Algoritmo VAD

Chapter 10
The ASA Difficult Airway Algorithm:

Analysis and Presentation of a
New Algorithm*
ANSGAR M. BRAMBRINK CARIN A. HAGBERG
I. Introduction C. Definition of Optimal-Best Attempt at

Conventional Mask Ventilation
II. The ASA Difficult Airway Algorithm
D. Options for the CICV Scenario
A. Patient Evaluation and Risk Assessment
E. Determinants of the Use of Muscle
B. Difficult Bag-Mask Ventilation
Relaxants for Difficult Airway
C. Awake Tracheal Intubation
Management
D. Difficult Intubation in the Unconscious or
F. Summary
Anesthetized Patient
E. The “Cannot Intubate, Cannot V. Introduction of a New Comprehensive
Ventilate” Scenario Airway Algorithm
F. Extubation of a Patient with a Difficult A. The Main Algorithm
Airway 1. The Nonpredicted Difficult Airway
G. Follow-up Care of a Patient with a 2. New Algorithm Pathways
Difficult Airway B. Shortcomings of the New Airway
Algorithm
III. Summary of the ASA Algorithm
C. Bloody Airways
IV. Problems with the ASA Algorithm and Likely D. Summary
Future Directions
VI. Conclusions
A. Terminology in the ASA Difficult Airway
Algorithm VII. Clinical Pearls
B. Definition of Optimal-Best Attempt at
Conventional Laryngoscopy
I. INTRODUCTION
outcomes associated with the DA include (but are not
There is strong evidence that successful airway manage- limited to) death, brain injury, cardiopulmonary arrest,
ment in the perioperative environment depends on spe- unnecessary tracheostomy, airway trauma, and damage
cific strategies. Suggested strategies from various subfields to teeth.
of medicine are now being linked together to form more The original ASA DAA was developed over a 2-year
comprehensive treatment plans or algorithms. The classic period by the ASA Task Force on Guidelines for Manage-
flow charts of this nature are the resuscitation algorithms ment of the Difficult Airway.1 The task force included
that provide evidence-based guidance during cardiopul- academicians, private practitioners, airway experts, adult
monary resuscitation worldwide. and pediatric anesthesia generalists, and a statistical
The purpose of the Algorithm on the Management of methodologist. The algorithm was introduced by ASA as
the Difficult Airway (DAA), published by the American a practice guideline in 1993. In 2003, the ASA task force
Society of Anesthesiologists (ASA), is to facilitate man- presented a revised algorithm that essentially retained the
agement of the difficult airway (DA) and to reduce the same concept but recommended a wider range of airway
likelihood of adverse outcomes. The principal adverse management techniques than was previously included,
based on more recent scientific evidence and the advent
of new technology.
*Parts of this chapter are adapted and modified from a previous publica- This chapter presents and explains the ASA DAA and
tion on a similar topic: Hagberg C, Lam N, Brambrink AM: Current
concepts in airway management in the operating room: A new approach
then provides a critical appraisal of the ASA algorithm
to the management of both complicated and uncomplicated airways. based on recent evidence from the literature. This is
Curr Rev Clin Anesth 28:73–88, 2007. followed by the presentation of a new, comprehensive
222
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CHAPTER 10 The ASA Difficult Airway Algorithm 223
airway management algorithm that provides an innova- Chapter 9). Recognizing the potential for difficulty leads
tive and highly structured approach resembling the to proper mental and physical preparation and an
guidelines for cardiopulmonary resuscitation. increased chance of a good outcome. In contrast, failure
Both algorithms are concerned with the maintenance to recognize this potential results in unexpected difficulty
of airway patency at all times. Special emphasis is placed in the absence of proper mental and, likely, physical
on an operating room setting, although the algorithm can preparation, with an increased chance for a catastrophic
be extrapolated to the intensive care unit, the ward, and outcome.
the entire perioperative environment and beyond. Both Airway evaluation should take into account any char-
algorithms are primarily intended for use by anesthesiolo- acteristics of the patient that could lead to difficulty in
gists or by individuals who deliver anesthetic care and the performance of (1) bag-mask or supraglottic airway
airway management under the direct supervision of an ventilation, (2) laryngoscopy, (3) intubation, or (4) a
anesthesiologist. The guidelines apply to airway manage- surgical airway. Routine patient evaluation can be best
ment during all types of anesthetic care and anesthetizing structured as follows (see Chapter 9 for details):
locations, and to patients of all ages.
Both airway algorithms focus primarily on further 1. Obtain an airway history to identify medical, surgical,
improving patient safety during the perioperative period. and anesthetic factors that may indicate the presence
Adherence to the principles of an airway management of a DA.
algorithm and widespread adoption of such a structured 2. Evaluate for systemic diseases (e.g., respiratory failure,
plan should result in a reduction of respiratory catastro- coronary artery disease) that might place limits on
phes and a decrease in perioperative morbidity and awake intubation, such as increased fraction of inspired
mortality. oxygen (FIO2), or require special attention, such as pre-
vention of sympathetic nervous system stimulation.
II. THE ASA DIFFICULT 3. Examine previous anesthetic records, which can yield
AIRWAY ALGORITHM useful information about previous airway management.
4. Conduct a physical examination of the airway to
A side-by-side comparison of the original (1993) and the detect physical characteristics that might indicate the
updated (2003) versions of the ASA DAA is presented presence of a DA (Table 10-1):
in Figure 10-1. The differences between the two algo- • Maximal mouth opening with tongue extension and
rithms are listed in Box 10-1. Certain aspects of the pharyngeal anatomy (e.g., uvula, tonsillar pillars)
algorithm require further explanation. • Length of the submental space (mandible to hyoid)
and the thyromental distance (mandible to thyroid
A. Patient Evaluation and Risk Assessment notch)
The ASA DAA begins with the most basic question of

whether or not the presence of a DA is recognized (see T A B L E 1 0 - 1
Components of the Preoperative Airway
Box 10-1 Differences between 1993 and 2003 Physical Examination
ASA Management of the Difficult
Airway Examination
Airway Algorithms
Component Nonreassuring Findings
1. Difficult ventilation is now listed first under item 1, “Assess Length of upper incisors Relatively long
the Likelihood and Clinical Impact of Basic Relation of maxillary and Prominent “overbite”
Management Problems.” Also, in the same category, mandibular incisors (maxillary incisors anterior
Difficult tracheostomy was added. during normal jaw to mandibular incisors)
2. A new item 2 was inserted: “Actively pursue closure
opportunities to deliver supplemental oxygen Relation of maxillary and Patient’s mandibular incisors
throughout the process of difficult airway mandibular incisors anterior to (in front of)
management.” during voluntary mandibular incisors
3. When considering the relative merits and feasibility of protrusion of the jaw
basic management choices (item 3), awake intubation Interincisor distance <3 cm
versus intubation attempts after induction of anesthesia Visibility of uvula Not visible when tongue is
should now be considered first, before noninvasive protruded with patient in
versus invasive techniques as the initial approach to sitting position (e.g.,
intubation. Mallampati class III or IV)
4. Use of the laryngeal mask airway (LMA) was Shape of palate Highly arched or very
incorporated into the algorithm in the awake induction narrow
limb and in both the nonemergency and emergency Compliance of Stiff, indurated, occupied
pathways for induction after general anesthesia (either mandibular space by mass, or nonresilient
as a ventilatory device or as a conduit for tracheal Thyromental distance <3 ordinary finger breadths
intubation). Length of neck Short
5. The option for “One more intubation attempt” was Thickness of neck Thick
removed. Range of motion of head Patient cannot touch tip of
6. Use of the rigid bronchoscope was added as an option and neck chin to chest or cannot
for emergency noninvasive ventilation. extend neck
224 PART 2 The Difficult Airway: Definition, Recognition, and the ASA Algorithm
ASA DIFFICULT AIRWAY ALGORITHM (1993)
1. Assess the likelihood and clinical impact of basic management problems:

A. Difficult intubation
B. Difficult ventilation
C. Difficulty with patient cooperation or consent
2. Consider the relative merits and feasibility of basic management choices:
Non-surgical technique for initial Surgical technique for initial

