Difficult Airway Management (ASA 2022)

Algorithm Steps

1. ▶

   Start

   Airway Assessment Required

   Evaluate airway before induction or emergency airway situation

   1. ◆

      Decision

      Is Difficult Airway Anticipated?

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

      1. ●

         Action

         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
         1. ✓

            Outcome

            Airway Secured

            Confirm with ETCO2, bilateral breath sounds, chest rise

      2. ●

         Action

         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
         1. ◆

            Decision

            First Laryngoscopy Attempt Successful?

            Direct or video laryngoscopy with optimized positioning

            1. ●

               Action

               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
               1. ◆

                  Decision

                  Can Oxygenate via Mask/SGA?

                  Attempt bag-mask ventilation or supraglottic airway

                  1. ●

                     Action

                     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
                     1. ●

                        Action

                        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
                  2. ⚠

                     Warning

                     ⚠️ 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
                     1. ●

                        Action

                        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
                        1. ✓

                           Outcome

                           Emergency Airway Established

                           Convert to definitive airway when stable