The difficult airway algorithm was designed to help practitioners deal with both anticipated and unanticipated difficult airway management. Before delivering any anesthetic care, a thorough history and physical examination should be performed to help predict any difficulty with airway management. While there is typically no single finding that predicts a difficult airway, the summation of history and physical data may suggest potential difficulty during airway management.
The difficult airway algorithm (Figure 86-1) is organized to help practitioners navigate various complications that arise during airway management. The first step in the difficult airway algorithm is assessing basic management options such as patient cooperation with various airway plans (ie, an awake intubation), ability to mask ventilate, potential effectiveness of a supraglottic airway device, ease of laryngoscopy, ease of intubation, and surgical airway feasibility. Evaluation should occur before attempting airway manipulation. In addition, there should be a plan to administer supplemental oxygen throughout the airway management process. One such example would be performing an awake intubation with supplemental oxygen via nasal cannula until the airway is secured. The last approach should include a plan to ease various airway management techniques. What is the feasibility of performing an awake versus sleep intubation? Is an awake surgical airway an option? Is video-assisted laryngoscopy warranted? Should preservation of spontaneous ventilation be maintained? These are questions that need to be answered before engaging in airway management as answers to these questions may change the plan. By approaching each of these questions and concerns prior to airway manipulation, the practitioner is prepared to deal with difficulties as they arise.
The difficult airway algorithm. (Reproduced with permission from Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2022; 136:31-81.)
UNANTICIPATED DIFFICULT AIRWAY
Despite a myriad of recommendations, there will undoubtedly be unanticipated difficulty with airway management. When navigating the difficult airway algorithm, decision points hinge on whether or not oxygenation and ventilation are adequate. The two arms of the flowchart start with either induction of general anesthesia or performing an awake intubation. Most difficulty in common anesthesia practice occurs after the induction of anesthesia has taken place and will initially focus on this arm of the flowchart. Once general anesthesia has been induced by a trained anesthesia provider and intubation has been unsuccessful, the patient is classified as having a difficult airway and swift decisions need to take place. The most important consideration is whether or not mask ventilation is adequate. All ventilation should be confirmed with exhaled CO2, in addition to other means of assessing ventilation. Once mask ventilation has been established, the urgency is removed, allowing for nonemergent techniques to establish oxygenation and ventilation. These techniques can include ...