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Difficult Airway Management (ASA 2022)

Difficult Airway Management (ASA 2022): Airway Assessment Required → Is Difficult Airway Anticipated? → Consider Awake Intubation → Airway Secured.

Pathway Overview

13 steps

Algorithm Steps

13 total

  1. 01Start

    Airway Assessment Required

    Evaluate airway before induction or emergency airway situation

  2. 02Decision

    Is Difficult Airway Anticipated?

    Evaluate predictors: Mallampati, thyromental distance, neck mobility, mouth opening, obesity, OSA, prior difficult airway

  3. 03Action

    Consider Awake Intubation

    Awake flexible bronchoscopic intubation with topical anesthesia. Maintain spontaneous ventilation.

    • Topicalize airway with 4% lidocaine
    • Consider nerve blocks (superior laryngeal, glossopharyngeal)
    • Use sedation cautiously (dexmedetomidine, low-dose propofol)
    • Have surgical airway backup ready
  4. 04Outcome

    Airway Secured

    Confirm with ETCO2, bilateral breath sounds, chest rise

  5. 05Action

    Proceed with Standard Induction

    Preoxygenate with 100% O2, induce anesthesia, attempt intubation

    • Preoxygenation 3-5 min or 8 vital capacity breaths
    • Position optimally (ramping for obese patients)
    • Have backup devices immediately available
    • Video laryngoscope recommended as first attempt
  6. 06Decision

    First Laryngoscopy Attempt Successful?

    Direct or video laryngoscopy with optimized positioning

  7. Path rejoins step 04Shared downstream outcome
  8. 07Action

    Alternative Intubation Strategy

    Maximum 3 total attempts by same provider

    • Change blade type/size
    • Use video laryngoscope if not used
    • Adjust head position
    • Use bougie/stylet
    • External laryngeal manipulation (BURP)
    • Call for experienced help
  9. 08Decision

    Can Oxygenate via Mask/SGA?

    Attempt bag-mask ventilation or supraglottic airway

  10. 09Action

    SGA for Ventilation ± Intubation

    Insert supraglottic airway device

    • Use 2nd generation SGA (i-gel, LMA Supreme)
    • Can intubate through intubating LMA
    • Consider flexible bronchoscopy through SGA
    • Limit to 2-3 SGA attempts
  11. Path rejoins step 04Shared downstream outcome
  12. 10Action

    Consider Waking Patient

    If oxygenation maintained, consider awakening for alternative plan

    • Allow emergence from anesthesia
    • Plan awake intubation or surgical airway
    • Regional/local anesthesia alternative if urgent surgery
  13. Path rejoins step 03Shared downstream outcome
  14. 11Warning

    ⚠️ CICO EMERGENCY

    Cannot Intubate, Cannot Oxygenate - Immediate surgical airway required

    • Declare emergency loudly
    • Call for surgical help
    • Perform cricothyrotomy or emergency tracheostomy
    • Scalpel-bougie technique preferred
  15. 12Action

    Emergency Cricothyrotomy

    Scalpel-bougie-tube technique

    • Identify cricothyroid membrane
    • Transverse stab incision through membrane
    • Insert bougie trachea-directed
    • Railroad 6.0 ETT over bougie
    • Confirm placement with ETCO2
  16. 13Outcome

    Emergency Airway Established

    Convert to definitive airway when stable

Guideline Source

2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway

DOI: 10.1097/ALN.0000000000004002View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Does not replace clinical judgment and experience
  • Equipment availability may vary by institution
  • Pediatric modifications may be required
  • Does not address awake intubation techniques in detail

Contraindicated Populations

neonates_without_modification

Applicable Regions

USEUglobal

EU: Compatible with DAS guidelines

US: Based on ASA 2022 guidelines

Version 1Next review: 2027-01-01

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Frequently Asked Questions

What is the Difficult Airway Management (ASA 2022)?

The Difficult Airway Management (ASA 2022) is a emergency clinical algorithm for Anesthesiology. It provides a structured decision tree to guide clinical decision-making, based on 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway.

What guideline is the Difficult Airway Management (ASA 2022) based on?

This algorithm is based on 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway (DOI: 10.1097/ALN.0000000000004002).

What are the limitations of the Difficult Airway Management (ASA 2022)?

Known limitations include: Does not replace clinical judgment and experience; Equipment availability may vary by institution; Pediatric modifications may be required; Does not address awake intubation techniques in detail. Individual patient factors may require deviation from these recommendations.

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