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Management of the difficult airway for general anesthesia in adults

Authors: William H Rosenblatt, MD, Carlos Artime, MD

Section Editor: Carin A Hagberg, MD, FASA
Deputy Editor: Marianna Crowley, MD

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Dec 2018. | This topic last updated: Mar 12, 2018.

INTRODUCTION — Difficulty with airway management for anesthesia has potentially serious implications, as failure to secure a patent
airway can result in hypoxic brain injury or death in a matter of minutes. Early recognition that a patient's airway may be difficult to
manage allows the clinician to plan the anesthetic to minimize the potential for serious airway-related morbidity.

In the unanticipated difficult airway, a pre-formulated strategy for airway management may reduce the likelihood of adverse outcomes
[1]. Difficulty may occur with facemask ventilation, placement of a supraglottic airway (SGA), laryngoscopy, and tracheal intubation.
Other significant airway-related complications include aspiration of gastric contents, laryngospasm, and bronchospasm. These airway
problems may occur in combination, leading to serious morbidity and mortality [2].

This topic will review patient factors that predict difficult airway management, the development of strategies for the initial management of
the predicted difficult airway in the operating room environment, management of the unanticipated difficult airway during induction of
general anesthesia, and extubation of the patient with a difficult airway. A general approach to airway management and specific
techniques and devices used to manage the airway are discussed separately, as is an approach to the difficult airway during emergency
intubation. (See "Airway management for induction of general anesthesia" and "Direct laryngoscopy and endotracheal intubation in
adults" and "Approach to the difficult airway in adults outside the operating room" and "Supraglottic devices (including laryngeal mask
airways) for airway management for anesthesia in adults".)

DEFINITIONS — For the purpose of this topic, the difficult airway is defined as the situation in which the anesthesia clinician
experiences difficulty with ventilation by mask or supraglottic airway (SGA), difficulty with endotracheal intubation, or both. Specifically:

● Difficult mask or SGA ventilation – Inability of an unassisted anesthesia clinician to maintain oxygenation or reverse signs of
inadequate ventilation

● Difficult SGA placement or endotracheal intubation – Requires multiple attempts

● Difficult laryngoscopy – Inability to visualize any portion of the vocal cords after multiple attempts

● Difficult endotracheal intubation – Inability to place a tracheal tube into the larynx and trachea after multiple attempts

RECOGNITION OF THE DIFFICULT AIRWAY — All patients undergoing anesthesia should have a complete history and anesthesia-
focused physical examination, including assessment of the airway (table 1) and factors that may influence airway management. One
goal of this evaluation is to predict the degree of difficulty with ventilation and intubation. Prediction that a patient will be difficult to mask
ventilate, ventilate with a supraglottic airway (SGA), or intubate leads to different airway management strategies, particularly when more
than one airway technique is likely to be problematic. The airway history and examination, including factors that predict difficulty with
airway management, are discussed more fully separately. (See "Airway management for induction of general anesthesia", section on
'Airway assessment'.)

● Difficult mask ventilation – Predictors of difficult mask ventilation include male gender, obstructive sleep apnea, absence of teeth,
presence of a beard, and other clinical features (table 2). The degree of difficulty varies and depends on both the number of
predictive factors and the skill of the clinician. (See "Airway management for induction of general anesthesia", section on 'Difficult
mask ventilation'.)

● Difficult SGA ventilation – Factors that predict difficulty ventilating with a SGA include reduced mouth opening; absence of teeth;
male gender; obesity; and glottic, hypopharyngeal, and subglottic pathology (table 3). (See "Airway management for induction of
general anesthesia", section on 'Difficult supraglottic airway device use'.)

● Difficult endotracheal intubation – Clinical features that predict difficult intubation are presented in the table (table 4). Those with
the highest predictive value for a difficult direct laryngoscopy are a prior history of a difficult intubation, a short thyromental distance,
and decreased range of motion of the neck. The greater the number of positive findings, the more likely intubation will be difficult.
 (See "Airway management for induction of general anesthesia", section on 'Difficult intubation'.)

PLANNING THE ANESTHETIC APPROACH — The plan for anesthesia and airway management for the patient with a predicted
difficult airway may differ from the standard approach. The following discussion is applicable to the anesthetic care of these patients
based on clinical assessment or prior history of difficulty. Creation of a general strategy for airway management is discussed more fully
elsewhere. (See "Airway management for induction of general anesthesia", section on 'Creation of a strategy for airway management'.)

Difficult airway guidelines — The American Society of Anesthesiologists (ASA) and other organizations have developed guidelines for
management of the patient with a difficult airway that include algorithms to aid in clinical decision-making (algorithm 1) [1,3-5]. A
fundamental recommendation of these guidelines is for the performance of a thorough, pre-management assessment of the airway and
other mitigating patient factors, with the goal of identifying patients at risk. Advanced recognition enables the practitioner to formulate a
specific management plan that includes the possibility of securing the airway before induction of general anesthesia (ie, awake
intubation). The algorithms proceed through specific decision points based on the success of the initial plan and the likelihood of
success of backup techniques. Structured training and use of these algorithms for difficult airways may decrease airway-related
morbidity [6,7]. Experienced personnel and specialized airway equipment are critical when airway management is difficult.

Airway Approach Algorithm — Our approach to developing an initial airway management strategy for the patient with a predicted
difficult airway is summarized in the Airway Approach Algorithm (algorithm 2) [8]. This algorithm consists of a series of five clinical
questions that lead the clinician to one of two entry points of the ASA Difficult Airway Algorithm (algorithm 1): awake intubation or
intubation after induction of general anesthesia. The goal of this approach is to avoid entering the emergency pathway of the algorithm
(ie, the "cannot intubate, cannot ventilate" scenario). The questions used to direct airway management in the Airway Approach
Algorithm include the following:

● Is airway control required?

● Could laryngoscopy be difficult?
● Could supraglottic ventilation be used?
● Is there risk of aspiration?
● Will the patient tolerate a period of apnea?

The answers to these questions are combined to create a strategy for airway management.

Regional versus general anesthesia — If appropriate for the surgical procedure, regional or local anesthesia may be preferable for the
patient with a potentially difficult airway. Some patients, however, may require unanticipated airway manipulation or conversion to
general anesthesia if the regional technique fails or is insufficient to complete the surgical procedure [1,3,9]. Thus, a plan must still be
made to manage the airway for patients having regional anesthesia [10]. In some cases, general anesthesia with elective management
of the airway may be preferred in order to avoid an emergent difficult intubation, should conversion become necessary (eg, due to
inadequate regional block). This decision should be made on a case-by-case basis based on the likelihood of the regional anesthetic
being successful and sufficient for the duration of the case, the degree of predicted airway difficulty, access to the airway during the
case, the clinician's experience, and the availability of specialized airway equipment and skilled assistance [4].

Timing of airway control — Patients without a predicted difficult airway typically undergo anesthetic induction prior to intubation. In
contrast, when a difficult airway is predicted, an awake intubation should be considered.

Awake intubation — Awake intubation should be considered if there is anticipated difficulty with tracheal intubation and any one of
the following (algorithm 2):

● Both mask and supraglottic airway (SGA) ventilation are likely to be difficult – Such patients are at risk for failed airway with
standard induction techniques. Although the SGA has a high success rate following difficulty with both mask ventilation and direct
laryngoscopy, there are patients for whom SGA use is likely to be difficult or to fail (table 3) [11]. (See "Airway management for
induction of general anesthesia", section on 'Difficult supraglottic airway device use'.)

● The stomach is not empty – Patients predicted to be difficult to intubate who have not fasted or who are otherwise at high risk for
regurgitation and aspiration of gastric contents (table 5) should be intubated awake and in control of their airway reflexes whenever
possible [1,4]. Airway topicalization can compromise airway protective reflexes and should be performed selectively, but thoroughly,
in patients at high risk of aspiration. In such patients, the oropharynx can be anesthetized, and topical glossopharyngeal nerve
blocks can be performed to blunt the gag reflex, but laryngeal and subglottic anesthesia should be avoided until immediately prior to
intubation. This can be accomplished by spraying local anesthetic solution through the flexible bronchoscope as it is advanced
during the process of laryngoscopy and intubation. (See "Flexible scope intubation for anesthesia", section on 'Topical anesthesia'.)

