Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults

C Frerk, V S Mitchell, A F McNarry, C Mendonca, R Bhagrath, A Patel, E P O'Sullivan, N M Woodall, I Ahmad
British Journal of Anaesthesia 2015, 115 (6): 827-48
These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. They are founded on published evidence. Where evidence is lacking, they have been directed by feedback from members of the Difficult Airway Society and based on expert opinion. These guidelines have been informed by advances in the understanding of crisis management; they emphasize the recognition and declaration of difficulty during airway management. A simplified, single algorithm now covers unanticipated difficulties in both routine intubation and rapid sequence induction. Planning for failed intubation should form part of the pre-induction briefing, particularly for urgent surgery. Emphasis is placed on assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions. It is recommended that the number of airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video- or fibre-optically guided intubation. If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Second-generation devices have advantages and are recommended. When both tracheal intubation and supraglottic airway device insertion have failed, waking the patient is the default option. If at this stage, face-mask oxygenation is impossible in the presence of muscle relaxation, cricothyroidotomy should follow immediately. Scalpel cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. The plans outlined are designed to be simple and easy to follow. They should be regularly rehearsed and made familiar to the whole theatre team.

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Ernest Moore

I suggest alerting a surgeon when a difficult airway is encountered. Cricothyrodotomy in an obese patient is challenging


luis chucas

very good wrottenn


Jorge Bejarano

Thank you so much for the paper, In our environment, we don't have cricotirotomy kit available every time, that's why I'm against to paralyze the patient when I face that situation, I prefer to keep the patient awake and try to intubate whit lydocaine spray with a minimum sedation by this way I avoid hemodynamic instability, and if I fail, I could get a second chance, I emphasize in a proper position, it could be in 45 degrees, sellick maneuver, a tube guide inside of it, J shape to the tube , and put my ear in proximal side of the tube to confirm if the air comes out before to introduce it, It has worked for me for many, but anyway emergency tracheotomy should be strongly considered when the patient is difficult to intubate and difficult to ventilate, but personally I avoid patient paralization, I find in spontaneous breathing my best ally in the pursuit of the airway.


Struan Reid

Make a surgical airway kit!
Size 5 or 6 cuffed tube, scalpel, some alcohol swabs and a bougie is all you need.
The fancy kits are sometimes very complicated to use if you have never played with them prior to emergency use.


Bill Anderson

Excellent review of how to manage the issue when it happens. As ever no consideration as to how, through available prudent practice, to prevent problems in the first place. Could we have a trial of the impact of adhering to the following simple helpful guideline? "Never deliberately render a patient apnoeic before you have seen the larynx on direct laryngoscopy" Slow induction of general anaesthesia, preserving spontaneous breathing with modern iv agents allows direct laryngoscopy which will reveal potential intubation issues.


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