A. vs.
approach to intubation approach to intubation
Intubation attempts after

B. Awake intubation vs. induction of general anesthesia
Preservation of Ablation of
C. vs.
spontaneous ventilation spontaneous ventilation
Awake intubation Intubation attempts after

induction of general anesthesia
Airway approached by Airway secured by

non-surgical intubation surgical access* Initial intubation Initial intubation
attempts successful* attempts unsuccessful
Succeed* Fail
From this point onwards,
repeatedly consider
the advisability of:
Cancel Consider feasibility Surgical
case of other options(a) airway* 1. Returning to spontaneous ventilation.
A 2. Awakening the patient.
3. Calling for help.
Non-emergency pathway Emergency pathway
Patient anesthetized, intubation unsuccessful, Patient anesthetized, intubation unsuccessful,

mask ventilation adequate mask ventilation inadequate
Alternative approaches Call for help

to intubation(b) If mask
ventilation
becomes
inadequate
Succeed* Fail after One more Emergency non-surgical
multiple intubation airway ventilation(d)
attempts attempt
Surgical Surgery Awaken Succeed* Fail Fail Succeed

airway* under mask patient(c)
anesthesia
Emergency Definitive
surgical airway(e)
airway*
B
Confirm intubation with exhaled CO2. (c) See awake intubation.
(a) Other options include (but are not limited to): surgery under mask anesthesia, (d) Options for emergency non-surgical airway ventilation include (but are not
surgery under local anesthesia infiltration or regional nerve blockade, or limited to): transtracheal jet ventilation, laryngeal mask ventilation, or
intubation attempts after induction of general anesthesia. esophageal-tracheal combitube ventilation.
(b) Alternative approaches to difficult intubation include (but are not limited to): use (e) Options for establishing a definitive airway include (but are not limited to):
of different laryngoscope blades, awake intubation, blind oral or nasal intubation, returning to awake state with spontaneous ventilation, tracheotomy, or
fiberoptic intubation, intubating stylet or tube changer, light wand, retrograde endotracheal intubation.
intubation, and surgical airway access.
A
Figure 10-1 A, The American Society of Anesthesiologists’ difficult airway algorithm (ASA DAA), published in 1993.
ASA DIFFICULT AIRWAY ALGORITHM (2003)
1. Assess the likelihood and clinical impact of basic management problems:
A. Difficult ventilation
B. Difficult intubation
C. Difficulty with patient cooperation or consent
D. Difficult tracheostomy
2. Actively pursue opportunities to deliver supplemental oxygen throughout the process of difficult airway management
3. Consider the relative merits and feasibility of basic management choices:
Intubation attempts after

A. Awake intubation vs.
Non-invasive technique for initial Invasive technique for initial

B. vs.
approach to intubation approach to intubation
Preservation of Ablation of
C. vs.
spontaneous ventilation spontaneous ventilation
4. Develop primary and alternative strategies:
Awake intubation Intubation attempts after

Airway approached by Invasive airway

non-invasive intubation access(b)*
Initial intubation Initial intubation
attempts successful* attempts unsuccessful
Succeed* Fail
From this point onwards consider:

Cancel Consider feasibility Invasive airway
1. Calling for help.
case of other options(a) access(b)*
A 2. Returning to spontaneous ventilation.
3. Awakening the patient.
Face mask ventilation adequate Face mask ventilation not adequate
Consider/attempt LMA
Non-emergency pathway
LMA adequate* Emergency pathway LMA not adequate
Ventilation adequate, or not feasible
intubation unsuccessful Ventilation not adequate,
If both intubation unsuccessful
face mask
Alternative approaches and LMA
ventilation Call for help
to intubation(c)
become
inadequate
Emergency non-surgical airway ventilation(e)
Successful Fail after multiple attempts Successful ventilation* Fail

