Update on difficult airway management with a proposal of a simplified algorithm, unified and applied to our daily clinical practice

  • Ivan Mauricio Arteaga a. Anesthesiology Department, Hospital de San José, Bogotá, Colombia. b. Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
Keywords: Airway Management; Intubation; Intratracheal; Ventilation; Tracheostomy; Anesthesia



Difficulties in managing the airway are still a major cause of morbidity, mortality, and anesthesia and critical care related claims.


Review the current trends and the recent evidence associated with management of the difficult airway to organize them into a simple, practical, and unified scheme.


Non-systematic search in PubMed, ScienceDirect, OVID, and SciELO, using the terms: airway management, airway emergency, difficult laryngoscopy, difficult intubation, difficult mask ventilation, and difficult ventilation. Evidence-based guidelines and expert consensus were prioritized.


Twenty-nine guidelines and expert consensus were found, of which 19 were published after 2004, 10 addressed to the general population, 3 to obstetrics, 4 to pediatrics, and 2 to trauma.


In terms of critical airway situations, there is purely observational evidence of actual situations or moderate-quality evidence under parallel situations. When evaluating risk, in addition to identifying predictors, it is important to consider the clinical circumstances that may worsen any potential problem. The newly developed techniques and devices are useful tools, but skills in conventional maneuvers and their optimization are irreplaceable. In addition to focusing on maneuvering to solve intubation or ventilation issues, the resuscitation practitioner must watch over the patient's general clinical condition and the potential causes of the problem. A simple and well supported thought process could facilitate the management of complex situations and improved outcomes.


