British Journal of Anaesthesia, 115 (6): 827–48 (2015)

doi: 10.1093/bja/aev371
Advance Access Publication Date: 10 November 2015
Special Article

SPECIAL ARTICLE

Difficult Airway Society 2015 guidelines for

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management of unanticipated difficult intubation
in adults†
C. Frerk1, *, V. S. Mitchell2, A. F. McNarry3, C. Mendonca4, R. Bhagrath5, A. Patel6,
E. P. O’Sullivan7, N. M. Woodall8 and I. Ahmad 9, Difficult Airway Society
intubation guidelines working group
1
Department of Anaesthesia, Northampton General Hospital, Billing Road, Northampton NN1 5BD, UK,
2
Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation
Trust, 235 Euston Road, London NW1 2BU, UK, 3Department of Anaesthesia, NHS Lothian, Crewe Road South,
Edinburgh EH4 2XU, UK, 4Department of Anaesthesia, University Hospitals Coventry & Warwickshire NHS Trust,
Clifford Bridge Road, Coventry CV2 2DX, UK, 5Department of Anaesthesia, Barts Health, West Smithfield, London
EC1A 7BE, UK, 6Department of Anaesthesia, The Royal National Throat Nose and Ear Hospital, 330 Grays Inn Road,
London WC1X 8DA, UK, 7Department of Anaesthesia, St James’s Hospital, PO Box 580, James’s Street, Dublin 8,
Ireland, 8Department of Anaesthesia, The Norfolk and Norwich University Hospitals NHS Foundation Trust,
Colney Lane, Norwich NR4 7UY, UK, and 9Department of Anaesthesia, Guy’s and St Thomas’ NHS Foundation
Trust, Great Maze Pond, London SE1 9RT, UK
*Corresponding author. E-mail: [email protected]

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.

† This Article is accompanied by Editorials aev298 and aev404.

Accepted: September 28, 2015
© The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial
License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided
the original work is properly cited. For commercial re-use, please contact [email protected]

827
828 | Frerk et al.

Key words: airway obstruction; complications; intubation; intubation, endotracheal; intubation, transtracheal; ventilation

Clinical practice has changed since the publication of the original performed before surgery to evaluate all aspects of airway man-
Difficult Airway Society (DAS) guidelines for management of agement, including front-of-neck access.
unanticipated difficult intubation in 2004.1 The 4th National The aim of the guidelines is to provide a structured response
Audit Project of the Royal College of Anaesthetists and Difficult to a potentially life-threatening clinical problem. They take into
Airway Society (NAP4) provided detailed information about the account current practice and recent developments.
factors contributing to poor outcomes associated with airway Every adverse event is unique, the outcome of which will be
management and highlighted deficiencies relating to judgement, influenced by patient co-morbidity, urgency of the procedure,
communication, planning, equipment, and training.2 New skill set of the anaesthetist, and available resources.2 6 It is ac-

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pharmacological agents and videolaryngoscopes have been knowledged that anaesthetists do not work in isolation and
introduced, and further research has focused on extending the that the role of the anaesthetic assistant is important in influen-
duration of apnoea without desaturation by improving preoxy- cing the outcome of an airway crisis.7 Decisions about the best al-
genation and optimizing patient position. ternatives in the event of difficulty should be made and discussed
These updated guidelines provide a sequential series of plans with the anaesthetic assistant before induction of anaesthesia.
to be used when tracheal intubation fails and are designed to These guidelines recognize the difficulties in decision-mak-
prioritize oxygenation while limiting the number of airway inter- ing during an unfolding emergency. They include steps to assist
ventions in order to minimize trauma and complications (Fig 1). the anaesthetic team in making the correct decisions, limiting
The principle that anaesthetists should have back-up plans in the number of airway intervention attempts, encouraging declar-
place before performing primary techniques still holds true. ation of failure by placing a supraglottic airway device (SAD) even
Separate guidelines exist for difficult intubation in paediatric when face-mask ventilation is possible, and explicitly recom-
anaesthesia, obstetric anaesthesia, and for extubation.3–5 mending a time to stop and think about how to proceed.
These guidelines are directed at the unanticipated difficult An attempt has been made to identify essential skills and
intubation. Every patient should have an airway assessment techniques with the highest success rate. Anaesthetists and

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.
 Difficult Airway Society 2015 guidelines | 829

anaesthetic assistants using these guidelines must ensure that Disclaimer

they are familiar with the equipment and techniques described.
It is not intended that these guidelines should constitute a min-
This may require acquisition of new skills and regular practice,
imum standard of practice, nor are they to be regarded as a sub-
even for experienced anaesthetists.
stitute for good clinical judgement.