intubation* Emergency
invasive airway
Invasive airway access(b)* Consider feasibility of other options(a) Awaken patient(d) access(b)*
B
Confirm ventilation, tracheal intubation, or LMA placement with exhaled CO2. (c) Alternative noninvasive approaches to difficult intubation include (but are not limited to): use of
(a) Other options include (but are not limited to): surgery utilizing face mask or LMA different laryngoscope blades, LMA as an intubation conduit (with or without fiberoptic
anesthesia, local anesthesia infiltration or regional nerve blockade. Pursuit of these options guidance), fiberoptic intubation, intubating stylet or tube changer, light wand, retrograde
usually implies that mask ventilation will not be problematic. Therefore, these options may be intubation, and blind oral or nasal intubation.
of limited value if this step in the algorithm has been reached via the Emergency Pathway. (d) Consider re-preparation of the patient for awake intubation or canceling surgery.
(b) Invasive airway access includes surgical or precutaneous tracheostomy or cricothyrotomy. (e) Options for emergency noninvasive airway ventulation include (but are not limited to): rigid
bronchoscope, esophageal-tracheal combitube ventilation, or transtracheal jet ventilation.
B
Figure 10-1, cont’d B, The revised (2003) ASA DAA. (A from American Society of Anesthesiologists Task Force on Management of the Difficult
Airway: Practice guidelines for management of the difficult airway: A report. Anesthesiology 78:597–602, 1993; B from Practice Guidelines for the
Management of the Difficult Airway: An updated report by the American Society of Anesthesiologists Task Force on the Management of the
Difficult Airway. Anesthesiology 98:1269–1277, 2003.)
• Side view to determine the ability to assume the induction of anesthesia and paralysis, which makes con-
“sniffing” position (flexion of the neck on the chest ventional intubation more difficult.6
and extension of the head on the neck) and to iden- Crucial to the success of endotracheal intubation
tify maxillary overbite while the patient is awake is proper preparation (see
• Nostril patency Chapter 11 for further details). Most intubation tech-
• Length and thickness of the neck niques work well in patients who are cooperative and
whose larynx is nonreactive to physical stimuli. In general,
Although each risk factor individually has a rather low the components of proper preparation for an awake intu-
positive predictive value for difficult intubation, when bation are the following:
combined these factors can provide a gestalt for DA • Psychological preparation (awake intubation pro-
management. ceeds more easily when the patient knows and
The findings of the airway history and physical exami- agrees with what is going to happen)
nation may be useful in guiding the selection of specific • Appropriate monitoring (i.e., electrocardiography,
diagnostic tests and consultation to further characterize noninvasive blood pressure monitoring, pulse oxim-
the likelihood or nature of the anticipated airway etry, and capnography)
difficulty.2 • Oxygen supplementation (e.g., nasal prongs, nasal
An “awake look” using direct laryngoscopy (after ade- cannula, suction channel of a fiberoptic broncho-
quate preparation) may be performed to assess intuba- scope [FOB], transtracheal catheter)7-10
tion difficulty further. If an adequate view is obtained, • Vasoconstriction of the nasal mucous membranes (if
endotracheal intubation may be performed, followed performing nasal intubation)
immediately by administration of an intravenous induc- • Administration of a drying agent
tion agent. • Judicious sedation (keeping the patient in meaning-
Presence of a pathologic factor or a combination of ful contact with the environment)
anatomic factors (large tongue size, small mandibular • Adequate airway topicalization (consider perfor-
space, or restricted atlanto-occipital extension) indicates mance of bilateral laryngeal nerve blocks, blocking
that the airway should be secured while the patient the lingual branch of the glossopharyngeal nerve and
remains awake (awake techniques). the superior laryngeal nerve)
• Aspiration prevention (see Chapter 12)
B. Difficult Bag-Mask Ventilation • Availability of appropriate airway equipment
The risk for difficult mask ventilation (DMV) is the first Box 10-2 lists the suggested ASA guidelines for con-
issue addressed in the most recent version of the DAA. tents of a portable airway management cart.11
Evidence from the literature3 suggests that the incidence
of DMV is 5% in the general adult population, that
the presence of DMV is associated with difficult intu
Box 10-2 Suggested Contents of the Portable
bation, and that DMV is not accurately predicted by
Storage Unit for Difficult Airway
anesthesiologists.
Management
Five independent criteria predict DMV (age >55 years,
body mass index >26 kg/m2, lack of teeth, presence of Important: The items listed here represent suggestions. The
mustache or beard, and history of snoring), and the pres- contents of the portable DA management cart should be
ence of two such risk factors indicates a high likelihood customized to meet the specific needs, preferences, and
of DMV.3 It is important to keep these risk factors in skills of the practitioner and health care facility.
mind, because some of them can be reversed. For example, 1. Rigid laryngoscope blades of alternative design and
DMV may possibly be preventable by shaving a patient’s size from those routinely used; may include a rigid
beard, leaving dentures in place during bag-mask ventila- fiberoptic laryngoscope
tion (BMV), and performing a workup and treating for 2. Endotracheal tubes of assorted sizes
possible obstructive sleep apnea. 3. Endotracheal tube guides, such as semirigid stylets,
ventilating tube changer, light wands, and forceps
designed to manipulate the distal portion of the
C. Awake Tracheal Intubation endotracheal tube
4. Laryngeal mask airways (LMAs) of assorted sizes; may
Awake intubation is generally more time-consuming for include the Fastrach intubation LMA and the ProSeal
the anesthesiologist and a more unpleasant experience LMA (LMA North America, San Diego, CA).
for the patient. However, if a difficult intubation is antici- 5. Fiberoptic intubation equipment
pated, awake endotracheal intubation is indicated for 6. Retrograde intubation equipment
three reasons: (1) the natural airway is better maintained 7. At least one device suitable for emergency nonsurgical
in most patients when they are awake (i.e., “no bridges airway ventilation, such as the esophageal-tracheal
are burned”); (2) the orientation of upper airway struc- Combitube (Tyco Healthcare, Mansfield, MA), a hollow
jet ventilation stylet, and a transtracheal jet ventilator
tures is easier to identify in the awake patient (i.e., muscle
8. Equipment suitable for emergency surgical airway
tone is maintained to keep the base of the tongue, val- access (e.g., cricothyrotomy)
lecula, epiglottis, larynx, esophagus, and posterior pha- 9. An exhaled carbon dioxide detector
ryngeal wall separated from one another)4,5; and (3) 10. A rigid ventilating bronchoscope
the larynx moves to a more anterior position with the
Box 10-3 Techniques for Difficult Airway D. Difficult Intubation in the Unconscious or
Management Anesthetized Patient
Important: This box lists commonly cited techniques in Three typical scenarios require the anesthesiologist to
alphabetic order. It is not a comprehensive list, and no manage a DA in an unconscious patient with a DA:
preference for a given technique or sequence of use is
(1) a comatose patient (e.g., secondary to trauma or
implied. Combinations of techniques may be employed.
The techniques chosen by the practitioner depend on the
intoxication); (2) a patient who absolutely refuses or
specific needs, preferences, skills, and clinical constraints in cannot tolerate awake intubation (e.g., a child, a mentally
the particular case. retarded patient, an intoxicated and combative patient);
and perhaps most commonly, (3) failure to recognize
Techniques for Difficult Intubation
intubation difficulty on the preoperative evaluation. Of
Alternative laryngoscope blades course, the preoperative airway evaluation is important
Awake intubation
even in the first and second situations, because the find-
Blind intubation (oral or nasal)
Fiberoptic intubation
ings may dictate the choice of intubation technique. In
Intubating stylet or tube changer all three of these situations, the patient may also have a
Invasive airway access full stomach.
Laryngeal mask airway as an intubating conduit All of the intubation techniques that are described for
Light wand the awake patient1,15 can be used in the unconscious or
Retrograde intubation anesthetized patient without modification. However,
Techniques for Difficult Ventilation direct laryngoscopy and fiberoptic laryngoscopy are likely
Esophageal-tracheal Combitube
to be more difficult in the paralyzed, anesthetized patient
Intratracheal jet stylet compared with the awake patient, because the larynx
Invasive airway access may move to a more anterior position, relative to other
Laryngeal mask airway structures, as a result of relaxation of oral and pharyngeal
Oral and nasopharyngeal airways muscles.6 In addition and more importantly, orientation
Rigid ventilating bronchoscope may be impaired because the upper airway structures can
Transtracheal jet ventilation coalesce into a horizontal plane instead of separating out
Two-person mask ventilation in a vertical plane.4,5
In the anesthetized patient whose trachea has proved
There are numerous methods to intubate the trachea difficult to intubate even with a video laryngoscope it is
or ventilate a patient (see Part Four of this text). Box 10-3 necessary to try to maintain gas exchange between intuba-
shows a list of the techniques contained within the ASA tion attempts (by mask ventilation) and, whenever pos-
guidelines. The techniques chosen depend, in part, on the sible, during intubation attempts through the use of (1)
anticipated surgery, the condition of the patient, and the supplemental oxygen11; (2) positive-pressure ventilation
skills and preferences of the anesthesiologist. Based on via an anesthesia mask that incorporates a self-sealing
recent evidence from the literature12-14 considerations diaphragm for entry of the FOB airway intubator (instead
should also include the use of video laryngoscopy, despite of the standard oropharyngeal airway)5,16; or (3) a laryngeal
the fact that this technique is not mentioned in the recent mask airway (LMA; LMA North America, Inc., San Diego,
ASA algorithm, but likely will be included in future revi- CA) as a conduit for the FOB (see Chapters 19 and 22).17
sions of the guidelines. One must not continue with the same technique that
Occasionally, awake intubation may fail owing to a did not work before. The amount of laryngeal edema and
lack of patient cooperation, equipment or operator limi- bleeding is likely to increase after every intubation
tations, or any combination thereof. An alternative route attempt, particularly with the use of a laryngoscope or
is chosen according to the precise cause of the failure: retraction blade. The most common scenario in the respi-
ratory catastrophes in the ASA closed claims study was
• Surgery may be canceled (e.g., the patient needs the development of progressive difficulty in ventilating
further counseling, airway edema or trauma has re by mask between persistent and prolonged failed intuba-
sulted, different equipment or personnel is necessary). tion attempts. The final result was inability to ventilate
• General anesthesia may be induced (the fundamen- by mask and provide gas exchange (see Chapter 55).18
tal problem must be considered to be a lack of For each additional attempt, consider modifications,
cooperation, and mask ventilation must be consid- such as improved sniffing position, external laryngeal
ered nonproblematic). manipulation, a new blade or new technique, or involve-
• Regional anesthesia may be considered (careful ment of a much more experienced laryngoscopist.
clinical judgment is required to balance risks and However, the number of intubation attempts should be
benefits; see Chapter 45). limited and the following options should be considered:
• A surgical airway may be created (if the surgery is (1) awaken the patient and do the procedure another day;
essential and general anesthesia is considered to be (2) continue anesthesia by mask or LMA ventilation;
inappropriate until intubation is accomplished); this (3) perform a surgical airway (tracheostomy or cricothy-
may be the best choice to secure the airway in rotomy) before the ability to ventilate the lungs by mask
patients with laryngeal or tracheal fracture or dis- is lost (see Fig. 10-1).
ruption, upper airway abscess, or combined If awakening the patient is not an option, for instance
mandibular-maxillary fractures. because surgery is emergent (e.g., cesarean section), and
ventilation can be maintained via mask or LMA, surgery failed airway, preparations for a surgical airway must
may be conducted as needed. Nevertheless, in some cases, begin immediately, and once the decision is made, it is
the airway must be secured by a surgical airway (e.g., essential to use an effective technique (see Chapters 30
thoracotomy, intracranial-head-neck cases, cases in which and 31). Despite limited familiarity with the procedure,
the patient is in the prone position). If regurgitation or the risks of an invasive rescue technique must be weighed
vomiting occurs at any time during attempts at endotra- against the risks of hypoxic brain injury or death.28
cheal intubation in an anesthetized patient,
• Immediately apply Trendelenburg position. F. Extubation of a Patient with a
• Turn the head, and perhaps the body, to the left. Difficult Airway
• Suction the mouth and pharynx with a large-bore
Extubation of the patient with a DA should be carefully
suction device.
assessed and performed. The anesthesiologist should
• Try endotracheal intubation while the patient is in
develop a strategy for safe extubation of these patients,
the lateral position (the tongue may be more out of
depending on the type of surgery, the condition of the
the way, but this position is unfamiliar to most
patient, and the skills and preferences of the anesthesiolo-
anesthesiologists).
gist. Additional considerations include the following:
• If the endotracheal tube (ETT) has been passed into
the esophagus, it may be left there; this may allow • Awake extubation versus extubation before return
decompression of the stomach, and it identifies the of consciousness
esophagus during subsequent intubation attempts • Clinical symptoms with the potential to impair ven-
(the disadvantage is that it interferes with satisfac- tilation (e.g., altered mental status, abnormal gas
tory mask seal). exchange, airway edema, inability to clear secretions,
• After securing the airway, consider tracheal suction- inadequate return of neuromuscular functions)
ing, mechanical ventilation, positive end-expiratory • Airway management plan if the patient is not able
pressure, fiberoptically guided saline lavage, steroids, to maintain adequate ventilation
antibiotics (see Chapter 35). • Short-term use of a ventilating tube exchanger (TE)
or jet stylet (can be used for ventilation and guided
E. The “Cannot Intubate, Cannot reintubation)
Ventilate” Scenario
The ideal method of extubation of a patient with a
In rare cases, it is impossible either to ventilate the lungs DA is gradual, step by step, and reversible at any time.
of a patient by mask or to intubate the trachea. This Extubation over a ventilating TE or jet stylet closely
“cannot intubate, cannot ventilate” (CICV) scenario is an approximates this ideal.16 The equipment that should
immediately life-threatening situation, and an alternative be immediately available for the extubation of a DA
ventilation procedure must be performed. Established includes that necessary for intubation of the DA (see
rescue methods are the LMA, Combitube (Tyco Health- Chapter 50).29
care, Mansfield, MA), transtracheal jet ventilation (TTJV),
rigid bronchoscope, and, ultimately, cricothyrotomy. G. Follow-up Care of a Patient with a
The development of the LMA was a major advance in Difficult Airway
the management of difficult intubation and difficult ven-
tilation scenarios. The LMA is suggested as a ventilation The presence and nature of the airway difficulty should
device or a conduit for a flexible FOB,19,20 and the Fas- be documented in the medical record. The intent of this
trach intubating LMA (ILMA) may also be utilized.10,17,21 documentation is to guide and facilitate the delivery of
The LMA and the Combitube are supraglottic ventila- future care. Aspects of documentation that may prove
tory devices and are not helpful if the airway obstruction helpful include the following:
is located at or below the glottic opening.22 Use of the • Description of the airway difficulties, which should
rigid bronchoscope may be required to establish a patent distinguish between difficulties with mask ventila-
airway because it allows ventilation even past an obstruction and those with tracheal intubation
tion at these levels. If immediately available, TTJV is rela- • Description of the airway management techniques
tively easy to perform and can be life-saving.23 However, used, which should indicate the beneficial or detri-
it carries significant risks such as subcutaneous emphy- mental role of each technique in management of
sema (if the upper airway is not patent or the catheter is the DA
not entirely tracheal) and barotrauma (too forced ventila- • Information given the patient (or responsible person)
tion or proximal airway obstruction)24 The techniques concerning the airway difficulty that was encoun-
mentioned can provide time until definitive airway man- tered. The intent of this communication is to assist
agement by tracheal intubation (via direct, fiberoptic, or the patient (or responsible person) in guiding and
retrograde technique) or by formal tracheostomy can be facilitating the delivery of future care. The informa-
performed.25,26 Future research will determine the role of tion conveyed may include, for instance, the pres-
the new rigid video laryngoscopes in the rescue of the ence of a DA, the apparent reasons for the difficulty,
“cannot intubate, cannot ventilate” scenario. and implications for future care.
Ultimately, a cricothyrotomy may be necessary, but
fewer than 50% of anesthesiologists feel competent to The provider should also strongly consider dispensing
perform one.27 Nevertheless, when one is faced with a or advising a Medic-Alert bracelet for the patient (see
Chapter 54). Finally, the anesthesiologist should evaluate Box 10-4 ASA Difficult Airway Algorithm Take-
and observe the patient for potential complications of Home Messages
DA management, such as airway edema, bleeding, tra-
cheal or esophageal perforation, pneumothorax, and 1. If suspicious of trouble → Secure the airway awake
aspiration. 2. If you get into trouble → Awaken the patient
3. Have plans B and C immediately available and in place
= think ahead
4. Intubation choices → Do what you do best
III. SUMMARY OF THE ASA ALGORITHM
Difficulty in managing the airway is the single most • Although it is intended to apply to all patients of all
important cause of major anesthesia-related morbidity ages, there are certain populations of patients in
and mortality. which further considerations are necessary. Exam-
Successful management of a DA begins with recogni- ples include pediatric patients (see Chapter 36),
tion of the potential problem. All patients should be obstetric patients (see Chapter 37), nonfasted
examined for their ability to open their mouth widely, patients, and patients with obstruction at or below
the structures visible on mouth opening, the size of the the level of the vocal cords.31
mandibular space, and the ability to assume the sniffing • The algorithm’s clinical end point is successful intu-
position. bation, but endotracheal intubation may not be nec-
If there is a good possibility that intubation or ventila- essary, and successful ventilation may suffice.
tion by mask, or both, will be difficult, the airway should • The algorithm is fairly complex, allowing a wide
be secured while the patient is still awake rather than choice of techniques at each stage, and its multiplic-
after induction of general anesthesia. For a successful ity of pathways may limit its clinical usefulness in
awake intubation, it is essential that the patient and the guiding day-to-day practice.32 Unlike the algorithm
provider be properly prepared. used in advanced life support (ACLS) guidelines, for
When the patient is properly prepared, any one of a example, the ASA DAA is not binary in nature.33
number of intubation techniques is likely to be success- • Somewhat vague terminology is used in its defini-
ful. If the patient is already anesthetized or paralyzed and tions of difficult tracheal intubation and difficult
intubation is found to be difficult, many repeated forceful laryngoscopy. Definitions of optimal-best attempts
attempts at intubation should be avoided, because laryn- at conventional laryngoscopy, mask ventilation, and
geal edema and hemorrhage will progressively develop, difficult laryngoscopy or intubation are important
and the ability to ventilate the lungs by mask may con- because they provide an end point at which the
sequently be lost. practitioner should stop using a particular approach
After several unsuccessful attempts at intubation, it (limiting risk) and move on to something that has a
may be best to awaken the patient; administer regional better chance of working (gaining benefit).
anesthesia, if appropriate (see Chapter 45); proceed with • The algorithm mentions ablation of spontaneous
the case using mask or LMA ventilation; or perform a ventilation with muscle relaxants but does not
semielective tracheostomy. If the ability to ventilate by discuss the great clinical management implications
mask is lost and the patient’s lungs cannot be ventilated, of muscle relaxants that have different durations of
LMA ventilation should be instituted immediately. If action.
LMA ventilation does not provide adequate gas exchange, • Although the algorithm advises confirmation of
either TTJV or a surgical airway should be instituted endotracheal intubation, the usefulness of capnog-
immediately. raphy for this purpose is limited during cardiac
Tracheal extubation of a patient with a DA over a jet arrest, which is not an uncommon consequence of
stylet permits a controlled, gradual, withdrawal from the the CICV scenario; the esophageal detector device
airway that is reversible in that ventilation and reintuba- is not similarly limited (see Chapter 32).
tion are possible at any time. • The algorithm does not provide a definitive flow
Four concepts emerge from the preceding discussion— chart for extubation of the DA that incorporates the
four very important, take-home messages on the ASA use of a device that can serve as a guide for expe-
DAA. These are presented in Box 10-4. dited reintubation or ventilation, if necessary.
• The role of regional anesthesia in patients with a
DA requires further clarification (see Chapter 45).
IV. PROBLEMS WITH THE ASA • The algorithm does not include the use of rigid
ALGORITHM AND LIKELY video laryngoscopy which has dramatically changed
FUTURE DIRECTIONS the day-to-day clinical practice in recent years and
has been shown to be able to rescue failed direct
The strength of the ASA DAA is twofold. First, it is very laryngoscopy, particularly in the DA.12,13
thorough and complete with respect to the options avail-
able when an anesthesiologist encounters a DA. Second, Several of the issues mentioned need more in-depth
it emphasizes the need for and importance of an orga- discussion, including the definition of difficult endotra-
nized approach to airway management.30 cheal intubation, the optimal-best attempt at laryngos-
On the other hand, the algorithm has several deficien- copy, the optimal-best attempt at mask ventilation, and
cies that diminish its application in clinical practice. the best muscle relaxant to use.
A. Terminology in the ASA Difficult