The key to awake intubation in the patient with a full stomach is a smooth course, with avoidance of gagging, coughing, and
vomiting. Whenever possible, the intubation should not be rushed. Rather, adequate time should be allowed for full local anesthetic
effect. The rapid sequence induction and intubation (RSII) technique, which relies on the ability to intubate rapidly, may not be
appropriate for the patient who may be difficult to intubate. (See "Rapid sequence induction and intubation (RSII) for anesthesia".)
 ● The patient will not tolerate an apneic period – The risk of oxygen (O2) desaturation is greatest in patients with certain risk
factors (eg, patients who are obese, are pregnant, or have pulmonary disease, as well as pediatric patients) (figure 1). When
difficult laryngoscopy is anticipated, awake intubation should be considered even when mask or SGA ventilation is predicted to be
easy.

The goal of awake intubation is to preserve spontaneous ventilation and patient cooperation while intubation is accomplished. Pediatric
patients and those with cognitive disability, altered mental status, or extreme anxiety may not tolerate airway procedures while awake.
When awake intubation is indicated but not feasible, induction of anesthesia with techniques that maintain spontaneous ventilation (eg,
inhalation induction) may reduce the occurrence of failed airways [8]. A higher level of vigilance for the risk of aspiration or loss of the
airway must be maintained. This may include preparations for an immediate surgical airway. (See "Emergency cricothyrotomy
(cricothyroidotomy)".)

Airway management after induction — The Airway Approach Algorithm (algorithm 2) includes two scenarios in which it is
appropriate to proceed with anesthetic induction prior to airway management:

● Laryngoscopy is not predicted to be difficult – If laryngoscopy is not predicted to be difficult after a focused review of the patient's
history and a physical evaluation of the airway, airway management can be attempted after induction of general anesthesia.
Because of the relatively low sensitivities, specificities, and predictive values of the commonly performed airway exams, this
determination is based in large part on clinical experience, including experience with the specific technique to be used (eg, direct or
indirect laryngoscopy).

● Laryngoscopy is predicted to be difficult, but ventilation by mask or SGA is predicted to be adequate, the patient is not at increased
risk for aspiration, and the patient will tolerate an apneic period.

Choice of induction technique — Intravenous (IV) medication is used for induction of general anesthesia for most adult patients. If
difficult airway management is predicted, IV induction is used when there is a high likelihood of successful ventilation by mask, SGA, or
endotracheal intubation and the patient is not at significant risk of gastric contents aspiration or rapid oxyhemoglobin desaturation. When
maintenance of spontaneous ventilation throughout airway management is preferred, an inhalation induction may be used, though IV
access should be established prior to inhalation induction. (See 'Inhalation induction' below.)

PLANNING THE AIRWAY MANAGEMENT APPROACH

Choice of airway device — Endotracheal intubation is considered by many to be the definitive method of airway control for patients
receiving general anesthesia. Not every patient, however, requires endotracheal intubation, including even the patient with a potentially
difficult airway. Regardless of the technique chosen for airway management, a backup plan must be in place, with the necessary
expertise and equipment immediately available. Techniques for use and various types of airway management devices are discussed
separately. (See "Devices for difficult emergency airway management in adults outside the operating room".)

● Facemask – Apart from the patient breathing spontaneously (with or without a general anesthetic), facemask ventilation is the most
basic of airway management techniques. It can be used for short cases when the anesthesiologist will have full access to the
patient's airway throughout the procedure. An advantage to facemask airway management for the patient who may be difficult to
intubate is that spontaneous ventilation can be maintained throughout the anesthetic. If mask ventilation is chosen, the surgeon
must agree that the procedure could be interrupted for airway control during the case, if necessary. (See 'Mask or supraglottic
airway ventilation' below.)

● Supraglottic airway (SGA) – Many patients who are predicted to be difficult to intubate and/or mask ventilate can be successfully
ventilated with a SGA. SGAs can be considered for use as the primary airway device when the risk of aspiration is relatively low
and the need for higher airway pressures is not anticipated. A SGA specifically designed to allow intubation through the device may
be a good choice for the patient who may be difficult to intubate. For longer procedures (ie, >3 hours) or for patients who will not be
positioned supine, a second-generation SGA (with a gastric drain) should be strongly considered. (See 'Mask or supraglottic airway
ventilation' below and "Supraglottic devices (including laryngeal mask airways) for airway management for anesthesia in adults".)

● Endotracheal tube (ETT) – Most anesthesiologists consider endotracheal intubation to be the definitive form of airway control. The
ETT affords the best protection of the airway against aspiration and allows controlled ventilation for long procedures performed in
any position, with or without muscle relaxation and with high airway pressures if necessary. A comparison between SGA and ETT
for airway management is discussed more fully elsewhere. (See "Airway management for induction of general anesthesia", section
on 'Supraglottic airway versus endotracheal tube' and 'Endotracheal intubation' below.)

Surgical airway — When the airway evaluation predicts that ventilation and endotracheal intubation are likely to be impossible (eg,
retropharyngeal abscess, large intraoral mass), a surgical airway may be indicated. In such cases, a surgeon should be consulted as
part of the airway management plan. The surgeon should be asked whether emergent cricothyrotomy, tracheostomy, or rigid
bronchoscopy would likely succeed if the airway is lost. If so, the surgeon and instrumentation for a surgical airway should be at the
bedside during attempts at airway control. If not, tracheostomy under local anesthesia may be indicated. (See "Emergency
cricothyrotomy (cricothyroidotomy)".)
Patients who are at extremely high risk of complete tracheal obstruction with induction of anesthesia (eg, anterior mediastinal mass) and
in whom a surgical airway is deemed impossible may benefit from establishing access for femorofemoral cardiopulmonary bypass under
local anesthesia before induction [12-16]. An example of such a case would be a large thyroid mass both compressing the trachea and
preventing access to the trachea. (See "Anesthesia for patients with an anterior mediastinal mass".)

PREPARATION FOR DIFFICULT AIRWAY MANAGEMENT — Once the anesthetic and airway management plans are established,
adequate preparation of necessary equipment, personnel, and the patient is essential.

Equipment preparation — Immediately prior to anesthesia, both routine and emergency airway equipment should be checked for
availability and functionality. An assortment of standard and alternative airway devices should be immediately available, including
facemasks, appropriate sizes and types of laryngoscopes (direct, indirect, flexible), oral and nasal airways, supraglottic airways (SGAs),
bougies, and equipment for front-of-neck access. We keep emergency airway supplies and advanced airway equipment on a mobile
cart, which should be in the anesthetizing location prior to induction of the patient with a potentially difficult airway, as recommended by
the American Society of Anesthesiologists (table 6). (See "Airway management for induction of general anesthesia", section on
'Preparation for induction of anesthesia'.)

Patient preparation — Prior to the induction of anesthesia, care of the patient with a predicted difficult airway includes preoxygenation
and careful positioning. Patients undergoing awake intubation need special consideration.

● Preoxygenation – Preoxygenation should be performed prior to any airway intervention in order to delay oxyhemoglobin
desaturation during periods of apnea or hypoventilation. Preoxygenation is especially important in patients who are prone to rapid
desaturation during apnea, particularly if prolonged periods of apnea are expected due to difficulty with airway management. This
includes obese, pregnant, and pediatric patients (figure 1). Patients with significant cardiopulmonary disease may not achieve
maximal oxyhemoglobin levels and will thus have a shortened safe apneic period.

Preoxygenation is performed via a tight-fitting facemask using 100 percent oxygen (O2) at a flow rate high enough to prevent
rebreathing (10 to 12 L/minute), aiming for an end-tidal concentration of O2 greater than 90 percent in order to maximize safe
apnea time. Patients should be preoxygenated with either three minutes of tidal volume breathing or eight vital-capacity breaths
over 60 seconds. These two techniques have been shown to be equally effective at preventing desaturation and are more effective
than four vital-capacity breaths over 30 seconds [17-21].