Methods Human factors

The Difficult Airway Society commissioned a working group to Human factors issues were considered to have contributed to ad-
update the guidelines in April 2012. An initial literature search verse outcomes in 40% of the instances reported to NAP4; how-
was conducted for the period January 2002 to June 2012 using da- ever, a more in-depth analysis of a subset of patients identified
tabases (Medline, PubMed, Embase, and Ovid) and a search en- human factor influences in every instance. Flin and colleagues9
gine (Google Scholar). The websites of the American Society of identified latent threats ( poor communication, poor training

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Anesthesiologists (http://www.asahq.org), Australian and New and teamwork, deficiencies in equipment, and inadequate sys-
Zealand College of Anaesthetists (http://www.anzca.edu.au), tems and processes) predisposing to loss of situation awareness
European Society of Anesthesiologists’ (http://www.esahq.org/ and subsequent poor decision-making as a precursor to final ac-
euroanaesthesia), Canadian Anesthesiologists’ Society (http:// tion errors.
www.cas.ca), and the Scandinavian Society of Anesthesiology Adoption of guidelines and a professional willingness to fol-
and Intensive Care Medicine (http://ssai.info/guidelines/) were low them are not enough on their own to avoid serious compli-
also searched for airway guidelines. English language articles cations of airway management during anaesthesia. All the
and abstract publications were identified using keywords and fil- instances reported to NAP4 occurred despite widespread dissem-
ters. The search terms were as follows: ‘Aintree intubating cath- ination of the original DAS guidelines, which had been published
eter’, ‘Airtraq’, ‘airway device’, ‘airway emergency’, ‘airway in 2004. The complexities of difficult airway management cannot
management’, ‘Ambu aScope’, ‘backward upward rightward be distilled into a single algorithm, and even the best anaesthetic
pressure’, ‘Bonfils’, ‘Bullard’, ‘bronchoscopy’, ‘BURP manoeuvre’, teams supported by the best guidelines will still struggle to per-
‘can’t intubate can’t ventilate’, ‘can’t intubate can’t oxygenate’, form optimally if the systems in which they operate are flawed.10
‘C-Mac’, ‘Combitube’, ‘cricoid pressure’, ‘cricothyroidotomy’, ‘cri- The 2015 guidelines acknowledge this.
cothyrotomy’, ‘C trach’, ‘difficult airway’, ‘difficult intubation’, During a crisis, it is common to be presented with more infor-
‘difficult laryngoscopy’, ‘difficult mask ventilation’, ‘difficult ven- mation than can be processed.11 This cognitive overload impairs
tilation’, ‘endotracheal intubation’, ‘esophageal intubation’, ‘Es- decision-making and can cause clinicians to ‘lose sight of the big
chmann stylet’, ‘failed intubation’, ‘Fastrach’, ‘fiber-optic scope’, picture’ and become fixated on a particular task, such as tracheal
‘fibreoptic intubation’, ‘fiberoptic scope’, ‘fibreoptic stylet’, ‘fibre- intubation or SAD placement. These guidelines provide an expli-
scope’ ‘Frova catheter’, ‘Glidescope’, ‘gum elastic bougie’, ‘hyp- cit instruction for the team to ‘stop and think’ to help reduce this
oxia’, ‘i-gel’, ‘illuminating stylet’, ‘jet ventilation catheter’, risk.
‘laryngeal mask’, ‘laryngeal mask airway Supreme’, ‘laryngos- Poor anaesthetic decision-making secondary to cognitive
copy’, ‘lighted stylet’, ‘light wand’, ‘LMA Supreme’, ‘Manujet’, errors and the impact of human factors in emergency airway
‘McCoy’, ‘McGrath’, ‘nasotracheal intubation’, ‘obesity’, ‘oe- management has recently been discussed.12 Cognitive aids are
sophageal detector device’, ‘oesophageal intubation’, ‘Pentax air- increasingly being used by clinicians during unfolding emergen-
way scope’, ‘Pentax AWS’, ‘ProSeal LMA′, ‘Quicktrach’, ‘ramping’, cies;13 for example, the Vortex Approach has been devised to sup-
‘rapid sequence induction’, ‘Ravussin cannula’, ‘Sanders inject- port decision-making during difficult airway management.14 The
or’, ‘Shikani stylet’, ‘sugammadex’, ‘supraglottic airway’, ‘suxa- algorithms that accompany these guidelines are intended as
methonium’, ‘tracheal introducer’, ‘tracheal intubation’, teaching and learning tools and have not been specifically de-
‘Trachview’, ‘Tru view’, ‘tube introducer’, ‘Venner APA’, ‘videolar- signed to be used as prompts during an airway crisis.
yngoscope’, and ‘videolaryngoscopy’. For any plan to work well in an emergency, it must be known
The initial search retrieved 16 590 abstracts. The searches to all members of the team and should be rehearsed. For rare
(using the same terms) were repeated every 6 months. In total, events, such as CICO, this rehearsal can be achieved with simula-
23 039 abstracts were retrieved and assessed for relevance by tion training, as has recently been included in the Australian and
the working group; 971 full-text articles were reviewed. Addition- New Zealand College of Anaesthetists continuing professional
al articles were retrieved by cross-referencing the data and hand- development requirements.15 16 This also provides the opportun-
searching. Each of the relevant articles was reviewed by at least ity to develop non-technical skills, such as leadership, team co-
two members of the working group. In areas where the evidence ordination, communication, and shared understanding of roles,
was insufficient to recommend particular techniques, expert which has been shown to improve performance in intensive
opinion was sought and reviewed.8 This was most notably the care and trauma teams.17 18
situation when reviewing rescue techniques for the ‘can’t intub- Structured communication between anaesthetists and an-
ate can’t oxygenate’ (CICO) situation. aesthetic assistants could help prepare for and deal with airway
Opinions of the DAS membership were sought throughout the difficulties. Talking before every patient, or at least before every
process. Presentations were given at the 2013 and 2014 DAS An- list, about the plan to manage difficulties should they develop
nual Scientific meetings, updates were posted on the DAS web- is good practice. At a minimum, this involves thinking about
site, and members were invited to complete an online survey the challenges that might be encountered and checking that
about which areas of the existing guidelines needed updating. the appropriate equipment is available.
Following the methodology used for the extubation guidelines,5 If airway management does become difficult after induction
a draft version of the guidelines was circulated to selected mem- of anaesthesia, a clear declaration of failure at the end of each
bers of DAS and acknowledged international experts for com- plan will facilitate progression through the airway strategy. The
ment. All correspondence was reviewed by the working group. use of a structured communication tool, such as PACE (Probe,
830 | Frerk et al.

