Expert consensus on difficult airway assessment

doi:10.21037/hbsn-23-46

Review

. 2023 Aug 1;12(4):545-566.

doi: 10.21037/hbsn-23-46. Epub 2023 May 19.

Expert consensus on difficult airway assessment

Ming Xia¹, Wuhua Ma², Mingzhang Zuo³, Xiaoming Deng⁴, Fushan Xue⁵, Denise Battaglini⁶, Vivek Aggarwal⁷, Giustino Varrassi⁸, Vladimir Cerny⁹, Ida Di Giacinto¹⁰, Rita Cataldo¹¹, Daqing Ma¹², Toru Yamamoto¹³, Martina Rekatsina¹⁴, Alessandro De Cassai¹⁵, Andrea Carsetti^{16

17}, Marvin G Chang¹⁸, Edwin Seet^{19

20}, Daniel P Davis^{21

22}, Michael G Irwin²³, Yuguang Huang^#²⁴, Hong Jiang^#¹

Affiliations

¹ Department of Anesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
² Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
³ Department of Anaesthesiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Science, Beijing, China.
⁴ Department of Anesthesiology, Plastic Surgery Hospital, CAMS and PUMC, Beijing, China.
⁵ Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
⁶ Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
⁷ Department of Conservative Dentistry & Endodontics, Jamia Millia Islamia, New Delhi, India.
⁸ Paolo Procacci Foundation, Roma, Italy.
⁹ Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic.
¹⁰ Unit of Anesthesia and Intensive Care, Mazzoni Hospital, Ascoli Piceno, Italy.
¹¹ Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Università Campus Bio-Medico of Rome, Roma, Italy.
¹² Division of Anaesthetics, Pain Medicine & Intensive Care, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, and Chelsea and Westminster Hospital, London, UK.
¹³ Division of Dental Anesthesiology, Graduate School of Medicine and Dental Sciences, Niigata University, Niigata, Japan.
¹⁴ Department of Anaesthesiology, National and Kapodistrian University of Athens, Athens, Greece.
¹⁵ Institute of Anesthesia and Intensive Care Unit, University Hospital of Padua, Padua, Italy.
¹⁶ Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy.
¹⁷ Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy.
¹⁸ Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.
¹⁹ Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
²⁰ Department of Anaesthesia, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
²¹ Division of Emergency Medical Services, Logan Health, Kalispell, MT, USA.
²² Air Methods Corporation, Greenwood Park, CO, USA.
²³ Department of Anesthesiology, The University of Hong Kong, Hong Kong, China.
²⁴ Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China.

^# Contributed equally.

PMID: 37600997
PMCID: PMC10432292
DOI: 10.21037/hbsn-23-46

Review

Expert consensus on difficult airway assessment

Ming Xia et al. Hepatobiliary Surg Nutr. 2023.

. 2023 Aug 1;12(4):545-566.

doi: 10.21037/hbsn-23-46. Epub 2023 May 19.

Authors

Affiliations

¹ Department of Anesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
² Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
³ Department of Anaesthesiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Science, Beijing, China.
⁴ Department of Anesthesiology, Plastic Surgery Hospital, CAMS and PUMC, Beijing, China.
⁵ Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
⁶ Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
⁷ Department of Conservative Dentistry & Endodontics, Jamia Millia Islamia, New Delhi, India.
⁸ Paolo Procacci Foundation, Roma, Italy.
⁹ Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic.
¹⁰ Unit of Anesthesia and Intensive Care, Mazzoni Hospital, Ascoli Piceno, Italy.
¹¹ Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Università Campus Bio-Medico of Rome, Roma, Italy.
¹² Division of Anaesthetics, Pain Medicine & Intensive Care, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, and Chelsea and Westminster Hospital, London, UK.
¹³ Division of Dental Anesthesiology, Graduate School of Medicine and Dental Sciences, Niigata University, Niigata, Japan.
¹⁴ Department of Anaesthesiology, National and Kapodistrian University of Athens, Athens, Greece.
¹⁵ Institute of Anesthesia and Intensive Care Unit, University Hospital of Padua, Padua, Italy.
¹⁶ Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy.
¹⁷ Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy.
¹⁸ Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.
¹⁹ Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
²⁰ Department of Anaesthesia, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
²¹ Division of Emergency Medical Services, Logan Health, Kalispell, MT, USA.
²² Air Methods Corporation, Greenwood Park, CO, USA.
²³ Department of Anesthesiology, The University of Hong Kong, Hong Kong, China.
²⁴ Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China.

^# Contributed equally.

PMID: 37600997
PMCID: PMC10432292
DOI: 10.21037/hbsn-23-46

Abstract

Background: Identifying a potentially difficult airway is crucial both in anaesthesia in the operating room (OR) and non-operation room sites. There are no guidelines or expert consensus focused on the assessment of the difficult airway before, so this expert consensus is developed to provide guidance for airway assessment, making this process more standardized and accurate to reduce airway-related complications and improve safety.

