Lesson 20

ASA Difficult Airway Algorithm (2022 Update)

• Overview: Provides a method for managing anticipated and unanticipated difficult airways to reduce adverse outcomes.

  • Aims to prevent death, brain damage, ICU admissions, and emergency airway placement.

• Structure: Divided into 3 parts:

  1. Pre-airway management decision-making tool.
  2. Awake airway management.
  3. Airway management after induction of anesthesia.

• Pre-Intubation Decisions:

  • Choose between awake or post-induction strategies based on:
  • Suspected difficult laryngoscopy.
  • Risk of difficult face mask ventilation.
  • Aspiration risks.
  • Risk of rapid desaturation.

• Awake Intubation Considerations:

  • Optimize oxygenation and evaluate for emergency invasive airway if required.

• Post-Induction Management:

  • Consider rocuronium (+ sugammadex if needed) instead of succinylcholine.
  • Limit attempts to minimize trauma (max 3 attempts + 1 by skilled clinician).
  • If intubation fails but ventilation is adequate, transition to a non-emergency pathway. If not, initiate an emergency pathway.

• Emergency Pathway Actions:

  • Call for help and attempt alternative intubation approaches.
  • Prepare for emergency invasive access if ventilation remains inadequate.

• Extubation Strategies:

  • Ensure skilled help is available, optimize oxygenation, and use an airway exchange catheter if applicable. Consider elective tracheostomy if needed.

• Difficult Airway Society Algorithm Overview:

  • Plan A: Success with facemask ventilation or laryngoscopy.
  • Plan B: Insert a supraglottic airway if intubation fails.
  • Plan C: Final attempt at facemask ventilation.
  • Plan D: Emergency cricothyroidotomy if unable to intubate or oxygenate (CICO scenario).