Since the supine position reduces functional residual capacity (FRC), preoxygenation in the semi-upright or reverse Trendelenburg
position is especially useful for obese patients or those with abdominal distention [22]. The use of noninvasive ventilation (NIV) for
preoxygenation has also been shown to prolong the time to desaturation during apnea [23]. The use of a nasal cannula for passive
apneic oxygenation during airway management can prolong the time to desaturation in high-risk patients [24-27]. We routinely
administer O2 via nasal cannulae (10 L/minute) during preoxygenation and intubation for patients with predicted difficult intubation.
This technique should also be considered in patients at high risk for desaturation during a rapid sequence induction, such as
patients with cardiopulmonary disease, as mentioned above, as well as obstetric and obese patients.

● Apneic oxygenation – In addition to preoxygenation, we suggest the use of apneic oxygenation throughout laryngoscopy for
patients at high risk of difficult intubation or rapid oxygen desaturation. Apneic oxygenation can be accomplished most simply with
passive oxygen insufflation via nasal cannula at 15 L/minute. Alternatives include the transnasal humidified rapid-insufflation
ventilatory exchange (THRIVE) and Supernova nasal mask ventilation systems, where available. Apneic oxygenation techniques
are unlikely to extend the safe apneic period in patients who have high grade obstructive lesions of the upper airway [28]. (See
"Preoxygenation and apneic oxygenation for intubation".)

● Patient positioning – Proper positioning for induction of anesthesia and airway management of the patient with a difficult airway is
essential. For direct laryngoscopy or video-assisted laryngoscopy (VAL) with a Macintosh-shaped blade, the head should be placed
in the sniffing position (atlanto-occipital extension with the head elevated 3 to 7 cm), if possible. A neutral head position is preferred
for highly-angulated videolaryngoscopes. Obese patients may require a ramped position, with head extension and the external
auditory canal at the same level as the sternal notch, in order to improve intubating conditions (figure 2) [29].

● Preparation for awake intubation – If awake intubation using a flexible intubation scope or other airway device is planned,
preparation should include the administration of a drying agent (eg, glycopyrrolate 0.2 mg IV), nasal mucosal vasoconstrictors (if
nasal intubation is a possibility), and anesthetic blocks (topical or invasive) of the upper airway. (See "Flexible scope intubation for
anesthesia", section on 'Patient preparation'.)

SECURING THE AIRWAY

Induction of anesthesia — In patients with anticipated difficult to manage airways, the induction technique may be modified in order to
ensure adequate ventilation or the ability to awaken the patient. Prior to induction, assisting personnel should be aware of the backup
plan should difficulty arise. Further details regarding the induction of anesthesia are presented separately. (See "General anesthesia:
Induction" and "Airway management for induction of general anesthesia", section on 'Intravenous induction'.)
 Intravenous induction — Intravenous (IV) induction of general anesthesia is usually performed when there is a high likelihood of
successful ventilation via facemask or supraglottic airway (SGA), or of successful intubation. For the patient with a difficult airway, an
induction regimen that allows return of spontaneous ventilation or awakening if attempts at ventilation are unsuccessful should be
strongly considered. General principles that should be followed include:

Induction agents — An adequate dose of short-acting medication should be used for induction (eg, propofol 1.5 to 2 mg/kg IV).
Alternative intravenous induction agents, and the advantages, adverse effects, and dosing of anesthetic induction agents are discussed
separately. (See "General anesthesia: Intravenous induction agents".)

Underdosing of induction agents may make mask ventilation or airway device placement more difficult.

Opioids — If an opioid is used as part of the induction regimen in order to reduce the physiologic response to intubation, a short-
acting opioid is preferred (eg, fentanyl 1 to 2 mcg/kg IV), and naloxone should be immediately available for reversal should
reestablishment of spontaneous ventilation be required. (See "Rapid sequence induction and intubation (RSII) for anesthesia", section
on 'Opioids' and "General anesthesia: Intravenous induction agents", section on 'Opioids'.)

Neuromuscular blocking agents — Careful consideration should be given to the administration of neuromuscular blocking
agents (NMBAs). NMBAs are administered for endotracheal intubation because they improve intubating conditions by facilitating
laryngoscopy and preventing reflexive laryngeal closure. We individualize the timing and selection of NMBA administration based on the
preoperative airway assessment.

Timing of administration — The timing of administration of NMBAs relative to the establishment of mask ventilation is
controversial. Classic teaching has been that mask ventilation should be established prior to the administration of NMBAs. In theory, 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 practice of withholding NMBAs until mask ventilation is established has been questioned, however, partly because of studies
reporting no change [30,31] or improvement in mask ventilation after administration of NMBAs in patients with normal airways [32] and
predicted difficulty with mask ventilation [33]. NMBAs may improve mask ventilation, especially when difficulty is the result of
laryngospasm, opioid-induced rigidity, or light anesthesia. In addition, withholding NMBAs could create a scenario in which mask
ventilation and intubation are impossible (a "can't ventilate, can't intubate" situation) where there would otherwise not be one.

Our approach to the timing of NMBA administration for patients with predicted airway difficulty is as follows:

● Difficult mask ventilation predicted – When mask ventilation is predicted to be difficult, but intubation is expected to be
straightforward, we may choose a NMBA that provides a rapid onset of intubating conditions (eg, succinylcholine or high-dose
rocuronium) without prior testing for the ability to ventilate by mask. (See 'Selection of NMBA' below.)

● Difficult intubation predicted – When mask ventilation is predicted to be straightforward, and intubation is expected to be difficult,
we do not test ventilation prior to the administration of NMBA.

● Difficult mask ventilation and difficult intubation predicted – For patients in whom we predict difficulty with both mask
ventilation and intubation, we perform awake intubation or inhalation induction of anesthesia, and we avoid the administration of
NMBAs until the ability to ventilate is proven.

Selection of NMBA — For IV induction during predicted difficult airway management, the selection of NMBA should depend on
which aspect of airway management is predicted to be difficult.

● Difficult mask ventilation predicted – When mask ventilation is predicted to be difficult, but laryngoscopy is predicted to be
straightforward, a strategy that allows rapid intubation while minimizing the need for mask ventilation should be employed. Options
include:

• Succinylcholine – Succinylcholine is a depolarizing NMBA. At a dose of 1 to 1.5 mg/kg IV, neuromuscular block is complete in
approximately one minute, and recovery occurs in six to nine minutes [34].

• Rocuronium – Rocuronium is a nondepolarizing NMBA. At a dose of 0.9 to 1.2 mg/kg IV, neuromuscular block is complete in
less than two minutes, with a variable, long duration of action (38 to 150 minutes) [35].

• Remifentanil – Remifentanil is an ultrashort-acting opioid that can be administered (3 to 5 mcg/kg IV with ephedrine 10 mg IV)
in place of NMBAs to achieve adequate intubating conditions without paralysis [36-38]. (See "Rapid sequence induction and
intubation (RSII) for anesthesia", section on 'Remifentanil intubation' and "Rapid sequence induction and intubation (RSII) for
anesthesia", section on 'Neuromuscular blocking agents (NMBAs)'.)

● Difficult intubation predicted – When mask ventilation is predicted to be straightforward but intubation is likely to be difficult, a
strategy that provides optimal intubating conditions should be employed. It is important to remember, however, that the ability to
mask ventilate may deteriorate with prolonged attempts at airway management.
 Options include:

• Succinylcholine, which provides a rapid onset of muscle relaxation, though its duration of action is variable (six to nine minutes)
[34].

• Rocuronium and vecuronium, which are intermediate-acting nondepolarizing NMBAs. Depending on the dose administered,
they provide optimal intubating conditions in one to three minutes. A certain degree of spontaneous recovery must occur before
these agents are reversed, which can take 20 minutes to over an hour depending on the specific agent and the dose
administered. These agents can be reversed from deep levels of neuromuscular blockade without waiting for spontaneous
recovery by using sugammadex (16 mg/kg with deep neuromuscular block), a novel chelating reversal agent. (See "Clinical
use of neuromuscular blocking agents in anesthesia" and "Emergence from general anesthesia", section on 'Assess and
reverse effects of neuromuscular blocking agents'.)

Reversal of deep rocuronium block with sugammadex has been shown to be significantly faster than spontaneous recovery of
succinylcholine block, but it can still require more than six minutes [39].

We do not employ a high-dose remifentanil technique when difficult intubation is predicted because the resultant opioid-induced
glottic closure and the lack of muscle relaxation may not provide optimal intubating conditions and may render mask ventilation
difficult. (See "Rapid sequence induction and intubation (RSII) for anesthesia", section on 'Remifentanil intubation' and "Rapid
sequence induction and intubation (RSII) for anesthesia", section on 'Neuromuscular blocking agents (NMBAs)'.)