Airway Algorithm
The original publications that introduced the ASA algo-
rithm and provided basic terms that define a DA were
relatively vague in their terminology1:
• Difficult mask ventilation: “It is not possible for the
anesthesiologist to provide adequate face mask ven-
tilation due to one or more of the following prob-
lems: inadequate mask seal, excessive gas leak or
excessive resistance to the ingress or egress of gas.”
• Difficult laryngoscopy: “Not being able to visualize
any portion of the vocal cords after multiple attempts
at conventional laryngoscopy.”
• Difficult intubation: “When tracheal intubation Figure 10-2 Troop Elevation Pillow with additional foam head rest.
requires multiple attempts in the presence or (Courtesy of Mercury Medical, Clearwater, FL.)
absence of tracheal pathology.”
• Failed intubation: “Placement of the tracheal tube
fails after multiple intubation attempts” (0.05% of
surgical patients and 0.13% to 0.35% in obstetric
An optimal-best attempt at conventional laryngoscopy is
patients).
defined as having the following characteristics34,35:
These definitions do not identify a specific Cormack-
Lehane grade to characterize larynx visibility, and they 1. Performed by a reasonably proficient anesthesiologist
do not state a specific number of attempts; therefore, on with at least 3 years of experience (Rationale: If such
both counts, they can be interpreted differently by indi- an experienced anesthesiologist is having difficulty in
vidual practitioners. Also, there is no mention of adju- visualizing the glottis, no other anesthesiologist or
vants such as positioning and use of appropriate surgeon needs to or should attempt the same
equipment to aid laryngoscopy, ventilation, and intuba- maneuver)
tion. Such information would allow the anesthesiologist 2. With the patient in the optimal “sniffing” position
to proceed in a new direction at certain junctures, (Rationale: No attempt is wasted because the position
knowing that continuing the same maneuvers would was suboptimal; slight flexion of the neck on the head
accomplish diminishing returns. and severe extension of the head on the neck aligns
In the same vein, it is important to define “attempt” in the oral, pharyngeal, and laryngeal axes into a straight
an airway management algorithm——for example, as line; positioning devices are necessary in the obese
physical placement and removal of the laryngoscope patient [Fig. 10-2])
blade. Moreover, an ideal airway management algorithm 3. Using the appropriate type and length of blade
should define and use the “optimal-best attempt” as the (Rationale: Macintosh-type blades work best in
unit, because optimizing the conditions for the various patients with little upper airway room, and Miller-
maneuvers has clearly been shown to have a profound type blades are ideal for patients who have small
effect on successful intubation. mandibular space, anterior larynx, large incisors, or a
long, floppy epiglottis). Based on most recent litera-
ture, a rigid video laryngoscope should be considered
B. Definition of Optimal-Best Attempt at least for the second attempt, if immediately
available.
at Conventional Laryngoscopy
4. Using the appropriate blade length (Rationale: Patients’
Difficulty in performing endotracheal intubation is the airways vary in size, and optimal fit of the blade to the
end result of the difficulties that occurred during laryn- airway allows the best possible pressure application
goscopy, which depends on the operator’s level of exper- to lift the epiglottis directly or indirectly)
tise, the patient’s characteristics, and circumstances. The 5. Having a low threshold for using optimal external laryn-
problem with multiple repeated attempts at conven- geal manipulation (OELM) or backward upward right-
tional laryngoscopy is the creation of laryngeal edema and ward pressure (BURP) (Fig. 10-3) (Rationale: Both
bleeding, which impair mask ventilation and subsequent maneuvers can frequently improve the laryngoscopic
endotracheal intubation attempts, thereby creating a view by at least one entire grade and should be an inher-
CICV situation. Therefore, it is imperative that the anes- ent part of laryngoscopy and an instinctive reflex response
thesiologist makes his or her optimal-best attempt at to a poor laryngoscopic view)
laryngoscopy as early as possible, under the best circum-
stances, which is usually the first or second attempt. If With this definition and no other confounding
the optimal-best attempt fails twice, an alternative plan factors, an optimal-best attempt at laryngoscopy may be
should be activated as the next step, so that no further achieved on the first attempt, and no more than three
risk is incurred from additional attempts without likely attempts should be required (e.g., wrong blade, wrong
benefit. length).
Two-person mask ventilation
2° Person does jaw thrust 2° Squeezes reservoir bag

