Management of the Difficult Airway

Patient Guideline Summary

Publication Date: November 8, 2021

Last Updated: November 21, 2023

Objective

This patient summary means to discuss key recommendations from the American Society of Anesthesiologists for the management of the difficult airway.

Overview

If you are not breathing, you are getting no oxygen. Without oxygen, death occurs within minutes. Therefore, an open airway is the first requirement for saving a life.

Securing an airway whenever you are at risk of oxygen deprivation is essential. In medical situations, this is the job of an anesthesiologist.

Situations that require a secured airway:
- General anesthesia for surgery
- Serious trauma, especially to the head, face, neck, or chest
- Aspirating (inhaling) solids or liquids – e.g., food, drowning
- Unconscious or semi-conscious mental state
- Neck swelling
- Paralysis that involves the diaphragm or vocal cords

This patient summary focuses on difficulties securing an open airway.

Diagnosis

The usual way to secure an airway is by intubation (inserting an endotracheal tube through your mouth or nose, past your vocal cords, and into your lungs).
When anticipating a need for a secure airway, the anesthesiologist will need to evaluate your airway for possible difficulties during intubation.
- Possible problems include:
  - Inability to fully open your mouth
  - Full stomach (since intubation might cause vomiting and aspiration)
  - Swollen tongue or the back of your throat
  - A stiff or splinted neck that prevents proper head positioning

Your anesthesiologist may want to use a scope to see your vocal cords and upper airway.

Treatment

Oxygen by mask and anesthesia (putting you to sleep) before intubation is standard practice.
Blood oxygen levels will be monitored continuously using a fingertip device.
There are multiple ways to secure an airway if the standard approach will not work. Options may include:
- Noninvasive devices: Rigid laryngoscopic blades of alternative designs and sizes (with adequate face mask ventilation after induction), adjuncts (e.g., introducers, bougies, stylets, alternative tracheal tubes, and supraglottic airways), video/video-assisted laryngoscopy, flexible intubation scopes, supraglottic airway devices, lighted or optical stylets, alternative optical laryngoscopes, and rigid bronchoscopes.
- Combination techniques: (1) direct or video laryngoscopy combined with either optical/video stylet, flexible scope intubation, airway exchange catheter, retrograde-placed guide wire, or supraglottic airway placement, and (2) supraglottic airway combined with either optical/video stylet, flexible scope intubation (with or without hollow guide catheter), or retrograde-placed guide wire.
- Invasive interventions: Surgical cricothyrotomy (inserting a breathing tube in a surgical opening in the throat) (e.g., scalpel-bougie-tube), needle cricothyrotomy with a pressure-regulated device, large-bore cannula cricothyrotomy or surgical tracheostomy (inserting a breathing tube in a surgical opening in the throat), retrograde wire–guided intubation, and percutaneous tracheostomy.
- Optimum oxygenation: Examples include low- or high-flow nasal oxygen during efforts securing a tube.
- Additional techniques: Visualization (any technique), flexible bronchoscopy, ultrasonography, or radiography.

Source Citation

Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, Fiadjoe JE, Greif R, Klock PA, Mercier D, Myatra SN, O'Sullivan EP, Rosenblatt WH, Sorbello M, Tung A. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2022 Jan 1;136(1):31-81. doi: 10.1097/ALN.0000000000004002. PMID: 34762729.

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.