Inhalation induction — Though IV induction is most often used in adults, inhalation induction can be used when the clinician wants
to maintain spontaneous ventilation until airway control (with facemask, SGA, or tracheal intubation) has been confirmed. This may be
preferred in patients predicted to have difficulty with intubation but not with mask ventilation. IV access should be obtained in adults prior
to inhalation induction when difficulty with airway management is anticipated.

Following preoxygenation with a tight fitting face mask, a volatile anesthetic is administered, starting at a low, gradually increasing
concentration. Sevoflurane is the agent of choice as its lack of pungency makes it generally well tolerated by the awake patient, and its
pharmacokinetics are such that it redistributes rapidly if airway obstruction occurs. Slowly increasing concentrations of sevoflurane leads
to progressive central nervous system depression, typically with the preservation of spontaneous respirations. If airway obstruction
occurs at any point during the induction, sevoflurane is discontinued, and redistribution results in awakening, typically with resolution of
the obstruction.

We avoid the addition of nitrous oxide (N2O) for induction when a difficult airway is expected. While N2O speeds induction, it must be
administered at a high concentration to be effective, thereby limiting the fraction of inspired oxygen (FiO2) and decreasing the safe
apneic period.

The patient may be intubated without muscle relaxation from deep inhalation anesthesia, such as 6% exhaled sevoflurane. Although
patients usually require ventilatory assistance to maintain adequate minute ventilation at this deep level of anesthesia, a benefit of
continuing spontaneous ventilatory efforts is that it speeds emergence if it is necessary to awaken the patient. Hypotension is likely at
this level of anesthesia, and vasopressor support may be necessary.

Alternatively, the clinician may support spontaneous respiratory efforts with increasing positive-pressure assistance by mask until
ventilation is completely controlled. Once mask ventilation is established, IV induction agents, opioids, or NMBAs may be administered
to optimize conditions for laryngoscopy and intubation.

Mask or supraglottic airway ventilation — After induction of anesthesia in the patient with a difficult airway, mask ventilation should
be established with 100 percent oxygen. Successful facemask ventilation depends on both patient factors and the skill of the clinician. In
most patients, at least some air movement is possible, although two-person ventilation and airway adjuncts may be needed; only a small
number of patients are actually impossible to ventilate and thus are at risk of a failed airway. For example, in an observational study,
impossible mask ventilation was present in only 0.15 percent of patients [40].

Various maneuvers may improve the ability to mask ventilate (see "Basic airway management in adults"):

● Placement of an oropharyngeal (or nasopharyngeal) airway

● Maneuvers to open the upper airway (eg, head tilt, chin lift (picture 1), or jaw thrust (picture 2))

● Two-person mask technique (two-handed mask technique (picture 3) with a second person to ventilate)

Patients with inadequate ventilation despite these maneuvers should have a SGA placed. This is the primary rescue technique for
patients with difficult or impossible mask ventilation, and most patients with difficult mask ventilation may be successfully ventilated
using a SGA [11]. Success with SGA ventilation is dependent on the clinician's skill and experience with specific devices. A variety of
types and sizes of SGAs are available; difficult ventilation can often be overcome by using an alternative.

Whenever both mask and SGA ventilation are impossible, skilled assistance should be summoned and endotracheal intubation
attempted. If unsuccessful, the emergency pathway in the American Society of Anesthesiologists (ASA) Difficult Airway Algorithm should
be followed and the patient awakened, if possible. Emergency invasive airway access may be necessary (algorithm 1). (See
"Emergency cricothyrotomy (cricothyroidotomy)".)

Endotracheal intubation — The choice of airway technique or device for intubation 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.

Direct laryngoscopy is the most common and usually the quickest technique for endotracheal intubation.

Alternatives to direct laryngoscopy include indirect laryngoscopy (eg, with videolaryngoscope [VL] or optical stylet), intubation through
an intubating SGA, and flexible scope intubation (FSI). FSI while asleep is more difficult than while awake due to relaxation of the
pharyngeal tissues. FSI through an endoscopy mask or an SGA permits ventilation during intubation.

Flexible intubation scopes are the most commonly used devices for awake intubation, but other advanced airway devices may also be
used in this setting, depending on the experience of the clinician and patient factors. Alternatives may be chosen when flexible scope
intubation would be difficult. For example, when blood or secretions soil the airway, a bladed technique such as video-assisted or direct
laryngoscopy may allow better visualization of the larynx. Awake placement of a laryngeal mask airway (LMA), a type of SGA, has been
described, either to facilitate endotracheal intubation or for ventilation for the anesthetic. These techniques are discussed separately.
Airway management techniques are discussed separately. (See "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".)

Repeated intubation attempts — Following an unsuccessful initial intubation attempt, resumption of ventilation is the priority, either
by noninvasive (ie, SGA) or invasive means, or by awakening the patient. Repeated attempts at intubation should not delay noninvasive
airway ventilation (ie, SGA) or emergency invasive airway access. We prefer to use an intubating SGA as the initial rescue device after
two failed attempts at direct laryngoscopy if mask ventilation is not adequate. An intubating SGA permits immediate ventilation and may
facilitate intubation with a standard-size endotracheal tube, without the need for an airway exchange catheter.

Repeated instrumentation of the airway may lead to bleeding, edema, and deterioration of the ability to ventilate. For this reason,
laryngoscopy attempts with any particular device should be limited. Data suggest that complications increase when more than two
attempts at direct laryngoscopy are made [41]. Intubating conditions should be optimized between attempts; for example, by improving
head and neck position, changing laryngoscope blade, using a different device, or by having a more experienced clinician manage the
airway.

Following initially unsuccessful attempts at intubation, no single subsequent technique is superior to others in all circumstances. For
example, in one series of 698 patients with both difficult mask ventilation and difficult laryngoscopy, intubation was eventually successful
with direct laryngoscopy in 177, direct laryngoscopy with bougie introducer in 284, VL in 163, and other techniques in 73; one patient
required emergent cricothyrotomy [42]. These devices and their use are discussed elsewhere. (See "Flexible scope intubation for
anesthesia" and "Direct laryngoscopy and endotracheal intubation in adults" and "Supraglottic devices (including laryngeal mask
airways) for airway management for anesthesia in adults" and "Video laryngoscopes and optical stylets for airway management for
anesthesia in adults".)

Based on the review of large data sets, expert groups have suggested that VL should be the first rescue technique employed when
direct laryngoscopy and/or mask or SGA ventilation have failed, because of high success rates. In a large, multicenter retrospective
study of failed DL utilizing the Multicenter Perioperative Outcomes Database, in 1619 rescue attempts, VL resulted in the highest
success rate (92 percent), compared with FSI (78 percent), use of an SGA as a conduit for intubation (78 percent), or the use of a
lighted stylet (77 percent) [43].

THE FAILED AIRWAY — The inability to either ventilate or intubate a patient is termed a "failed airway." With adequate planning and an
algorithmic approach to airway management, the failed airway should be an extremely rare event.

Help should be summoned as soon as difficulty is encountered, and the emergency pathway of the difficult airway algorithm should be
followed (algorithm 1). If the patient cannot be awoken, emergency invasive airway access must be attempted [1]. Invasive airway
management techniques include cricothyrotomy, surgical tracheotomy, and transtracheal jet ventilation. Choice of technique depends on
the expertise of the clinician, availability of equipment and personnel, and technical patient factors. (See "Emergency cricothyrotomy
(cricothyroidotomy)".)

EXTUBATION — Adverse airway events are common at the time of extubation [44-48]. While most of the problems that occur during
extubation are minor, rarely they may result in hypoxic injury or death. 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.

A number of surgical and patient factors increase the risk of adverse events at the time of extubation, including preexisting airway
difficulties, surgical or anesthetic events that have affected the airway, and restricted airway access because of surgical dressings or
fixation devices (table 7) [23].

Prior to extubation of the difficult or at-risk airway, an extubation strategy must be formulated that includes a plan for reintubation if
necessary, including the same assortment of personnel and equipment that were present at induction.