Alert, Challenge, Emergency), can aid communication of con- minimizing the risk of airway obstruction, but this is not well tol-
cerns when cognitive overload and hierarchical barriers might erated by the conscious patient.40
otherwise make this difficult.19 Cricoid pressure should be applied with a force of 10 N when
Our profession must continue to acknowledge and address the patient is awake, increasing to 30 N as consciousness is lost.41 42
the impact of environmental, technical, psychological, and Although the application of cricoid pressure creates a physical
physiological factors on our performance. Human factors issues barrier to the passage of gastric contents, it has also been
at individual, team, and organizational levels all need to be con- shown to reduce lower oesophageal sphincter tone, possibly
sidered to enable these 2015 guidelines to be as effective as making regurgitation more likely.43 44 Current evidence suggests
possible. that if applied correctly, cricoid pressure may improve the view
on direct laryngoscopy.45 However, there are many reports dem-
onstrating that it is often poorly applied, and this may make
Preoperative assessment and planning mask ventilation, direct laryngoscopy, or SAD insertion more dif-
ficult.46–52 If initial attempts at laryngoscopy are difficult during

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Airway management is safest when potential problems are iden-
tified before surgery, enabling the adoption of a strategy, a series rapid sequence induction, cricoid pressure should be released.
of plans, aimed at reducing the risk of complications.2 This should be done under vision with the laryngoscope in
Preoperative airway assessment should be performed rou- place and suction available; in the event of regurgitation,41 cri-
tinely in order to identify factors that might lead to difficulty coid pressure should be immediately reapplied.
with face-mask ventilation, SAD insertion, tracheal intubation, Second-generation SADs offer greater protection against as-
or front-of-neck access. piration than first-generation devices and are recommended
Prediction of difficulty in airway management is not com- should intubation fail during a rapid sequence induction.
pletely reliable;20–22 the anaesthetist should have a strategy in
place before the induction of anaesthesia, and this should be dis-
cussed at the team brief and the sign-in ( pre-induction) phase of Plan A. Mask ventilation and tracheal
the WHO Surgical Safety Checklist.23 24 intubation
Assessment of the risk of aspiration is a key component of
The essence of Plan A (Table 1) is to maximize the likelihood of
planning airway management. Steps should be taken before sur-
successful intubation at the first attempt or, failing that, to
gery to reduce the volume and pH of gastric contents by fasting
limit the number and duration of attempts at laryngoscopy in
and pharmacological means. Mechanical drainage by nasogas-
order to prevent airway trauma and progression to a CICO
tric tube should be considered in order to reduce residual gastric
situation.
volume in patients with severely delayed gastric emptying or in-
All patients should be optimally positioned and preoxyge-
testinal obstruction.2
nated before induction of anaesthesia. Neuromuscular block fa-
cilitates face-mask ventilation53 54 and tracheal intubation.
Rapid sequence induction Every attempt at laryngoscopy and tracheal intubation has the
potential to cause trauma. A suboptimal attempt is a wasted at-
The placement of a cuffed tube in the trachea offers the greatest
tempt and having failed, the chance of success declines with
protection against aspiration. Suxamethonium is the traditional
each subsequent attempt.55 56 Repeated attempts at tracheal in-
neuromuscular blocking agent of choice because its rapid