3 Hand jaw thrust/mask seal 2° Hand jaw thrust/mask seal
1° 1°
1
3
2
H
C
2° 2°
Figure 10-4 Optimal mask ventilation. Left, Two-person effort when

second person knows how to perform jaw thrust; right, two-person
effort when second person can only squeeze the reservoir bag.
Figure 10-3 Determining optimal external manipulation (OELM)

with the free (right) hand. OELM should be an inherent part of laryn-
D. Options for the CICV Scenario
goscopy and is performed when the laryngoscopic view is poor. Both the LMA and the Combitube have been shown to
Ninety percent of the time, the best view is obtained by pressing
over the thyroid cartilage (T, hand position 1) or the cricoid cartilage
work well to rescue airway emergencies.17,36,37 The ASA
(C, position 2); pressing over the hyoid bone (H, position 3) may also DAA does not dictate the order of preference of these
be effective. devices in the CICV situation, but the following consid-
erations must be taken into account: (1) the anesthesiolo-
gist’s own experience and level of comfort in the use of
C. Definition of Optimal-Best Attempt these methods, (2) the availability of these devices,
at Conventional Mask Ventilation (3) the type of airway obstruction (upper versus lower),
and (4) the benefits and risks involved.
If the patient cannot be intubated, gas exchange is depen- The ProSeal LMA usually forms a better seal than the
dent on mask ventilation. If the patient cannot be venti- LMA-Classic and provides improved protection against
lated by mask, a CICV situation exists, and immediate aspiration.38-48 When properly positioned, the Combitube
resuscitation maneuvers must be instituted. Because each allows ventilation with a higher seal pressure than the
of the acceptable responses to a CICV situation has its LMA-Classic, protects against regurgitation,49 and allows
own risks, the decision to abandon mask ventilation further attempts at intubation while the esophageal cuff
should be made after the anesthesiologist has made an protects the airway.50 The Combitube has been succ
optimal-best attempt at mask ventilation. essfully used in difficult intubation and CICV situa-
An optimal-best attempt at conventional mask ventilation tions,49,51-55 including ventilation failure with an LMA.56
is defined as having the following characteristics34,35: Both the LMA and the Combitube are supraglottic
ventilatory devices (Fig. 10-5). They cannot solve a truly
1. Performed by a reasonably proficient anesthesiologist glottic problem (e.g., spasm, massive edema, tumor,
with at least 3 years of experience (Rationale: as above) abscess) or a subglottic problem.37 If an obstacle is sus-
2. With the patient in the optimal sniffing position pected to exist in the glottic or subglottic area, the ven-
(Rationale: as above) tilatory mechanism (e.g., ETT, TTJV, rigid ventilating
3. Using two-person BMV with the most proficient anes- bronchoscope, surgical airway) needs to be positioned
thesiologist holding the mask and the less proficient below the level of the lesion. The ASA DAA does not
anesthesiologist squeezing the bag (Fig. 10-4) (Ratio- discriminate between the obstructed and the unob-
nale: Usually this leads to a far better mask seal, better structed airway, and this is a critical weakness of the
jaw thrust, and therefore higher tidal volume than can algorithm.
be achieved with one person in a difficult-to-mask
patient)
4. Using appropriately sized oropharyngeal or nasopha- E. Determinants of the Use of Muscle
ryngeal airway devices that have been inserted cor- Relaxants for Difficult Airway Management
rectly (Rationale: This provides a canal for airflow Muscle relaxants have different characteristics regarding
through the soft tissue of the upper airway; establishes time of onset and duration that significantly determine
and improves tidal volume) their advantages and disadvantages in the context of
If mask ventilation is very poor or nonexistent, even airway management (Table 10-2). The key elements in
with a vigorous two-person effort in the presence of large the choice of a nondepolarizing muscle relaxant are
artificial airways, this constitutes a classic CICV scenario, whether mask ventilation will be adequate and what
and the team needs to start potentially life-saving plan B rescue plan has been determined. For instance, with the
(see Fig. 10-1). induction of general anesthesia in an uncooperative
Figure 10-5 The laryngeal mask airway (left) and the Combitube (right) are supraglottic ventilatory devices.
patient who has a DA, the anesthesiologist should con- position or the type of laryngoscope is necessary for final
sider the relative merits of preservation of spontaneous success. Glycopyrrolate at a dose of 0.2 to 0.4 mg should
ventilation versus use of muscle relaxants. Alternatively, be administered in conjunction with the repeated dose
if a small dose of succinylcholine (0.5 to 0.75 mg/kg) is of succinylcholine in order to prevent a bradycardic
used, good intubating conditions can be achieved within response.
75 seconds for about 60 seconds, allowing an early-
awaken option if the ETT cannot be placed. In contrast, F. Summary
use of succinylcholine during DA management may not
be the best choice if mask ventilation is considered pos- In summary, the ASA DAA has worked well over the past
sible and the alternative plan of action is FOB.5 decade. In fact, there has been a very dramatic decrease
Moreover, endotracheal intubation can be successfully (30% to 40%) in the number of respiratory-related mal-
accomplished without the use of any muscle relaxant, practice lawsuits, brain damage, and deaths attributable
and this option should be considered in certain situa- to anesthesia since 1990 (Fig. 10-6).60 However, a number
tions.57,58 Another consideration is that in most patients, of issues have emerged that indicate that the algorithm
prior administration of a small dose of a nondepolarizing can be improved, as discussed earlier. Consideration of
neuromuscular blocker may slightly diminish the dura- these issues should make the algorithm still more clini-
tion of action of succinylcholine,59 and therefore the cally specific and functional. Nonetheless, the DAA pro-
time to spontaneous recovery of airway reflexes may be vides excellent guidelines for anesthesiologists in their
shortened. clinical decision-making for patients with DAs. Success-
Experts are debating whether a second dose of succi- ful management in these cases is key to reducing the risk
nylcholine should be provided during a cannot-intubate of anesthesia-related morbidity and mortality.
situation when the patient resumes spontaneous ventila-
tion. We believe that this practice is appropriate if the V. INTRODUCTION OF A NEW
chance of successful endotracheal intubation is high (i.e., COMPREHENSIVE AIRWAY ALGORITHM
a fairly good laryngoscopic grade at the initial attempt)
and laryngoscopy is difficult because of incomplete paral- Based on the reasoning presented to this point, currently
ysis. A second dose of succinylcholine may also be appro- available evidence from the literature, and a plethora of
priate when mask ventilation is possible, the laryngoscopist clinical experience, we created a new and comprehensive
is highly skilled, and a simple change in either the patient’s algorithm for airway management with the intent of
TABLE 10-2
Advantages and Disadvantages of Muscle Relaxants with Different Durations of Action
Muscle Relaxant Advantages Disadvantages
Succinylcholine Permits the awaken option at the earliest A period of poor ventilation (spontaneous or with positive
time possible pressure) may occur as the drug wears off
Does not permit a smooth transition to plan B (e.g., use of
a fiberoptic bronchoscope) and so on
Nondepolarizing Permits a smooth transition to plan B and so Does not allow awaken option at an early time
on, provided mask ventilation is adequate
RESPIRATORY SYSTEM DAMAGING