Prior to extubation, neuromuscular blockade should be reversed, and the patient should be normothermic, hemodynamically stable, and
adequately spontaneously ventilating. Patients should be preoxygenated prior to extubation with administration of 100 percent oxygen
(O2) and positive end-expiratory pressure or continuous positive airway pressure in order to maximize the safe apneic period if problems
occur. The oropharynx should be thoroughly suctioned to remove blood and secretions, and a soft bite block should be placed between
the patient's molars to prevent occlusion of the tracheal tube if the patient bites down during emergence. The patient with a difficult
airway should be extubated when he or she is fully awake, responding to commands, and able to maintain his or her own airway.
Supplemental O2 should be provided by standard facemask, or portable CPAP device if indicated, immediately after extubation and
continued while the patient is transported to the recovery room.

For the extubation of a patient with an at-risk airway, we place an airway exchange catheter (AEC) to facilitate reintubation, if necessary.
The AEC is a 100-cm-long, flexible, hollow plastic tube designed to maintain access to the airway after extubation and can be used to
guide reintubation by serving as a stylet.

Prior to extubation, the AEC is passed through the endotracheal tube (ETT) into the trachea prior to extubation, with the tip of the AEC
just beyond the end of the ETT. The ETT is removed over the AEC, and the AEC is left in place in the trachea, taped securely, until the
possible need for reintubation has passed.

An AEC carefully positioned above the carina is generally well-tolerated, allowing coughing, swallowing, and talking. Supplemental O2
can be administered through the catheter if hypoxemia occurs, but should not be routinely performed, as barotrauma can result in cases
of laryngospasm or other upper airway obstruction.

If reintubation is required, an ETT is passed over the AEC, often while performing direct or indirect laryngoscopy to retract soft tissue.
Most complications associated with the use of an AEC (including patient discomfort, coughing, and barotrauma) result from too-deep
insertion (ie, to the level of or past the carina).

DIFFICULT AIRWAY MANAGEMENT IN THE TRAUMA PATIENT — Patients with traumatic injury should be presumed to have difficult
airways. They should be treated with full stomach precautions, and depending on the specific injury, may be at risk for cervical spine
injury. (See "Initial management of trauma in adults", section on 'Cervical spine immobilization'.)

Airway management for trauma patients may be complicated by time pressure, hemodynamic instability, and lack of patient cooperation
with examination and procedures.

Some of the management strategies that are usually followed for patients without traumatic injury may be inappropriate in patients with
trauma. As examples, awakening the trauma patient after failure of airway management is rarely an option, and awake intubation may
be impractical or contraindicated, even when an impossible to manage airway is recognized. Thus surgical front-of-neck access may the
best first choice management option in some patients with trauma. An approach to difficult airway management in trauma patients is
shown in an algorithm (algorithm 3). Airway management for trauma patients is discussed separately, and is shown in tables (table 8
and table 9 and table 10 and table 11). (See "Anesthesia for adults with acute spinal cord injury", section on 'Airway management' and
"Anesthesia for patients with acute traumatic brain injury", section on 'Airway management' and "Anesthesia for adult trauma patients",
section on 'Airway management'.)

SUMMARY AND RECOMMENDATIONS

● We use algorithms to systematically plan induction (algorithm 2) and airway management (algorithm 1) for the patient with a
potentially difficult airway. The approach begins with assessment of the airway and other patient factors, and proceeds through
specific decision points based on success of the initial plan and likelihood of success of backup techniques. (See 'Planning the
anesthetic approach' above.)

● The best indication that a patient may be easily ventilated or intubated is a history of prior success. In the absence of prior records,
the best available methods to predict difficulty with mask ventilation (table 2), supraglottic airway (SGA) ventilation (table 3), and
direct laryngoscopy (table 4) are based on physical examination of the airway and a review of comorbid conditions. (See
'Recognition of the difficult airway' above.)

● Awake intubation should be considered if there is anticipated difficulty with tracheal intubation AND one of the following (algorithm
2) (see 'Awake intubation' above):

• Both mask and supraglottic airway (eg, laryngeal mask airway [LMA]) ventilation are likely to be difficult
• The stomach is not empty (the patient is at risk for aspiration of gastric contents)
• The patient will not tolerate an apneic period (eg, severe obesity, pregnancy, pulmonary disease)
● When at least one method of airway management has a high likelihood of success, most patients may be induced in the standard
fashion (with intravenous [IV] agents prior to intubation) with some modification in technique. Inhalation induction may be indicated
in certain patient populations in order to preserve spontaneous ventilation until the airway is controlled. (See 'Induction of
anesthesia' above.)

● We manage the difficult airway according to the American Society of Anesthesiologists (ASA) Difficult Airway Algorithm (algorithm
1).

• Check emergency airway equipment (table 6) and discuss backup airway plans with assisting personnel, whether the initial
plan is for mask ventilation, use of a SGA, or endotracheal intubation. In rare cases, the safest plan may be a tracheostomy
under local anesthesia, or a surgeon standing by during airway management for a possible emergency surgical airway.

• Position the patient for laryngoscopy and preoxygenate with 100 percent oxygen (O2) using a tight-fitting facemask for three to
five minutes, eight deep breaths over one minute, or until expired concentration of O2 reaches 90 percent. (See 'Equipment
preparation' above and 'Patient preparation' above.)

• Place a SGA promptly in patients with inadequate mask ventilation despite best efforts. Maintenance of adequate ventilation is
the first priority. Whenever both mask and SGA ventilation are impossible, skilled assistance should be summoned and
intubation attempted. Awakening the patient or using emergency invasive airway access should be considered if the patient is
not quickly intubated. (See 'Mask or supraglottic airway ventilation' above.)

• Intubate using a familiar technique judged to have the greatest likelihood of success in the specific patient. If repeated attempts
at intubation are required, conditions should be optimized between attempts, including repositioning and changing to more
experienced personnel. We limit repeat attempts at intubation as they may result in edema, trauma, bleeding, and deterioration
of ventilation. (See 'Repeated intubation attempts' above.)

• Emergency invasive airway access, including surgical or percutaneous airway and transtracheal jet ventilation, may be
required when ventilation is inadequate and intubation attempts have failed. (See 'The failed airway' above.)

● Airway complications are common at the time of extubation. A plan should be in place for extubation and the immediate
postoperative period for the patient with a difficult airway. If intubation has been difficult, or if the course of the surgical procedure or
anesthetic suggests that reintubation would be difficult, an airway exchange catheter should be positioned in the trachea prior to
extubation. The catheter should be kept in place until the potential need to reintubate has passed. (See 'Extubation' above.)

● Patients with traumatic injury should be presumed to have a difficult airway. They should be treated with full stomach precautions,
and may be at risk for cervical spine injury. Options for airway management in trauma patients may be limited by lack of patient
cooperation and time constraints. Awakening the patient after failed airway management is rarely an option (algorithm 3). (See
'Difficult airway management in the trauma patient' above.)

Use of UpToDate is subject to the Subscription and License Agreement.