tubation may reduce the likelihood of effective airway rescue
onset allows early intubation without the need for bag–mask
with a SAD.57 These guidelines recommend a maximum of
ventilation. Several studies have compared suxamethonium
three attempts at intubation; a fourth attempt by a more experi-
with rocuronium for rapid sequence induction, and although
enced colleague is permissible. If unsuccessful, a failed intub-
some have shown better intubating conditions with suxameth-
ation should be declared and Plan B implemented.
onium, others have found that after rocuronium 1.2 mg kg−1
the speed of onset and intubation conditions are compar-
able.25–30 Suxamethonium-induced fasciculation increases oxy-
gen consumption during apnoea, which may become relevant
Table 1 Key features of Plan A
in the event of airway obstruction.31 32 The ability to antagonize
the effect of rocuronium rapidly with sugammadex may be an
advantage,30 although it should be remembered that this does
not guarantee airway patency or the return of spontaneous ven- • Maintenance of oxygenation is the priority
tilation.33 34 If rapid antagonism of rocuronium with sugamma- • Advantages of head-up positioning and ramping are
dex is part of the failed intubation plan, the correct dose (16 mg highlighted
kg−1) must be immediately available.35 36 • Preoxygenation is recommended for all patients
Cricoid pressure is applied to protect the airway from contam- • Apnoeic oxygenation techniques are recommended in
high-risk patients
ination during the period between loss of consciousness and
• The importance of neuromuscular block is emphasized
placement of a cuffed tracheal tube. This is a standard compo-
• The role of videolaryngoscopy in difficult intubation is
nent of a rapid sequence induction in the UK.37 It is often over-
recognized
looked that cricoid pressure has been shown to prevent gastric
• All anaesthetists should be skilled in the use of a
distension during mask ventilation and was originally described
videolaryngoscope
for this purpose.38 39 Gentle mask ventilation after the applica- • A maximum of three attempts at laryngoscopy are
tion of cricoid pressure and before tracheal intubation prolongs recommended (3+1)
the time to desaturation. This is most useful in those with poor • Cricoid pressure should be removed if intubation is difficult
respiratory reserve, sepsis, or high metabolic requirements and
also provides an early indication of the ease of ventilation.
A force of 30 N provides good airway protection, while
 Difficult Airway Society 2015 guidelines | 831

Position abolishes laryngeal reflexes, increases chest compliance, and fa-

cilitates face-mask ventilation.53 54 95 Complete neuromuscular
Good patient positioning maximizes the chance of successful
block should be ensured if any difficulty is encountered with air-
laryngoscopy and tracheal intubation. In most patients, the
way management.96 Rocuronium has a rapid onset and can be
best position for direct laryngoscopy with a Macintosh-style
antagonized immediately with sugammadex, although the inci-
blade is achieved with the neck flexed and the head extended
dence of anaphylaxis may be higher than with other non-de-
at the atlanto-occipital joint; the classic ‘sniffing’ position.58–60
polarizing neuromuscular blocking agents.97–99
In the obese patient, the ‘ramped’ position should be used rou-
tinely to ensure horizontal alignment of the external auditory
meatus and the suprasternal notch because this improves the Mask ventilation
view during direct laryngoscopy.61–64 This position also improves Mask ventilation with 100% oxygen should begin as soon as pos-
airway patency and respiratory mechanics and facilitates passive sible after induction of anaesthesia. If difficulty is encountered,
oxygenation during apnoea.65 66 the airway position should be optimized and airway manoeuvres