EVENTS BY YEAR OF EVENT
CLAIMS FOR DEATH AND BRAIN
40% DAMAGE BY YEAR OF EVENT
35%**
50%
Total claims in this time period (%)
Death
Total claims in this time period (%)

28% 41%** Brain damage
30%
25% 40%
33% 32%
30% 27%**
20% 17%**
20%
15%
13%
10% 10%
10% 6%
0% 0%
1975–79 1980–84 1985–89 1990+ 1975–79 1980–84 1985–89 1990+
n=640 n=1494 n=957 n=101 n=640 n=1494 n=957 n=101
** P ≤.01 between 1975 and 1990+ time periods; N = 3282 **P ≤.01 between 1975 and 1990+ time periods; N = 3282
Claims for respiratory system damaging events as a proportion Claims for death and brain damage as a proportion of all
of all claims in the database for each 5-year time period. B claims in the database for each 5-year time period.
Note: N does not equal the sum of n as there are some
A claims in the database prior to 1975 or no date is known.
Figure 10-6 A, The incidence of respiratory system damaging events as a proportion of all claims in the database for each 5-year period
(N = 3282). **P ≤ 0.01 between 1975 and 1990+ time periods. B, Claims for death and brain damage as a proportion of all claims in the
database for each 5-year time period (N = 3282). **P ≤ 0.01. (In both A and B, N does not equal the sum of n because there are some claims
in the database for which the date is before 1975 or unknown.) (From Cheney FW: Committee on Professional Liability: Overview. ASA Newsletter
58:7–10, 1994.)
improving patient safety during the perioperative period. a specific paradigm to address extubation of the patient
This new airway algorithm includes several subalgorithms with a DA.
that address the various potential clinical scenarios and
suggest clear procedures and readily available equipment A. The Main Algorithm
to solve the problem.
Most recently we incorporated the use of video laryn- This algorithm (Fig. 10-7) is intended for and limited to
goscopy into the new comprehensive airway algorithm elective surgery in the operating room and does not
based on new evidence that strongly supports its role include airway trauma and crash intubations. As with the
either as primary device or as first rescue device during ASA algorithm, the crux of management of the DA lies
the management of a difficult airway.12,13 in its recognition (Box 10-5). If difficulties are antici-
The main algorithm comprises all the necessary infor- pated, surgery under regional anesthesia may be consid-
mation for routine airway management. It is supple- ered. However, there are anesthetic, surgical, and patient
mented with four subalgorithms (A through D) that factors that may render the option of regional anesthesia
describe maneuvers and instruments necessary to solve for surgery inappropriate (Box 10-6). If regional anesthe-
various DA scenarios and are organized in an escalating sia is considered appropriate and successful anesthesia is
manner according to the immediate threat of the respec- achieved, then surgery may proceed. However, if regional
tive scenario. In addition, a fifth subalgorithm (E) sug- anesthesia fails, then the option for an awake airway
gests a standardized approach for extubation of these technique or inhalation induction should be considered.
patients. Similarly, if regional anesthesia is not an appropriate
option for surgery, then the performance of an awake
• Subalgorithm A = cannot ventilate, cannot intubate
intubation or inhalation induction is recommended.
(CICV)
The choice of awake versus asleep spontaneous ventila-
• Subalgorithm B = can ventilate but cannot intubate
tion depends on the experience of the anesthesiologist
via laryngoscopy
and the patient’s level of cooperation. In general, the
• Subalgorithm C = ventilation established through a
awake technique is the safest technique. However, in some
subglottic airway, further management options
patients (e.g., children; mentally retarded or incapacitated
• Subalgorithm D = surgical airway management
patients; aggressive, intoxicated, or delirious patients), an
• Subalgorithm E = extubation of a patient with a
awake technique may not be possible. Additionally, in
known or suspected DA
patients with cervical spine pathology who are at risk for
Extubation of these patients carries significant risks and neurologic injury, extreme caution should be exercised
requires a systematic approach. To our knowledge, this during an awake technique, and precautions should be
new airway algorithm is the only algorithm that provides undertaken to prevent any cervical movement.
History and
physical examination
Anticipate difficult airway?
Yes No
Operation under Proper

RA possible? positioning
Yes Preoxygenation
Figure 10-7 The main algorithm for airway manage-

RA successful? Induction of GA ment. BMV, Bag-mask ventilation; GA, general anes-
No thesia; RA, regional anesthesia. (Courtesy of Ansgar
Yes Brambrink, MD, and Carin Hagberg, MD.)
Continued at No
Continue with A BMV adequate?
surgery
Yes
Awake intubation;
consider video Muscle relaxant
laryngoscope
or
inhalation induction
Continued at No Laryngoscopy with use
B of external laryngeal
manipulation successful?
Yes
Continue anesthesia
Box 10-5 Individual Predictors of Difficult Airway Failure of an awake technique usually falls into three
Management* categories: oversedation, obscuration of vision (by blood
or secretions), and technical difficulties. If the patient is
History oversedated, airway issues may become complicated. If
Congenital/acquired syndromes, malignancy, trauma, or optimal attempts at BMV are successful, then Pathway B
disease states affecting the airway (e.g., diabetes, may be followed. However, if optimal attempts at BMV
obstructive sleep apnea)
fail, the anesthesiologist should quickly proceed to
Recent difficult intubation
Prior surgery involving the larynx or neck
Pathway A. If difficulty occurs with any of the awake
fiberoptic techniques as a result of blood, mucus, or secre-
Physical tions such that adequate visualization is not possible, a
Facial hair (beard or mustache) blind technique may be considered (see “Bloody Airways.”)
Prominent protruding teeth or dentures Additionally, more invasive techniques, such as a surgical
Micrognathia airway or retrograde intubation may be performed.
Limited mouth opening <4 cm
Inability to protrude mandible 1. The Nonpredicted Difficult Airway
Mallampati class III or IV
Thyromental distance <6 cm Although projected difficulties with airway management
Hyomental distance <4 cm may not be present, making an optimal-best attempt at
Sternomental distance <12 cm ventilation and intubation is paramount. First, even the
Limited range of motion of neck <80° best airway assessment will not detect 100% of DAs, as
Neck circumference >60 cm is evident from the literature. Second, the optimal-best
Body mass index (BMI) >30 kg/m2 attempt allows the anesthesiologist to follow the algo-
Upper airway obstruction rithm quickly and appropriately. Third, when the first
Presence of blood or vomitus in oropharynx attempt is the optimal-best attempt, this allows a greater
Tracheal deviation
margin of safety before patient decompensation begins.
*Includes predictors of difficult mask ventilation, difficult Fourth, making the first attempt the optimal-best attempt
laryngoscopy, difficult intubation, and surgical airway. minimizes repeated attempts at airway manipulation,
Emergency
Box 10-6 Factors Influencing the Choice of
Regional Anesthesia (RA) in Patients
with a Difficult Airway (DA) A Cannot ventilate
Anesthesiologist
Expertise in both RA and DA management
Enough preoperative time to perform RA technique Cannot intubate 1 DL/VL attempt
Appropriate RA technique for surgical procedure Cannot ventilate (without relaxation)
Prepared for alternative plans for DA management
No Yes
Patient
Informed consent Call for help STAT Tracheal
Cooperative and calm (Anesthesiologist and/or surgeon) intubation
Adequate intravenous access
Hemodynamically stable
Ability to tolerate sedation, if required
Ability to communicate with anesthesiologist throughout Fixed obstruction
procedure at or below cords?
No history of claustrophobia
Dependable and reliable Yes
Willing and able to supplement RA with local anesthetics
Cooperative with primary and alternative plans for DA Awaken
management patient
Surgical Procedure
Yes No No
Nonemergent
Appropriate duration
Awake Intubation SGA or
Patient position allows airway access during surgery stylet
intubation ILMA
Procedure can be interrupted technique
Limited or moderate blood loss
Support
Equipment, including a DA cart with specialized devices Successful?
and airway adjuncts
Staff (additional experienced anesthesiologists and Yes, ETT Yes, SGA No
operating room nurses) or ILMA
Continue Continued at Continued at

