubaon  or exible  bronchoscosopy dicult  or
impossible.
In our study, there were no paents  in whom failed mask
venlaon,  failed SGA placement and failed tracheal intubaon
all occurred and had not been ancipated.  Only a very small
number of paents  required a subgloc  surgical airway. In all
three paents,  the diculty  had been ancipated  and the
surgical team was present to carry out emergency surgical
tracheotomy. None of the paents  had cricothyrotomy by the
anesthesiologists, suggesng  that it is very unlikely that the
anesthesiologists will ever gain adequate personal experience
with cricothyrotomy.
are the only pragmacTraining
 methodsintosimulators
gain skill. and animal models
There were no cases of hypoxic injury in this review. Our
department had emphasized that oxygenaon took precedence
over intubaon,  and emphasized stopping mulple  intubaon
aempts  and changing to alternave  methods early. This was to
avoid turning a dicult airway into an impossible airway. Failed
intubaon  is not itself life threatening, yet is frequently
associated with serious complicaons  [2,7], as repeated
aempts   can damage the upper airway and make mask
venlaon   very dicult  [8,18]. In 2011, the 4th Naonal  Audit
project of the Royal College of Anaesthests in UK esmated  an
incidence of one serious airway complicaon  per 22000 cases,
and that this could be as high as one in 5000 cases [7,11]. Our
single centre study populaon  of 37805 paents  may be too
small to provide a rate of such complicaons.
In our instuon,  all paents  have a simple standardized
evaluaon  of the airway as part of preoperave  evaluaon,  and
this is conrmed  at the “me  out” prior to the inducon  of  report by the American Society of Anesthesiologists task force on
anesthesia. Our emphasis is on reducing the incidence of 
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2018
Vol.1 No.1:5
unancipated  dicult  airways, and being prepared. There was
low sensivity   and specicity,  and very low posive  predicve
value of the airway evaluaon  and individual risk factors in our
paents. This is similar to other more extensive and complicated
airway evaluaon systems, which all also had limited sensivity
and specicity  [9,19,20]. Many paents  in whom diculty  was
ancipated  eventually had easy airway management, with only
5.1% having dicult  airways. Conversely, in paents  evaluated
as not having a dicult airway, the negave predicve value was
very high and 98.7% did not have any problems. The residual
1.3% had unancipated diculty.
laryngoscopy and intubaon,  but also for dicult  mask
venlaon,  dicult SGA, dicult surgical airway. In our paents,
short thyromental distance was the strongest predictor of a
dicult  airway. Thyromental distance is considered to be an
indicator of mandibular space [21] and reects  whether
displacement of the tongue by the laryngoscope blade will be
easy or dicult.   We included checking for limited neck
movement, limited mouth opening and poor denon  to
prevent unancipated  diculty   due to these factors. In
parcular,   severely limited mouth opening would require
alternave   methods such as bronchoscopic nasal intubaon  or
subgloc surgical airways. Despite the limitaons  of this simple
evaluaon,   our results suggest that it prevents unancipated
diculty  with inseron  of a laryngoscope or SGA. The paents
who did have unancipated  dicult  airways had anatomical
variaons   that could be managed with bougies and
videolaryngoscopes.
There are a few limitaons   of our study. As a teaching
hospital, we have a wide range of clinical experience and
competency and it is possible that some airways diagnosed as
dicult  by more junior anaesthests  may not be dicult  in
more experienced hands. Secondly, although diculty  was
ancipated  in many paents,   only a small proporon  was
eventually reported as being dicult,  as SGAs were used
instead. Thirdly, the wide use of SGA will result in lower rates of 
dicult intubaon, but this reects contemporary pracce.
Conclusion
In conclusion, most dicult  airway incidents were managed
by using a small range of methods, and avoiding mulple
aempts   at tracheal tube or SGA inseron.  Bougies and
videolaryngoscope enabled successful intubaon  in a large
proporon  of dicult  intubaon  paents.   A simple standard
preoperave  airway evaluaon,   which was conrmed  before
inducon  of anesthesia, helped prevent unancipated
impossible airways. While SGAs can be used for rescue
oxygenaon during dicult  intubaon,  we cauon that dicult
SGA and dicult intubaon can coexist in some paents.
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 Journal of Anaesthesiology and Critical Care 2018

Vol.1 No.1:5

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