1. Kheterpal S, Han R, Tremper KK, et al. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology 2006; 105:885-891.
2. Baker P. Assessment before airway management. Anesthesiol Clin 2015; 33:257-278.
3. Naguib M, Scamman FL, O’Sullivan C, et al. Predictive performance of three multivariate difficult tracheal intubation models: a double-blind, case-controlled study. Anesth Analg 2006; 103:1579-1581.
4. Peterson GN, Domino KB, Caplan RA, et al. Management of the difficult airway: a closed claims analysis. Anesthesiology 2005; 103:33-39.
5. Crosby ET. An evidence-based approach to airway management: is there a role for clinical practice guidelines? Anaesthesia 2011; 66 (suppl 2):112-118.
6. Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth 2015; 115:827-848.
7. Mushambi MC, Kinsella SM, Popat M, et al. Obstetric Anaesthetists’ Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics. Anaesthesia 2015; 70:1286-1306.
8. Black AE, Flynn PE, Smith HL, et al. Association of Pediatric Anaesthetists of Great Britain and Ireland. Development of a guideline for the management of the unanticipated difficult airway in pediatric practice. Paediatr Anaesth 2015; 25:346-362.
9. Henderson JJ, Popat MT, Latto IP, et al. Difficult Airway Society-Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004; 59:675-694.
10. Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on management of the difficult airway. Anesthesiology 2013; 118:251-270.
11. Law JA, Broemling N, Cooper RM, et al. The difficult airway with recommendations for management: part 1: difficult tracheal intubation encountered in an unconscious/induced patient. Can J Anaesth 2013; 60:1089-1118.
12. Law JA, Broemling N, Cooper RM, et al. The difficult airway with recommendations for management: part 2: the anticipated difficult airway. Can J Anaesth 2013; 60:1119-1138.
13. Combes X, Le Roux B, Suen P, et al. Unanticipated difficult airway in anesthetized patients: prospective validation of a management algorithm. Anesthesiology 2004; 100:1146-1150.
14. Weiss M, Engelhardt T. Proposal for the management of the unexpected difficult pediatric airway. Paediatr Anaesth 2010; 20:454-464.
15. Walker RW, Ellwood J. The management of difficult intubation in children. Paediatr Anaesth 2009; 19 (suppl 1):77-87.
16. Mhyre JM, Healy D. The unanticipated difficult intubation in obstetrics. Anesth Analg 2011; 112:648-652.
17. Vasdev GM, Harrison BA, Keegan MT, et al. Management of the difficult and failed airway in obstetric anesthesia. J Anesth 2008; 22:38-48.
18. Petrini F, Accorsi A, Adrario E, et al. Recommendations for airway control and difficult airway management. Minerva Anestesiol 2005; 71:617-657.
19. Frova G, Guarino A, Petrini F, et al. Gruppo di Studio, SIAARTI., “Vie Aeree Difficili” Recommendations for airway control and difficult airway management in paediatric patients. Minerva Anestesiol 2006; 72:723-748.
20. Frova G, Sorbello M. Algorithms for difficult airway management: a review. Minerva Anestesiol 2009; 75:201-209.
21. Sztark F, Francon D, Combes X, et al. Which anaesthesia techniques for difficult intubation? Particular situations: question 3. Société Française d’Anesthésie et de Réanimation. Ann Fr Anesth Reanim 2008; 27:26-32.
22. Combes X, Pean D, Lenfant F, et al. Difficult airway-management devices. Establishment and maintenance: question 4. Société Française d’Anesthésie et de Réanimation. Ann Fr Anesth Reanim 2008; 27:33-40.
23. Ollerton JE, Parr MJ, Harrison K, et al. Potential cervical spine injury and difficult airway management for emergency intubation of trauma adults in the emergency department: a systematic review. Emerg Med J 2006; 23:3-11.
24. Dupanovic M, Fox H, Kovac A. Management of the airway in multitrauma. Curr Opin Anaesthesiol 2010; 23:276-282.
25. Rosenblatt WH. The Airway Approach Algorithm: a decision tree for organizing preoperative airway information. JClin Anesth 2004; 16:312-316.
26. Kalinowski CP, Kirsch JR. Strategies for prophylaxis and treatment for aspiration. Best Pract Res Clin Anaesthesiol 2004; 18:719-737.
27. Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med 2012; 59:165-175.
28. Tanoubi I, Drolet P, Donati F. Optimizing preoxygenation in adults. Can J Anaesth 2009; 56:449-466.
29. Dhara SS. Retrograde tracheal intubation. Anaesthesia 2009; 64:1094-1104.
30. Lehavi A, Weisman A, Katz Y. Retrograde tracheal intubation: an alternative in difficult airway management. Harefuah 2008; 147:59-64. 93.
31. Ho AM, Chung DC, To EW, et al. Total airway obstruction during local anesthesia in a non-sedated patient with a compromised airway. Can J Anaesth 2004; 51:838-841.
32. Altman KW, Waltonen JD, Kern RC. Urgent surgical airway intervention: a 3 year county hospital experience. Laryngoscope 2005; 115:2101-2104.
33. Hawksworth CR, Purdie J. Failed combined spinal epidural then failed intubation at an elective caesarean section. Hosp Med 1998; 59:173.
34. Ahmad I, Bailey CR. Time to abandon awake fibreoptic intubation? Anaesthesia 2016; 71:12-16.
35. Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg 2004; 99:607-613.
36. Collins SR. Direct and indirect laryngoscopy: equipment and techniques. Respir Care 2014; 59:850-862. discussion 862-864.
37. Gataure PS, Vaughan RS, Latto IP. Simulated difficult intubation. Comparison of the gum elastic bougie and the stylet. Anaesthesia 1996; 51:935-938.
38. Marfin AG, Pandit JJ, Hames KC, et al. Use of the bougie in simulated difficult intubation. 2. Comparison of single-use bougie with multiple-use bougie. Anaesthesia 2003; 58:852-855.
39. Chaparro-Mendoza K, Luna-Montufar CA, Gómez JM. Video-laringoscopios: ¿la solución para el manejo de la vía aérea difícil o una estrategia más? Rev Colomb Anestesiol 2015; 43:225-233.
40. Behringer EC, Kristensen MS. Evidence for benefit vs novelty in new intubation equipment. Anaesthesia 2011; 66 (suppl 2):57-64.
41. Lewis SR, Butler AR, Parker J, et al. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation. Cochrane Database Syst Rev 2016; 15:CD011136.
42. Caponas G. Intubating laryngeal mask airway. Anaesth Intensive Care 2002; 30:551-569.
43. Gerstein NS, Braude DA, Hung O, et al. The Fastrach Intubating Laryngeal Mask Airway: an overview and update. Can J Anaesth 2010; 57:588-601.
44. Michálek P, Miller DM. Airway management evolution: in a search for an ideal extraglottic airway device. Prague Med Rep 2014; 115: 87-103.
45. Hernandez MR, Klock PAJr, Ovassapian A. Evolution of the extraglottic airway: a review of its history, applications, and practical tips for success. Anesth Analg 2012; 114:349-368.
46. Walker RW. The laryngeal mask airway in the difficult paediatric airway: an assessment of positioning and use in fiberoptic intubation. Paediatr Anaesth 2000; 10:53-58.
47. Halaseh BK, Sukkar ZF, Hassan LH, et al. The use of ProSeal laryngeal mask airway in caesarean section: experience in 3000 cases. Anaesth Intensive Care 2010; 38:1023-1028.
48. Brimacombe J, Keller C. The ProSeal laryngeal mask airway. Anesthesiol Clin North Am 2002; 20:871-891.
49. Maitra S, Khanna P, Baidya DK. Comparison of laryngeal mask airway Supreme and laryngeal mask airway Pro-Seal for controlled ventilation during general anaesthesia in adult patients: systematic review with meta-analysis. Eur J Anaesthesiol 2014; 31:266-273.
50. Kopman AF, Kurata J. Can’t intubate, can’t ventilate: is “rescue reversal” a pipe-dream? Anesth Analg 2012; 114:924-926.
51. El-Orbany M, Woehlck HJ. Difficult mask ventilation. Anesth Analg 2009; 109:1870-1880.
52. Saddawi-Konefka D, Hung SL, Kacmarek RM, et al. Optimizing mask ventilation: literature review and development of a conceptual framework. Respir Care 2015; 60:1834-1840.
53. Parmet JL, Colonna-Romano P, Horrow JC, et al. The laryngeal mask airway reliably provides rescue ventilation in cases of unanticipated dificult tracheal intubation along with dificult mask ventilation. Anesth Analg 1998; 87:661-665.
54. Agro F, Frass M, Benumof JL, et al. Current status of the Combitube: a review of the literature. J Clin Anesth 2002; 14:307-314.
55. Vanner R. Emergency cricothyrotomy. Curr Anaesth Crit Care 2001; 12:238-243.
56. Coté CJ, Hartnick CJ. Pediatric transtracheal and cricothyrotomy airway devices for emergency use: which are appropriate for infants and children? Paediatr Anaesth 2009; 19 (suppl 1): 66-76.
How to Cite
Arteaga IM. Update on difficult airway management with a proposal of a simplified algorithm, unified and applied to our daily clinical practice. Colomb. J. Anesthesiol. [Internet]. 2018 Jan. 1 [cited 2023 Jun. 7];46(1):55-64. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/321


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How to Cite
Arteaga IM. Update on difficult airway management with a proposal of a simplified algorithm, unified and applied to our daily clinical practice. Colomb. J. Anesthesiol. [Internet]. 2018 Jan. 1 [cited 2023 Jun. 7];46(1):55-64. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/321


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