anesthesia C D
which may lead to greater morbidity. Therefore, the algo-

rithm emphasizes proper positioning and the use of
Figure 10-8 Pathway A: cannot ventilate, cannot intubate.
external laryngeal pressure even in patients without pre- DL, Direct laryngoscopy; ETT, endotracheal tube; ILMA, intubating
dicted airway difficulty. laryngeal mask airway; SGA, supraglottic airway; VL, video
After proper positioning, preoxygenation, and induc- laryngoscopy.
tion of general anesthesia, adequacy of BMV should be
assessed. (An exception may be made for patients who 2. New Algorithm Pathways
undergo a rapid-sequence induction). If BMV is deemed
a. PATHWAY A
adequate, intermediate- or long-acting muscle relaxants
can be given to aid direct laryngoscopy. Liberal use of The CICV scenario is an emergency situation in which
external laryngeal manipulation to optimize the laryngos- the optimal-best attempt at ventilation and intubation
copist’s view of the glottic opening is recommended. If has failed (Fig. 10-8). If muscle relaxants have not been
BMV is inadequate despite optimal positioning and administered, then one further laryngoscopy attempt,
placement of an oropharyngeal or nasopharyngeal airway, preferably using a video laryngoscope if available, or a
then the “emergency situation,” Pathway A, should be conventional direct laryngoscope.12,13 without muscle
followed. relaxation can be made (preferably by another experi-
If direct laryngoscopy is successful, then surgery may enced anesthesiologist). If tracheal intubation fails, assis-
proceed. However, if direct laryngoscopy is unsuccessful tance should be summoned. Thereafter, the algorithm
and BMV is adequate, then the “elective measures,” alerts the anesthesiologist to the difference in airway
Pathway B, should be followed. In performing a rapid- management with respect to the possibility of a fixed
sequence induction, a short-acting muscle relaxant is obstruction (e.g., tumor, vocal cord paralysis) at or below
usually given after induction of general anesthesia without the cords.
checking BMV adequacy; therefore, if the anesthesiolo- If the patient has no known obstruction at or below
gist fails to intubate after induction, he or she should the cords, a supraglottic airway (SGA) may help establish
proceed directly to Pathway B and continue along the ventilation. If ventilation is inadequate via an SGA, then
algorithm based on the initial laryngoscopic view. a surgical airway (Pathway D) should be performed. If an
SGA does establish adequate ventilation, then Pathway airway has not been established. After calling for assis-
C is recommended, in which endotracheal intubation is tance and repeating laryngoscopy, using a video laryngo-
performed with an SGA in place. scope, if available, the management is divided based on the
If the patient has a known fixed obstruction at or grade of glottic view. If a Cormack-Lehane grade 2B or 3
below the cords, then use of an SGA would be inappro- laryngoscopic view is visualized, an intubating stylet, or
priate. Ventilation attempts with an SGA would most special laryngoscopic blade or video laryngoscope can be
likely be unsuccessful. If awakening the patient is a valid helpful. If this is successful, surgery may proceed. However,
option, an awake intubation technique should be per- if the attempt is not successful, then adequacy of BMV
formed. If awakening the patient is not an option, must be reassessed, especially if BMV has not been
an intubating stylet in combination with a video laryngo- attempted previously (i.e., rapid-sequence induction). If
scope or a rigid bronchoscope should be used. These BMV is adequate, then further elective measures may be
devices, unlike an SGA, allow the provider to establish a considered. If a grade 4 laryngoscopic view is observed, a
conduit beyond the obstructed area. Again, if these retrograde technique may be considered or the anesthesi-
approaches are unsuccessful, rapid progression to a surgi- ologist may proceed directly to SGA or ILMA, depending
cal airway via Pathway D is advised. on the availability of equipment and the expertise of the
anesthesiologist. However, if BMV is inadequate, then it
b. PATHWAY B is likely inappropriate to perform a fiberoptic intubation
Pathway B (Fig. 10-9) is derived from a situation where (FOI) or retrograde intubation. Instead, the anesthesiolo-
oxygenation and ventilation are adequate but a definitive gist should recognize this as an emergent situation and
immediately attempt SGA or ILMA.
No Emergency
c. PATHWAY C
Cannot intubate Pathway C (Fig. 10-10) represents a situation in which

B the patient is anesthetized and oxygenation and ventila-
but can ventilate
tion are adequate via an SGA. The decision to intubate
depends on the answer to the question, “Is endotracheal
Call for assistance intubation necessary for the surgical procedure?” If the
(Anesthesiologist and/or surgeon) answer is “No,” surgery may continue with an SGA. If the
answer is “Yes,” FOI through the SGA with an Aintree
Intubation Catheter (Cook Critical Care, Bloomington,
Reattempt laryngoscopy IN) may be performed. Alternatively, if an ILMA or
(change blade length/type, [e.g., VL]
2nd laryngoscopist)
CTrach (LMA International, Singapore) was inserted as
Grade of glottic view? the SGA, intubation via these devices is appropriate.
However, if intubation attempts fail, it would be appro-
Grade Grade 4 priate to awaken the patient and perform an awake
2b or 3 intubation.
Intubating BMV d. PATHWAY D
stylet, special adequate?
laryngoscope In Pathway D (Fig. 10-11), all attempts to oxygenate and
blades Yes No ventilate the patient have been unsuccessful. A surgical
airway is crucial, and in patients older than 6 years of age,
FOI, special the cricothyroid membrane (CTM) remains the window
laryngoscope
blades, or
to the airway. However, if the patient is younger than 6
No retrograde* years old, the CTM is not well developed, and TTJV or
the performance of a surgical tracheostomy is advised.
Successful? Successful?
Patient Anesthetized, Oxygenation
Yes and Ventilation Adequate via SGA
Yes No
Endotracheal intubation No Continue

Continue SGA or ILMA C
anesthesia necessary for operation? anesthesia
Yes No
Yes
Awaken patient
Continued at Continued at No Awake intubation
C D FOI in combo with SGA
or
Yes postpone surgery
* May proceed directly to SGA, if desired Continue anesthesia
Figure 10-9 Pathway B: can ventilate, but cannot intubate via Figure 10-10 Pathway C: ventilation established through a subglot-
laryngoscopy. FOI, Fiberoptic intubation; ILMA, intubating laryngeal tic airway, further management options. FOI, Fiberoptic intubation;
mask airway; SGA, supraglottic airway; VL, video laryngoscopy. SGA, supraglottic airway.
All Attempts to Oxygenate Unsuccessful, Extubation of Patients with a Difficult Airway*

Mask Ventilation Impossible
Routine extubation No Postpone
E
D Surgical airway criteria met? extubation
Yes
No Surgical
Patient: Child <6 yrs?
cricothyrotomy* Place TE and
extubate
Yes
Adequate
Transtracheal jet VE/SpO2?
ventilation or surgical Yes No
tracheostomy*
Timely TE Improvement Inadequate VE/SpO2
removal** • O2 insufflation
* Obtain surgeon’s assistance, but without unnecessary • Jet ventilation
delay, if possible
Figure 10-11 Pathway D: surgical airway management.
Reintubate over
TE using DL or VL
e. PATHWAY E No Yes

