Difficult Airway Management Clinical Practice Guidelines (ASA, 2021)

American Society of Anesthesiologists

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

December 03, 2021

Guidelines for management of difficult airways were published in November 2021 by the American Society of Anesthesiologists in  Anesthesiology.[1]

Before initiating anesthetic care or airway management, ensure that an airway risk assessment is performed to identify patient, medical, surgical, environmental, and anesthetic factors that may indicate potential for a difficult airway.

Properly position the patient and administer supplemental oxygen before initiating management of a difficult airway; continue to deliver supplemental oxygen when feasible throughout difficult airway management, including extubation.

Identify a strategy for awake intubation; for a patient who can be adequately ventilated but is difficult to intubate; for a patient who cannot be ventilated or intubated; and for difficulty with emergency invasive airway rescue.

When appropriate, perform awake intubation if difficult intubation is suspected and if one or more of the following apply: difficult ventilation (face mask/supraglottic airway); increased risk of aspiration; patient is likely incapable of tolerating a brief apneic episode; or there is expected difficulty with emergency invasive airway rescue.

Before attempting intubation of an anticipated difficult airway, determine the benefit of a noninvasive versus an invasive approach to airway management.

When encountering an unanticipated difficult airway, determine the benefit of waking and/or restoring spontaneous breathing and determine the benefit of a noninvasive versus an invasive approach to airway management.

Confirm tracheal intubation using capnography or end-tidal carbon dioxide monitoring. When uncertain about the location of the tracheal tube, determine whether either to remove the tube and attempt ventilation or to use additional techniques to confirm position of the tube.

Have a preformulated strategy for extubation and subsequent airway management. Assess the relative merits and feasibility of short-term use of an airway exchange catheter and/or supraglottic airway that can help guide reintubation.

When feasible, use supplemental oxygen throughout the extubation process.

Use postextubation steroids and/or racemic epinephrine when appropriate.


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