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such as a chin lift or jaw thrust should be attempted. Oral and
Preoxygenation and apnoeic techniques to maintain nasopharyngeal airways should be considered, and a four-
oxygenation handed technique (two-person or pressure-controlled mechan-
ical ventilation) should be used.100 The ‘sniffing’ position
All patients should be preoxygenated before the induction of gen-
increases the pharyngeal space and improves mask ventila-
eral anaesthesia.67 De-nitrogenation can be achieved with an ap-
tion.101 Inadequate anaesthesia or inadequate neuromuscular
propriate flow of 100% oxygen into the breathing system,
block make mask ventilation more difficult.102 103
maintaining an effective face-mask seal68 until the end-tidal
oxygen fraction is 0.87–0.9.69 Many other preoxygenation techni-
ques have been described.70–79 Choice of laryngoscope
Preoxygenation increases the oxygen reserve, delays the onset The choice of laryngoscope influences the chance of successful
of hypoxia, and allows more time for laryngoscopy, tracheal intub- tracheal intubation. Videolaryngoscopes offer an improved
ation,65 69 and for airway rescue should intubation fail. In healthy view compared with conventional direct laryngoscopy and are
adults, the duration of apnoea without desaturation (defined as now the first choice or default device for some anaesthe-
the interval between the onset of apnoea and the time peripheral tists.104–113 Regular practice is required to ensure that the improved
capillary oxygen saturation reaches a value of ≤90%) is limited to view translates reliably into successful tracheal intubation.114
1–2 min whilst breathing room air, but can be extended to 8 min All anaesthetists should be trained to use, and have immediate
with preoxygenation.69 Preoxygenation using a 20–25° head-up access to, a videolaryngoscope.115 The flexible fibrescope or
position80 81 and continuous positive airway pressure has been optical stylets, such as Bonfils (Karl Storz), Shikani (Clarus Med-
shown to delay the onset of hypoxia in obese patients.82–84 The ical), or Levitan FPS scope™ (Clarus Medical), may be the pre-
duration of apnoea without desaturation can also be prolonged ferred choice for individuals who are expert in their use.116–122
by passive oxygenation during the apnoeic period (apnoeic oxy- The first and second choice of laryngoscope will be determined
genation). This can be achieved by delivering up to 15 litres by the anaesthetist’s experience and training.
min−1 of oxygen through nasal cannulae, although this may be
uncomfortable for an awake patient.65 85 86 Nasal Oxygenation
Tracheal tube selection
During Efforts Of Securing A Tube (NODESAT) has been shown to
extend the apnoea time in obese patients and in patients with a Tracheal tubes should be selected according to the nature of the
difficult airway.87 Transnasal humidified high-flow oxygen (up to surgical procedure, but their characteristics can influence the
70 litres min−1) via purpose-made nasal cannulae has been ease of intubation. A smaller tube is easier to insert because a bet-
shown to extend the apnoea time in obese patients and in patients ter view of the laryngeal inlet is maintained during passage of the
with difficult airways,88 although it’s efficacy as a means of preox- tube between the cords. Smaller tubes are also less likely to cause
ygenation has not been evaluated fully.89 90 Apnoeic oxygenation trauma.123 ‘Hold-up’ at the arytenoids is a feature of the left-facing
is an area of recent research interest about which further evidence bevel of most tracheal tubes, and can occur particularly whilst rail-
is awaited. The administration of oxygen by nasal cannulae in roading larger tubes over a bougie, stylet, or fibrescope.124 125 This
addition to standard preoxygenation and face-mask ventilation problem can be overcome by rotating the tube anticlockwise to
is recommended in high-risk patients. change the orientation of the bevel or by preloading the tube so
that the bevel faces posteriorly and by minimizing the gap be-
tween the fibrescope and the tube during fibre-optic intub-
Choice of induction agent
ation.125–127 Tubes with hooded, blunted, or flexible tips, such as
The induction agent should be selected according to the clinical the Parker Flex-Tip™ (Parker Medical), and tubes supplied with
condition of the patient. Propofol, the most commonly used induc- the Intubating LMA® (Teleflex Medical Europe Ltd) have been de-
tion agent in the UK, suppresses laryngeal reflexes and provides signed to reduce the incidence of this problem.128–132
better conditions for airway management than other agents.91–93
The 5th National Audit Project of the Royal College of Anaesthe-
Laryngoscopy
tists highlighted the relationship between difficult airway manage-
ment and awareness.94 It is important to ensure that the patient is In these guidelines, an attempt at laryngoscopy is defined as the in-
adequately anaesthetized during repeated attempts at intubation. sertion of a laryngoscope into the oral cavity. Every attempt should
be carried out with optimal conditions because repeated attempts
at laryngoscopy and airway instrumentation are associated with
Neuromuscular block
poor outcomes and the risk of developing a CICO situation.56 133–
136
If intubation is difficult, further attempts should not proceed If difficulty is encountered, help should be summoned early, re-
without full neuromuscular block. Neuromuscular block gardless of the level of experience of the anaesthetist.
832 | Frerk et al.

