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

Abstract

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airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video- or fibre-optically guided intubation.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.

Keywords: airway obstruction; complications; intubation; intubation, endotracheal; intubation, transtracheal; ventilation.

Fig 1

Difficult Airway Society difficult intubation guidelines: overview. Difficult Airway Society, 2015, by permission of the Difficult Airway Society. This image is not covered by the terms of the Creative Commons Licence of this publication. For permission to re-use, please contact the Difficult Airway Society. CICO, can't intubate can't oxygenate; SAD, supraglottic airway device.

Fig 2

Management of unanticipated difficult tracheal intubation in adults. Difficult Airway Society, 2015, by permission of the Difficult Airway Society. This image is not covered by the terms of the Creative Commons Licence of this publication. For permission to re-use, please contact the Difficult Airway Society. SAD, supraglottic airway device.

Fig 3

The laryngeal handshake. (a) The index finger and thumb grasp the top of the larynx (the greater cornu of the hyoid bone) and roll it from side to side. The bony and cartilaginous cage of the larynx is a cone, which connects to the trachea. (b) The fingers and thumb slide down over the thyroid laminae. (c) Middle finger and thumb rest on the cricoid cartilage, with the index finger palpating the cricothyroid membrane.

Fig 4

Cricothyroidotomy technique. Cricothyroid membrane palpable: scalpel technique; ‘stab, twist, bougie, tube’. (a) Identify cricothyroid membrane. (b) Make transverse stab incision through cricothyroid membrane. (c) Rotate scalpel so that sharp edge points caudally. (d) Pulling scalpel towards you to open up the incision, slide coude tip of bougie down scalpel blade into trachea. (e) Railroad tube into trachea.

Fig 5

Failed intubation, failed oxygenation in the paralysed, anaesthetized patient. Technique for scalpel cricothyroidotomy. Difficult Airway Society, 2015, by permission of the Difficult Airway Society. This image is not covered by the terms of the Creative Commons Licence of this publication. For permission to re-use, please contact the Difficult Airway Society.