Difficult airway infographic: Adult patients

ECMO: extracorporeal membrane oxygenation.

* The airway manager's assessment and choice of techniques should be based on their previous experience; available resources, including equipment, availability, and competency of help; and the context in which airway management will occur.

¶ Review airway strategy: Consider anatomical/physiologic airway difficulty risk, aspiration risk, infection risk, other exposure risk, equipment and monitoring check, role assignment, and backup and rescue plans. Awake techniques include flexible intubation scope, videolaryngoscopy, direct laryngoscopy, supraglottic airway, combined devices, and retrograde wire-aided.

Δ Invasive airways include surgical cricothyroidotomy, needle cricothyroidotomy with a pressure-regulated device, large-bore cannula cricothyroidotomy, or surgical tracheostomy. Elective invasive airways include the above, retrograde wire-guided intubation, and percutaneous tracheostomy. Other options include rigid bronchoscopy and ECMO.

◊ Invasive airway is performed by an individual trained in invasive airway techniques, whenever possible.

§ Adequate ventilation by any means (eg, face mask, supraglottic airway, tracheal intubation) should be confirmed by capnography, when possible.

¥ Follow-up care includes postextubation care (ie, steroids, racemic epinephrine), counseling, documentation, team debriefing, and encouraging patient difficult airway registry.

‡ Postpone the case/intubation and return with appropriate resources (eg, personnel, equipment, patient preparation, awake intubation).

† In an unstable situation or when airway management is mandatory after a failed awake intubation, a switch to the airway management with the induction of anesthesia pathway may be entered with preparations for an emergency invasive airway.

** Low- or high-flow nasal cannula, head elevated position throughout procedure. Noninvasive ventilation during preoxygenation.

¶¶ Alternative device examples: supraglottic airway, direct laryngoscope, videolaryngoscope, flexible intubation scope.

ΔΔ Limit attempts^¥¥, alternate and optimize^‡‡ techniques, avoid task fixation.

◊◊ First versus second generation supraglottic airway with intubation capability for initial or rescue supraglottic airway.

§§ Videolaryngoscopy as an option for initial or rescue tracheal intubation.

¥¥ The intent of limiting attempts at tracheal intubation and supraglottic airway insertion is to reduce the risk of bleeding, edema, and other types of trauma that may increase the difficulty of mask ventilation and/or subsequent attempts to secure a definitive airway. Persistent attempts at any airway intervention, including ineffective mask ventilation, may delay obtaining an emergency invasive airway. A reasonable approach may be to limit attempts with any technique class (ie, face mask, supraglottic airway, tracheal tube) to three, with one additional attempt by a clinician with higher skills.

‡‡ Optimize: suction, relaxants, repositioning. Face mask: oral/nasal airway, two-hand mask grip. Supraglottic airway: size, design, repositioning, first versus second generation. Tracheal tube: introducer, rigid stylet, hyperangulated videolaryngoscopy, blade size, external laryngeal manipulation. Consider other causes of inadequate ventilation (including but not limited to laryngospasm and bronchospasm).