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16. Belmont MJ, Wax MK, DeSouza FN. The difficult airway: cardiopulmonary bypass--the ultimate solution. Head Neck 1998; 20:266.
17. Baraka AS, Taha SK, Aouad MT, et al. Preoxygenation: comparison of maximal breathing and tidal volume breathing techniques.
Anesthesiology 1999; 91:612.
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20. Nimmagadda U, Chiravuri SD, Salem MR, et al. Preoxygenation with tidal volume and deep breathing techniques: the impact of
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21. Pandit JJ, Duncan T, Robbins PA. Total oxygen uptake with two maximal breathing techniques and the tidal volume breathing
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22. Dixon BJ, Dixon JB, Carden JR, et al. Preoxygenation is more effective in the 25 degrees head-up position than in the supine
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23. Difficult Airway Society Extubation Guidelines Group, Popat M, Mitchell V, et al. Difficult Airway Society Guidelines for the
management of tracheal extubation. Anaesthesia 2012; 67:318.
24. Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg
Med 2012; 59:165.
25. Ramachandran SK, Cosnowski A, Shanks A, Turner CR. Apneic oxygenation during prolonged laryngoscopy in obese patients: a
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26. Taha SK, Siddik-Sayyid SM, El-Khatib MF, et al. Nasopharyngeal oxygen insufflation following pre-oxygenation using the four deep
breath technique. Anaesthesia 2006; 61:427.
27. Sakles JC, Mosier JM, Patanwala AE, et al. First Pass Success Without Hypoxemia Is Increased With the Use of Apneic
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28. Doyle AJ, Stolady D, Mariyaselvam M, et al. Preoxygenation and apneic oxygenation using Transnasal Humidified Rapid-
Insufflation Ventilatory Exchange for emergency intubation. J Crit Care 2016; 36:8.
29. Collins JS, Lemmens HJ, Brodsky JB, et al. Laryngoscopy and morbid obesity: a comparison of the "sniff" and "ramped" positions.
Obes Surg 2004; 14:1171.
30. Ikeda A, Isono S, Sato Y, et al. Effects of muscle relaxants on mask ventilation in anesthetized persons with normal upper airway
anatomy. Anesthesiology 2012; 117:487.
31. Goodwin MW, Pandit JJ, Hames K, et al. The effect of neuromuscular blockade on the efficiency of mask ventilation of the lungs.
Anaesthesia 2003; 58:60.
32. Warters RD, Szabo TA, Spinale FG, et al. The effect of neuromuscular blockade on mask ventilation. Anaesthesia 2011; 66:163.
33. Soltész S, Alm P, Mathes A, et al. The effect of neuromuscular blockade on the efficiency of facemask ventilation in patients
difficult to facemask ventilate: a prospective trial. Anaesthesia 2017; 72:1484.
34. Naguib M, Samarkandi AH, El-Din ME, et al. The dose of succinylcholine required for excellent endotracheal intubating conditions.
Anesth Analg 2006; 102:151.
35. Magorian T, Flannery KB, Miller RD. Comparison of rocuronium, succinylcholine, and vecuronium for rapid-sequence induction of
anesthesia in adult patients. Anesthesiology 1993; 79:913.
36. Klemola UM, Mennander S, Saarnivaara L. Tracheal intubation without the use of muscle relaxants: remifentanil or alfentanil in
combination with propofol. Acta Anaesthesiol Scand 2000; 44:465.
37. Trabold F, Casetta M, Duranteau J, et al. Propofol and remifentanil for intubation without muscle relaxant: the effect of the order of
injection. Acta Anaesthesiol Scand 2004; 48:35.
38. Bouvet L, Stoian A, Rimmelé T, et al. Optimal remifentanil dosage for providing excellent intubating conditions when co-
 administered with a single standard dose of propofol. Anaesthesia 2009; 64:719.
39. Lee C, Jahr JS, Candiotti KA, et al. Reversal of profound neuromuscular block by sugammadex administered three minutes after
rocuronium: a comparison with spontaneous recovery from succinylcholine. Anesthesiology 2009; 110:1020.
40. Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation: a review of 50,000
anesthetics. Anesthesiology 2009; 110:891.
41. Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg 2004;
99:607.
42. Kheterpal S, Healy D, Aziz MF, et al. Incidence, predictors, and outcome of difficult mask ventilation combined with difficult
laryngoscopy: a report from the multicenter perioperative outcomes group. Anesthesiology 2013; 119:1360.
43. Aziz MF, Brambrink AM, Healy DW, et al. Success of Intubation Rescue Techniques after Failed Direct Laryngoscopy in Adults: A
Retrospective Comparative Analysis from the Multicenter Perioperative Outcomes Group. Anesthesiology 2016; 125:656.
44. Asai T, Koga K, Vaughan RS. Respiratory complications associated with tracheal intubation and extubation. Br J Anaesth 1998;
80:767.
45. Rose DK, Cohen MM, Wigglesworth DF, DeBoer DP. Critical respiratory events in the postanesthesia care unit. Patient, surgical,
and anesthetic factors. Anesthesiology 1994; 81:410.
46. Cheney FW, Posner KL, Lee LA, et al. Trends in anesthesia-related death and brain damage: A closed claims analysis.
Anesthesiology 2006; 105:1081.
47. Lienhart A, Auroy Y, Péquignot F, et al. Survey of anesthesia-related mortality in France. Anesthesiology 2006; 105:1087.
48. http://www.rcoa.ac.uk/nap4 (Accessed on November 10, 2014).

Topic 90615 Version 15.0

GRAPHICS

Components of the preoperative airway physical examination

Airway examination component Nonreassuring findings

Length of upper incisors Relatively long

Relationship of maxillary and mandibular incisors during normal jaw Prominent "overbite" (maxillary incisors anterior to mandibular
closure incisors)

Relationship of maxillary and mandibular incisors during voluntary Patient cannot bring mandibular incisors anterior to (in front of)
protrusion of mandible maxillary incisors

Interincisor distance Less than 3 cm

Visibility of uvula Not visible when tongue is protruded with patient in sitting position
(eg, Mallampati class >2)

Shape of palate Highly arched or very narrow

Compliance of mandibular space Stiff, indurated, occupied by mass, or non-resilient

Thyromental distance Less than three ordinary finger-breadths

Length of neck Short

Thickness of neck Thick

Range of motion of head and neck Patient cannot touch tip of chin to chest or cannot extend neck

This table displays some findings of the airway physical examination that may suggest the presence of a difficult intubation. The
decision to examine some or all of the airway components shown on this table is dependent on the clinical context and judgment of
the practitioner. The table is not intended as a mandatory or exhaustive list of the components of an airway examination. The order of
presentation in this table follows the "line of sight" that occurs during conventional oral laryngoscopy.

From: Apfelbaum JL, Hagberg CA, Caplan RA, et al. 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. Anesthesiology 2013; 118:251. DOI:
10.1097/ALN.0b013e31827773b2. Copyright © 2013 American Society of Anesthesiologists. Reproduced with permission from Lippincott Williams
& Wilkins. Unauthorized reproduction of this material is prohibited.

Graphic 108981 Version 3.0

Predictors of difficult mask ventilation

Older age (adult)

Male gender

Obesity (BMI >26 kg/m 2)

Edentulous

Facial hair (especially beard)

Mallampati oropharyngeal grade 3 or 4

Mandibular protrusion (inability to protrude)

Thyromental distance (short)

Snoring (indication of OSA)

Abnormal neck anatomy

Risk of difficult mask ventilation increases with greater number of predictors.

BMI: body mass index; OSA: obstructive sleep apnea.

Information from:
1. Langeron O, Masso E, Huraux C, et al. Prediction of difficult mask ventilation. Anesthesiology 2000; 92:1229.
2. Kheterpal S, Healy D, Aziz MF, et al. Incidence, predictors, and outcome of difficult mask ventilation combined with difficult laryngoscopy: a
report from the multicenter perioperative outcomes group. Anesthesiology 2013; 119:1360.

Graphic 94434 Version 4.0

Predictors of difficult supraglottic airway ventilation

Male gender

Obesity (BMI >30 kg/m 2)

Poor dentition or large incisors

Neck radiation history

Reduced mouth opening

Reduced cervical spine motion

Tonsillar hypertrophy

Glottic, hypopharyngeal, and subglottic pathology

Factors that predict difficulty with ventilation using a supraglottic airway such as the LMA.

BMI: body mass index; LMA: laryngeal mask airway.

Data from:
1. Ramachandran SK, Mathis MR, Tremper KK, et al. Predictors and clinical outcomes from failed Laryngeal Mask Airway Unique™: a study of
15,795 patients. Anesthesiology 2012; 116:1217.
2. Law JA, Broemling N, Cooper RM, et al. The difficult airway with recommendations for management--part 2--the anticipated difficult
airway. Can J Anaesth 2013; 60:1119.

Graphic 94436 Version 6.0

Predictors of difficult endotracheal intubation (by direct laryngoscopy)

Prior difficult intubation

Interincisor (intergingival edentulous patients) gap (<4 cm)

Thyromental distance (<6 cm)

Sternomental distance (<12 cm)*

Head and neck extension (<30 degrees from neutral)

Mallampati oropharyngeal classification (class 3 or 4)

Mandibular protrusion (inability to prognath)*

Neck circumference (>40 cm)*

Sub-mental compliance (hard and noncompliant)*

Physical findings predictive of difficult endotracheal intubation. The greater the number of positive findings, the more likely intubation
by direct laryngoscopy will be difficult. The highest positive predictive value comes from a history of difficulty with intubation, or
findings of a short thyromental distance or decreased range of motion of the neck.

