2022 ASA Practice Guidelines for the Management of the Difficult Airway

Summary by Herbie Bennett MD, 12.30.21

The American Society of Anesthesiologists has updated their Practice Guidelines for Management of the Difficult Airway, which are now available online and will be in print with the Jan 2022 edition of Anesthesiology (51 glorious pages). Of note, the 2022 guidelines were developed in conjunction with over a dozen other national and international medical societies. The prior iteration of these guidelines was published in 2013. While the fundamental philosophy of the recommendations remains the same, there have been several significant clarifications and additions, as outlined below.

Updates
- The difficult airway algorithm flowsheet now includes more explicit recommendations on when to consider an awake intubation, in recognition of the increased success in securing the airway. These include suspected difficult laryngoscopy, suspected difficult ventilation with face mask/supraglottic airway, significant increased risk of aspiration, increased risk of rapid desaturation, suspected difficult emergency airway situation. Additionally, the ASA recommends that “any one factor alone may be clinically important enough to warrant an awake intubation.”
- Optimize oxygenation throughout the process of securing the airway. Consensus recommendation points towards using low- or high-flow nasal cannula during the awake intubation attempt. The head should be kept elevated.
- The 2022 Guidelines make frequent mention of limiting repeat intubation attempts and calling for back-up if initially unsuccessfully—re-assessment and changing airway management modality may be warranted. Additionally, in the event of a cannot ventilate/cannot intubate situation, the algorithm now has in ALL CAPS AND IN RED: LIMIT ATTEMPTS AND BE AWARE OF THE PASSAGE OF TIME. CALL FOR HELP / INVASIVE ACCESS. In the event of a non-emergency cannot intubate situation, the recommendation includes ‘limit attempts and consider awakening the patient.’ The 2022 guidelines emphasize the importance of a systematic approach in management of the airway, conducted quickly and efficiently.
- From the guidelines: Meta-analyses of randomized controlled trials comparing video-assisted laryngoscopy with direct laryngoscopy in patients with predicted difficult airways reported improved laryngeal views, a higher frequency of successful intubations, a higher frequency of first attempt intubations, and fewer intubation maneuvers with video-assisted laryngoscopy.

Specifics for a pediatric difficult airway
- If difficult airway is suspected or known, transfer to a tertiary care center if feasible
- With an unsuccessful intubation attempt, limit attempts, consider calling for help, and ensure adequate anesthetic depth.
- With marginal or impossible ventilation/oxygentation with face mask or supraglottic airway, exclude/treat anatomical and functional obstruction. Consider calling for invasive access or ECMO.

Relevant, but unchanged, recommendations from prior Practice Guidelines
- Before the initiation of anesthetic care or airway management, ensure that an airway risk assessment is performed by the person(s) responsible for airway management whenever feasible to identify patient, medical, surgical, environmental, and anesthetic factors (e.g., risk of aspiration) that may indicate the potential for a difficult airway.
- Ensure that a portable storage unit that contains specialized equipment for difficult airway management is immediately available.
- If a difficult airway is known or suspected, ensure that a skilled individual is present or immediately available to assist with airway management when feasible.
- The uncooperative or pediatric patient may restrict the options for difficult airway management, particularly options that involve awake intubation. Airway management in the uncooperative or pediatric patient may require an approach (e.g., intubation attempts after induction of general anesthesia) that might not be regarded as a primary approach in a cooperative patient.
- In the event of an unanticipated and emergency difficult airway management, call for help.
- Confirmation of tracheal intubation should be accomplished with capnography or end-tidal carbon dioxide monitoring. Alternative confirmatory modalities include, but are not limited to: visualization (any technique), flexible bronchoscopy, ultrasonography, or radiography.