After a secure airway has been established, there will Yes
Continued at Remove TE Admit
come a time when extubation is necessary. Consultants B BMV adequate? to ICU
of the ASA Task Force on Management of the Difficult
Airway,5 as well as the Canadian Airway Focus Group, No
recommended a preformulated strategy for extubation of
the DA.61 Extubation strategies are discussed in detail in Continued at
Chapter 50. Extubation strategies for the DA include, but A
are not limited to, bronchoscopic examination under
general anesthesia through an SGA, substitution of an
ETT with an SGA, and extubation over a TE. * Multiple attempts at DL or use of alternative device
Pathway E (Fig. 10-12) is an extubation algorithm in because of expected difficulty performing DL
which a TE used is for patients who underwent multiple
attempts at direct laryngoscopy or for whom alternative **If there is no evidence of laryngeal edema or
respiratory difficulty
rescue devices were used. It should also be used for
Figure 10-12 Pathway E: a standardized approach for extubation
patients with a known or suspected DA who have under- of a patient with a known or suspected difficult airway. BMV, Bag-
gone successful intubation. If the patient has met the mask ventilation; DL, direct laryngoscopy; ICU, intensive care unit;
extubation criteria (Box 10-7), one of the aforemen- Spo2, peripheral oxygen saturation by pulse oximetry; TE, tube
tioned extubation strategies can be used. A TE may be exchanger; VE, ventilation; VL, video laryngoscopy.
placed and the ETT removed over it, leaving the TE in
the trachea. If ventilatory parameters and oxygenation B. Shortcomings of the New
are adequate, the TE can then be removed, provided Airway Algorithm
there is no evidence of laryngeal edema or respiratory
difficulty. The length of time for which these catheters This new comprehensive algorithm is designed for use by
are left in place is most commonly 30 to 60 minutes, anesthesiologists dealing with patients who are to undergo
although durations as long as 72 hours have been reported surgery. It is not designed for crash intubations or dis-
in the literature. Clinical judgment should be used accord- rupted airways. It is not an attempt to encompass all
ing to the particular situation. airway situations. Rather, it focuses on airway issues in
If minute ventilation, tidal volume, or oxygen satura- the operating room and guides the practitioner more
tion is inadequate, passive insufflation of oxygen or jet thoroughly than other algorithms do in that setting.
ventilation may improve the situation. If improvement To simplify the flow of decision making, the situations
does not occur or fails to be persistent, reintubation over of failed awake technique and bloody airways are covered
a TE using direct laryngoscopy or video laryngoscopy is in this chapter text rather than in the actual algorithm.
necessary. However, reintubation over the TE may not be Also, a bloody airway can occur at any time in any
successful for various reasons (e.g., kinked TE, wrong size pathway.
TE, accidental TE removal, ETT catching at the aryte- Some airway management algorithms attempt to cover
noids). If reintubation is unsuccessful, the TE should be all airway scenarios. They may mention several devices
removed and BMV adequacy ascertained. If BMV is ade- (e.g., Combitube, lighted stylets, ILMA, fiberoptic tech-
quate, the provider can attempt to establish an airway via niques) without clarification as to their limitations and,
Pathway B in a semielective fashion. If BMV is inade- more importantly, when they are not appropriate or con-
quate, the situation has become emergent, and one should traindicated. Blind nasal intubation may be promoted
continue rapidly down Pathway A. without consideration of disrupted airways and the
Box 10-7 Routine Extubation Criteria Additionally, it clearly delineates pathways for intubation
via an SGA, for airway issues encountered during awake
Awake, alert, able to follow commands fiberoptic intubations, and for extubation. Furthermore,
• Sustained eye opening for pediatric patients or patients these guidelines address issues such as bloody airways, as
unable to understand commands
well as exclusion criteria for regional and awake tech-
Vital signs stable niques. Although this algorithm does not include crash
• Blood pressure, pulse rate, temperature intubations and disrupted airways, it focuses on airway
• Respiratory rate ≤30 breaths/min issues in the operating room in great detail.
• O2 saturation
Protective reflexes returned
• Gag
VI. CONCLUSIONS
• Swallow Specific strategies can be linked together to form more
• Cough comprehensive treatment plans or algorithms. The first
Adequate reversal of neuromuscular blockade comprehensive airway algorithm was introduced by the
• TOF 4/4, sustained tetany at 50 Hz ASA in 1993, and after two revisions this algorithm has
• Strong hand grip now provided guidance for more than 15 years. Yet,
• Unassisted head lift (>5 sec) several shortcomings of the ASA algorithm can be identi-
Arterial blood gases reasonable with FiO2 40% fied. In this chapter, we present a new comprehensive
• pH > 7.30 airway management algorithm that eliminates some of
• PaO2 ≥ 60 mm Hg the critical weaknesses of the predecessor ASA DAA.
• PaCO2 < 50 mm Hg Based on its binary character, similar to that of ACLS
Respiratory mechanics adequate algorithms, this new airway algorithm provides immedi-
• Tidal volume > 5 mL/kg ate direction in critical situations.
• Vital capacity > 15 mL/kg As the practice of airway management becomes more
• NIF > −20 cm H2O advanced, anesthesiologists must become both knowl-
For patients at risk for laryngeal edema, consider cuff leak
edgeable and proficient in the use of various airway
test and airway inspection devices and techniques. Although no airway algorithm
• FOB evaluation can be practiced in its entirety on a regular basis, anes-
thesiologists need to incorporate alternative devices and
Fio2, Fraction of inspired oxygen; FOB, fiberoptic bronchoscopy; techniques into their daily practice so that they can
NIF, negative inspiratory force; Paco2, carbon dioxide tension; develop the confidence and skill required for their suc-
Pao2, oxygen tension; TOF, train-of-four stimulation.
cessful use in the emergent setting. All of the equipment
described should be available for regular practice, and a
DA cart or portable unit should be located near every
possibility of converting a clean airway to a bloody airway. anesthetizing location. Finally, appropriate follow-up and
Airway trauma may not be covered (and is also not communication should be performed so that future care-
covered in this algorithm). Finally, in other airway algo- takers will not unwittingly reproduce the same experi-
rithms, the rapidly emerging and highly promising tech- ence and risk.
nology of video laryngoscopy is not considered and there
is a lack of guidelines for using the SGA as a conduit for
intubation. VII. CLINICAL PEARLS
• There is strong evidence demonstrating that successful
C. Bloody Airways airway management in the perioperative environment
depends on the specific strategies used. The purpose of
If blood appears in the airway as a result of awake or the American Society of Anesthesiologists Algorithm
asleep intubation techniques, direct visualization through on the Management of the Difficult Airway (ASA
a FOB may be technically challenging. In these cases, a DAA) is to facilitate management of the difficult
video laryngoscopy plus high-volume oral-pharyngeal airway (DA) and to reduce the likelihood of adverse
suction or a “blind” technique may be more useful. Three outcomes.
commonly used “blind” techniques are lightwand intuba-
tion, ILMA, and retrograde intubation. • We are presenting a new comprehensive airway man-
agement algorithm that is organized like the BLS/
ACLS algorithms in a binary fashion and eliminates
D. Summary some of the weaknesses of the ASA DAA.
The new comprehensive algorithm presented here • Based on most recent evidence, video laryngoscopy
streamlines the various airway management decisions, emerges as a superior alternative for primary manage-
allowing the airway provider to focus on using rather ment of the difficult airway and as an excellent rescue
than choosing airway devices. It emphasizes that the first device for failed DL in such circumstance.
attempt should be the best attempt and distinguishes
supraglottic from nfraglottic obstruction. Also, it provides • Recognizing the potential for difficulty leads to proper
for the first time a systematic and evidence-based role for mental and physical preparation and increases the
video laryngoscopy in management of the difficult airway. chance of a good outcome.
• Airway evaluation should take into account any char- • Although no airway algorithm can be practiced in its
acteristics of the patient that could lead to difficulty in entirety on a regular basis, anesthesiologists need to
the performance of (1) bag-mask or supraglottic airway incorporate alternative devices and techniques into
ventilation, (2) laryngoscopy, (3) intubation, or (4) a their daily practice so that they can develop the confi-
surgical airway. dence and skill required for their successful use in the
emergent setting.
• In the anesthetized patient whose trachea has proved
to be difficult to intubate, it is necessary to try to main-
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Chapter 10

The ASA Difficult Airway Algorithm:

I. Introduction C. Definition of Optimal-Best Attempt at

The ASA DAA begins with the most basic question of

ASA DIFFICULT AIRWAY ALGORITHM (1993)

1. Assess the likelihood and clinical impact of basic management problems:

2. Consider the relative merits and feasibility of basic management choices:

Non-surgical technique for initial Surgical technique for initial

Intubation attempts after

Awake intubation Intubation attempts after

Airway approached by Airway secured by

Non-emergency pathway Emergency pathway

Patient anesthetized, intubation unsuccessful, Patient anesthetized, intubation unsuccessful,

Alternative approaches Call for help

Surgical Surgery Awaken Succeed* Fail Fail Succeed

ASA DIFFICULT AIRWAY ALGORITHM (2003)

1. Assess the likelihood and clinical impact of basic management problems:

Intubation attempts after

Non-invasive technique for initial Invasive technique for initial

4. Develop primary and alternative strategies:

Awake intubation Intubation attempts after

Airway approached by Invasive airway

From this point onwards consider:

Face mask ventilation adequate Face mask ventilation not adequate

Successful Fail after multiple attempts Successful ventilation* Fail

A. Terminology in the ASA Difficult

Two-person mask ventilation

2° Person does jaw thrust 2° Squeezes reservoir bag

Figure 10-4 Optimal mask ventilation. Left, Two-person effort when

Figure 10-3 Determining optimal external manipulation (OELM)

RESPIRATORY SYSTEM DAMAGING

Total claims in this time period (%)

Anticipate difficult airway?

Operation under Proper

Figure 10-7 The main algorithm for airway manage-

Continue Continued at Continued at

which may lead to greater morbidity. Therefore, the algo-

Cannot intubate Pathway C (Fig. 10-10) represents a situation in which

Endotracheal intubation No Continue

* May proceed directly to SGA, if desired Continue anesthesia

All Attempts to Oxygenate Unsuccessful, Extubation of Patients with a Difficult Airway*

e. PATHWAY E No Yes

States: Have we made any progress? J Clin Anesth 15:418–422,

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