* Also predicts difficult video laryngoscopy (in addition to large tonsils and epiglottis and history of Cormack and Lehane grade 3 or 4 at direct
laryngoscopy).

Information from:
1. Tremblay MH, Williams S, Robitaille A, Drolet P. Poor visualization during direct laryngoscopy and high upper lip bite test score are
predictors of difficult intubation with the GlideScope videolaryngoscope Anesth Analg 2008; 106:1495.
2. Aziz MF, Healy D, Kheterpal S, et al. Routine clinical practice effectiveness of the Glidescope in difficult airway management: an analysis of
2,004 Glidescope intubations, complications, and failures from two institutions. Anesthesiology 2011; 114:34.
3. Hung OR, Pytka S, Morris I, et al. Clinical trial of a new lightwand device (Trachlight) to intubate the trachea. Anesthesiology 1995;
83:509.
4. Hung OR, Pytka S, Morris I, et al. Lightwand intubation: II--Clinical trial of a new lightwand for tracheal intubation in patients with difficult
airways. Can J Anaesth 1995; 42:826.

Graphic 94433 Version 5.0

American Society of Anesthesiologists difficult airway algorithm

SGA: supraglottic airway; LMA: laryngeal mask airway; ILMA: intubating laryngeal mask airway.
* Confirm ventilation, tracheal intubation, or SGA placement with exhaled CO 2 .
¶ Invasive airway access includes surgical or percutaneous airway, jet ventilation, and retrograde intubation.
Δ Other options include (but are not limited to): surgery utilizing face mask or supraglottic airway (SGA) anesthesia (eg, LMA, ILMA, laryngeal tube),
local anesthesia infiltration, or regional nerve blockade. Pursuit of these options usually implies that mask ventilation will not be problematic.
Therefore, these options may be of limited value if this step in the algorithm has been reached via the Emergency Pathway.
◊ Alternative difficult intubation approaches include (but are not limited to): video-assisted laryngoscopy, alternative laryngoscope blades, SGA (eg,
LMA or ILMA) as an intubation conduit (with or without fiberoptic guidance), fiberoptic intubation, intubating stylet or tube changer, light wand, and
blind oral or nasal intubation.
§ Emergency noninvasive airway ventilation consists of a SGA.
¥ Consider re-preparation of the patient for awake intubation or canceling surgery.

Reproduced with permission from: Apfelbaum JL, Hagberg CA, Caplan RA, et al. 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. Anesthesiology 2013; 118:251. DOI:
10.1097/ALN.0b013e31827773b2. Copyright © 2013 by the American Society of Anesthesiologists, Inc. Unauthorized reproduction of this material is
prohibited.

Graphic 94447 Version 8.0

Airway Approach Algorithm for anesthesia

A decision tree approach to entry in the American Society of Anesthesiologists Difficult Airway
Algorithm.

TTJV: transtracheal jet ventilation.

Modified with permission from: Rosenblatt WH, Sukhupragarn W. Airway Management. In: Clinical
Anesthesia, 7th ed, Barash PG, Cullen BF, Stoelting RK, et al. (Eds), Lippincott Williams & Wilkins,
Philadelphia 2013. Copyright © 2013 Lippincott Williams & Wilkins. www.lww.com.

Graphic 94754 Version 9.0

Conditions that increase risk of aspiration during induction of anesthesia

Full stomach – nonfasted, emergency surgery or trauma

Pregnancy after 12 to 20 weeks gestation (gestational age for increased risk is controversial)

Symptomatic gastroesophageal reflux

Diabetic or other gastroparesis

Hiatal hernia

Gastric outlet obstruction

Esophageal pathology

Bowel obstruction

Increased intra-abdominal pressure – ascites, abdominal mass

Graphic 98506 Version 8.0

Time to oxygen desaturation

Preoxygenation prolongs the period between paralysis with succinlycholine

and oxygen desaturation in all patients, but to varying degrees depending on
patient attributes. This diagram shows the time to desaturation for several
different clinical conditions.

Reproduced with permission from: Benumof JL, Dagg R, Benumof R. Critical

hemoglobin desaturation will occur before return to an unparalyzed state following 1
mg/kg intravenous succinylcholine. Anesthesiology 1997; 87:979. Copyright ©
1997 Lippincott Williams & Wilkins.

Graphic 56716 Version 12.0

Suggested contents of difficult airway cart in the operating room

Rigid laryngoscope blades of alternate design and size from those routinely used; this may include a rigid fiberoptic laryngoscope.

Videolaryngoscope.

Tracheal tubes of assorted sizes.

Tracheal tube guides. Examples include (but are not limited to) semirigid stylets, ventilating tube-changer, light wands, and forceps
designed to manipulate the distal portion of the tracheal tube.

Supraglottic airways (eg, LMAs or ILMAs of assorted sizes for noninvasive airway ventilation/intubation).

Flexible fiberoptic intubation equipment.

Equipment suitable for emergency invasive airway access.

An exhaled carbon dioxide detector.

The items listed in this table represent suggestions. The contents of the portable storage unit should be customized to meet the
specific needs, preferences, and skills of the practitioner and healthcare facility.

LMA: laryngeal mask airway; ILMA: intubating LMA.

From: Apfelbaum JL, Hagberg CA, Caplan RA, et al. 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. Anesthesiology. 2013; 118:251. DOI:
10.1097/ALN.0b013e31827773b2. Copyright © 2013 American Society of Anesthesiologists. Reproduced with permission from Wolters Kluwer
Health. Unauthorized reproduction of this material is prohibited.

Graphic 89959 Version 7.0

Ramp position illustration

In the ramp position, the patient's head and torso are elevated such that the external
auditory meatus and the sternal notch are horizontally aligned (black line). This
position allows for a better view of the glottis in obese patients and should be used
unless there are contraindications (eg, possible cervical spine injury).

Graphic 95285 Version 4.0

Head-tilt/chin-lift maneuver

To relieve upper airway obstruction, the clinician uses two hands to extend the patient's
neck. While one hand applies downward pressure to the patient's forehead, the tips of the
index and middle finger of the second hand lift the mandible at the chin, which lifts the
tongue from the posterior pharynx. The head-tilt/chin-lift maneuver may be used in any
patient in whom cervical spine injury is NOT a concern.

Graphic 70710 Version 6.0

Jaw-thrust maneuver

The jaw-thrust maneuver is used to relieve upper airway obstruction by

moving the tongue anteriorly with the mandible, minimizing the tongue's
ability to obstruct the airway. With the patient supine and the clinician
standing at the head of the bed, the technique is performed by placing the
heels of both hands on the parieto-occipital areas on each side of the
patient's head, then grasping the angles of the mandible with the index and
long fingers, and displacing the jaw anteriorly. The jaw-thrust maneuver may
be used in the patient in whom cervical spine injury is a concern.

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Two-handed bag mask ventilation techniques

There are two ways to perform the two-handed technique. In the traditional method (picture
A), both thumbs and index fingers hold pressure along the inferior and superior ridges of the
mask. The other three fingers on each hand hold the mandible, in a fashion similar to the
one-handed mask hold, and perform a simultaneous chin-lift and jaw-thrust maneuver. This
position may not be comfortable to maintain for long periods of time. We recommend
another method that uses the stronger thenar eminences to hold the mask in place (picture
B). The thenar eminences are positioned parallel to each other along the long axis of each
side of the mask, allowing the four remaining fingers to provide chin-lift and jaw-thrust
maneuvers.

Graphic 82048 Version 4.0

Risk factors for airway complications with extubation

Preexisting airway difficulties

Difficult mask ventilation at induction

Difficult tracheal intubation at induction

History of difficult airway management

Obesity and/or obstructive sleep apnea

Increased risk for aspiration of gastric contents

Perioperative airway deterioration

Surgical factors (anatomical distortion, hemorrhage, hematoma, edema)

Nonsurgical factors (dependent edema due to positioning, airway trauma from prior airway management, aggressive fluid
management)

Restricted airway access

Halo fixation

Mandibulomaxillary fixation

Surgical implants

Cervical collar

Large head/neck dressings

Source: Popat M, Mitchell V, Dravid R, et al. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia 2012;
67:318.

