Difficult airway management is a core competency for every anesthesia provider. The updated ASA Difficult Airway Algorithm provides a systematic approach to both anticipated and unanticipated difficult airways, with emphasis on having a primary plan, backup plan, and emergency invasive airway plan before every induction. Preparation, communication, and knowing when to call for help are as important as technical skill.
ASA Difficult Airway Algorithm updated 2022: emphasizes cognitive aids, team communication, and early supraglottic airway use
Mallampati, thyromental distance, neck mobility, and mouth opening are imperfect but useful screening tools
Cannot-intubate-cannot-oxygenate (CICO): emergency front-of-neck access (cricothyrotomy) is the final rescue
Video laryngoscopy should be considered first-line for anticipated difficult intubation
Awake intubation with flexible bronchoscope remains the gold standard for predicted difficult airways
When video laryngoscopy provides a good glottic view but the tube won't pass, use a bougie rather than re-attempting with more force. The most common cause of failed intubation with video laryngoscopy is difficulty with tube delivery, not visualization.
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