Methods: Seven members from the Airway Management Group of the Chinese Society of Anaesthesiology (CSA) met to discuss the first draft and then this was sent to 15 international experts for review, comment, and approval. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) is used to determine the level of evidence and grade the strength of recommendations. The recommendations were revised through a three-round Delphi survey from experts.

Results: This expert consensus provides a comprehensive approach to airway assessment based on the medical history, physical examination, comprehensive scores, imaging, and new developments including transnasal endoscopy, virtual laryngoscopy, and 3D printing. In addition, this consensus also reviews some new technologies currently under development such as prediction from facial images and voice information with the aim of proposing new research directions for the assessment of difficult airway.

Conclusions: This consensus applies to anesthesiologists, critical care, and emergency physicians refining the preoperative airway assessment and preparing an appropriate intubation strategy for patients with a potentially difficult airway.

Keywords: Expert consensus; airway management; difficult airway.

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Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-23-46/coif). VC reports institutional research grants from Charles University in Prague at University Hospital Hradec Kralove in different areas of interest, received consulting fees from in the past 5 years from Behring, Baxter, BBraun, Octapharma, and he serves as expert court witness for the area of anesthesia and intensive care 25 years and he is President of the Czech Society of Anesthesiology and Intensive Care. The other authors have no conflicts of interest to declare.

Figures

**Figure 2**
The modified Mallampati test.

**Figure 3**
The detailed bedside tests include neck circumference, thyromental distance, sternomental distance, hyomental distance, thyromental height.

See this image and copyright information in PMC

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References

1. Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2022;136:31-81. 10.1097/ALN.0000000000004002 - DOI - PubMed
1. Cook TM, Woodall N, Frerk C, et al. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth 2011;106:617-31. 10.1093/bja/aer058 - DOI - PubMed
1. Griesdale DE, Bosma TL, Kurth T, et al. Complications of endotracheal intubation in the critically ill. Intensive Care Med 2008;34:1835-42. 10.1007/s00134-008-1205-6 - DOI - PubMed
1. Jaber S, Amraoui J, Lefrant JY, et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Crit Care Med 2006;34:2355-61. 10.1097/01.CCM.0000233879.58720.87 - DOI - PubMed
1. Schwartz DE, Matthay MA, Cohen NH. Death and other complications of emergency airway management in critically ill adults. A prospective investigation of 297 tracheal intubations. Anesthesiology 1995;82:367-76. 10.1097/00000542-199502000-00007 - DOI - PubMed

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[1] Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2022;136:31-81. 10.1097/ALN.0000000000004002 - DOI - PubMed

[2] Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2022;136:31-81. 10.1097/ALN.0000000000004002 - DOI - PubMed

[3] Cook TM, Woodall N, Frerk C, et al. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth 2011;106:617-31. 10.1093/bja/aer058 - DOI - PubMed

[4] Cook TM, Woodall N, Frerk C, et al. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth 2011;106:617-31. 10.1093/bja/aer058 - DOI - PubMed

[5] Griesdale DE, Bosma TL, Kurth T, et al. Complications of endotracheal intubation in the critically ill. Intensive Care Med 2008;34:1835-42. 10.1007/s00134-008-1205-6 - DOI - PubMed

[6] Griesdale DE, Bosma TL, Kurth T, et al. Complications of endotracheal intubation in the critically ill. Intensive Care Med 2008;34:1835-42. 10.1007/s00134-008-1205-6 - DOI - PubMed

[7] Jaber S, Amraoui J, Lefrant JY, et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Crit Care Med 2006;34:2355-61. 10.1097/01.CCM.0000233879.58720.87 - DOI - PubMed

[8] Jaber S, Amraoui J, Lefrant JY, et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Crit Care Med 2006;34:2355-61. 10.1097/01.CCM.0000233879.58720.87 - DOI - PubMed

[9] Schwartz DE, Matthay MA, Cohen NH. Death and other complications of emergency airway management in critically ill adults. A prospective investigation of 297 tracheal intubations. Anesthesiology 1995;82:367-76. 10.1097/00000542-199502000-00007 - DOI - PubMed

[10] Schwartz DE, Matthay MA, Cohen NH. Death and other complications of emergency airway management in critically ill adults. A prospective investigation of 297 tracheal intubations. Anesthesiology 1995;82:367-76. 10.1097/00000542-199502000-00007 - DOI - PubMed

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Expert consensus on difficult airway assessment

Affiliations

Expert consensus on difficult airway assessment

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