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Difficult airway management algorithm in trauma

BMV: bag-valve mask; CP: cricoid pressure; DA: difficult airway; DL: direct laryngoscopy; FIS: flexible intubation
scope; FSI: flexible scope intubation; GA: general anesthesia; LMA: laryngeal mask airway; MILS: manual in-line
stabilization; RSI: rapid sequence intubation; SGA: supraglottic airway; VAL: video-assisted laryngoscopy; ASA:
American Society of Anesthesiologists.
* Confirm ventilation, tracheal intubation or SGA placement with standard confirmatory techniques (exhaled CO 2 ,
misting of tube, auscultation of breath sounds, improving SpO 2 ). If perfusion (and exhaled CO 2 ) absent, use additional
confirmation methods (eg, repeat laryngoscopy, bronchoscopy, esophageal detector device, chest radiograph).
¶ Other options in ASA algorithm: ​
Ventilation with a face mask or SGA might be difficult or impossible in a patient with maxillofacial trauma.
Local anesthesia infiltration or regional nerve blockade are of limited value in extensive trauma surgery.
Δ Invasive airway access includes surgical or percutaneous cricothyrotomy or tracheostomy, transtracheal jet
ventilation and retrograde intubation.
◊ Emergency non-invasive airway ventilation consists of SGA.
§ Aborting the case and awakening the patient to optimize and re-attempt intubation via a different airway technique
(eg, awake intubation) is impractical in most trauma cases due to the emergent condition of the patient.
¥ Alternative difficult intubation approaches include (but are not limited to): VAL, SGA (eg, LMA as an intubation
conduit with or without flexible scope guidance), flexible scope intubation, intubating stylet or tube changer, and light
wand. Blind intubation (oral or nasal) is discouraged in patients with maxillofacial trauma and laryngeal or tracheal
injury.
‡ Surgical airway kit should be immediately available.

Algorithm adapted with permission from: Hagberg CA, Kaslow O. Difficult airway management algorithm in trauma:
Updated by COTEP. ASA Monitor 2014; 78:56. Copyright © 2014 American Society of Anesthesiologists. Excerpted
from ASA Monitor (2014) of the American Society of Anesthesiologists. A copy of the full text can be obtained from
ASA, 1061 American Lane, Schaumburg, IL, 60173-4973 or online at www.asahq.org.

Graphic 112959 Version 2.0

Airway management for patients with airway disruption

Perform awake intubation if major laryngeal or tracheal/bronchial tear, provided the patient is awake, cooperative, hemodynamically
stable, and able to maintain adequate O 2 saturation.

If patient is uncooperative and DA is not otherwise suspected, consider rapid sequence intubation (RSI) using VAL and FIS.

Consider intubation and airway evaluation with VAL if a supralaryngeal defect is present. VAL has the added benefit of allowing
multiple viewers, aiding in examination and surgical planning.

For infralaryngeal and tracheal injury, consider RSI followed by DL and insertion of an FIS (with appropriately sized endotracheal tube
[ETT] already loaded over it) through the larynx to rapidly evaluate for possible airway injury. The ETT is then introduced over the FIS
and the cuff positioned below the level of injury. [1,2]

Avoid positive pressure ventilation and transtracheal jet ventilation proximal to tear.

If bronchial disruption is suspected, consider lung separation via placement of a double lumen tube or bronchial blocker.

Consider cardiopulmonary bypass.

O 2 : oxygen; DA: difficult airway; VAL: video-assisted laryngoscopy; FIS: flexible intubation scope; DL: direct laryngoscopy.

References: ​
1. Diez C, Varon AJ. Airway management. In: Essentials of Trauma Anesthesia, Varon AJ, Smith CE (Eds), Cambridge University Press 2012.
2. Desjardins G, Varon AJ. Airway management for penetrating neck injuries. The Miami experience. Resuscitation 2001; 48:71.
Reproduced with permission from: Hagberg CA, Kaslow O. Difficult airway management algorithm in trauma: Updated by COTEP. ASA Monitor
2014; 78:56. Copyright © 2014 American Society of Anesthesiologists. Excerpted from ASA Monitor (2014) of the American Society of
Anesthesiologists. A copy of the full text can be obtained from ASA, 1061 American Lane, Schaumburg, IL, 60173-4973 or online at
www.asahq.org.

Graphic 113247 Version 3.0

Airway management for patients with oral and maxillofacial trauma

Radiologic results are crucial to discern anatomic distortion and airway integrity.

Limited mouth opening and accumulated blood, secretions, and foreign bodies can all obscure visualization and compromise DL, VAL, and
FSI.

Perform awake intubation if patient is cooperative, stable, and able to clear airway; this will maintain both spontaneous ventilation and
O 2 saturation.

If awake, intubation fails, airway compromise occurs or the patient is agitated, an awake tracheostomy may be the best approach.

BVM ventilation may be difficult and result in displacement of facial fractures or even airway compromise.

Blind intubation (oral and nasal) is discouraged: It may dislodge foreign bodies (teeth, bony fragments, blood clot) into the airway or
create a false passage. Blind nasal attempts in the setting of midface fracture may lead to violation of the cranial vault.

Nasal intubation is not contraindicated in a patient with lateral or posterior skull base fractures; FSI could be safely performed even if the
fracture occurred in the central anterior skull base. Risk versus benefit discussion for choosing nasal route for intubation should be
documented in a patient's record.

If initial oral intubation interferes with the surgical approach, it can be converted later to submental or nasal intubation.

DL: direct laryngoscopy; VAL: video-assisted laryngoscopy; FSI: flexible scope intubation; O 2 : oxygen; BVM: bag-valve mask.

Reproduced with permission from: Hagberg CA, Kaslow O. Difficult airway management algorithm in trauma: Updated by COTEP. ASA Monitor
2014; 78:56. Copyright © 2014 American Society of Anesthesiologists. Excerpted from ASA Monitor (2014) of the American Society of
Anesthesiologists. A copy of the full text can be obtained from ASA, 1061 American Lane, Schaumburg, IL, 60173-4973 or online at
www.asahq.org.

Graphic 113248 Version 3.0

Airway management for patients with airway compression

Awake intubation is recommended if the patient is cooperative, stable, and can maintain spontaneous ventilation, airway patency, and
adequate O 2 saturation.

Personnel able to perform a surgical airway should be prepared to immediately intervene should life-threatening airway obstruction occur.

Consider opening the wound if an expanding postoperative neck hematoma is suspected.

Maintain spontaneous ventilation with induction of GA.

Position tracheal tube below level of obstruction. Fiberoptic confirmation may be required.

SGA is not recommended.

VAL and FSI are good choices as long as they allow visualizing airway.

O 2 : oxygen; GA: general anesthesia; SGA: supraglottic airway devices; VAL: video-assisted laryngoscopy; FSI: flexible scope intubation.

Reproduced with permission from: Hagberg CA, Kaslow O. Difficult airway management algorithm in trauma: Updated by COTEP. ASA Monitor
2014; 78:56. Copyright © 2014 American Society of Anesthesiologists. Excerpted from ASA Monitor (2014) of the American Society of
Anesthesiologists. A copy of the full text can be obtained from ASA, 1061 American Lane, Schaumburg, IL, 60173-4973 or online at
www.asahq.org.

Graphic 113250 Version 5.0

Airway management for patients with closed head injury

Key points:

In a patient with a DA, perform awake intubation if the patient is awake (GCS ≥9), cooperative, hemodynamically stable, and able to
maintain adequate O 2 saturation.*

Keep cerebral perfusion pressure at 60 to 70 mmHg. [1]

Avoid hypoxia and hypercarbia.

DA: difficult airway; GCS: Glasgow coma scale; O 2 : oxygen.

*Patients with a brain injury may NOT be cooperative and this will make awake intubation challenging.

Reference:
1. Carney N, Totten AM, O'Reilly C, et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery
2017; 80:6.
Based on Hagberg CA, Kaslow O. Difficult airway management algorithm in trauma: Updated by COTEP. ASA Monitor 2014; 78:56. Copyright ©
2014 American Society of Anesthesiologists. A copy of the full text can be obtained from ASA, 1061 American Lane, Schaumburg, IL, 60173-4973
or online at www.asahq.org.

Graphic 113753 Version 3.0