If intubation is difficult, there is little point in repeating the Successful placement of a SAD creates the opportunity to
same procedure unless something can be changed to improve stop and think about whether to wake the patient up, make a fur-
the chance of success. This may include the patient’s position, ther attempt at intubation, continue anaesthesia without a tra-
the intubating device or blade, adjuncts such as introducers and cheal tube, or rarely, to proceed directly to a tracheostomy or
stylets, depth of neuromuscular block, and personnel. The number cricothyroidotomy.
of attempts at laryngoscopy should be limited to three. A fourth at- If oxygenation through a SAD cannot be achieved after a max-
tempt should be undertaken only by a more experienced colleague. imum of three attempts, Plan C should be implemented.

External laryngeal manipulation Supraglottic airway device selection and placement

External laryngeal manipulation applied with the anaesthetist’s As difficulty with intubation cannot always be predicted, every
right hand or backward, upward, and rightward pressure (BURP) anaesthetist should have a well-thought-through plan for such
an eventuality. The decision about which SAD to use for rescue

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on the thyroid cartilage applied by an assistant may improve the
view at laryngoscopy.137–142 A benefit of videolaryngoscopy is should have been made before induction of anaesthesia, and
that the anaesthetic assistant is also able to see the effects of this choice should be determined by the clinical situation, device
laryngeal manipulation.143 availability, and operator experience.
NAP4 identified the potential advantages of second-gener-
ation devices in airway rescue and recommended that all hospi-
Use of a bougie or stylet tals have them available for both routine use and rescue airway
The gum elastic bougie is a widely used device for facilitating tra- management.2 Competence and expertise in the insertion of
cheal intubation when a grade 2 or 3a view of the larynx is seen any SAD requires training and practice.172–176 All anaesthetists
during direct laryngoscopy.144–146 Pre-shaping of the bougie facil- should be trained to use and have immediate access to second-
itates successful intubation.147 It can also be helpful during vi- generation SADs.
deolaryngoscopy.148 149 Blind bougie insertion is associated
with trauma and is not recommended in a grade 3b or 4 Cricoid pressure and supraglottic airway device insertion
view.150–155 The ‘hold-up’ sign may signal the passage of the
bougie as far as small bronchi,156 but it is associated with risk Cricoid pressure decreases hypopharyngeal space177 and impedes
of airway perforation and trauma, especially with single-use bou- SAD insertion and the placement of both first- and second-gener-
gies.153 157–159 Forces as little as 0.8 N can cause airway trauma.153 ation devices.178–181 Cricoid pressure will have been removed dur-
The characteristics of bougies vary, and this may affect their per- ing Plan A if laryngoscopy was difficult and (in the absence of
formance.153 Once the bougie is in the trachea, keeping the regurgitation) should remain off during insertion of a SAD.
laryngoscope in place enhances the chance of successful intub-
ation.129 Non-channelled videolaryngoscopes with angulated Second-generation supraglottic airway devices
blades necessitate the use of a pre-shaped stylet or bougie to
It has been argued that second-generation SADs should be used
aid the passage of the tracheal tube through the cords.160–163
routinely because of their efficacy and increased safety when com-
When using a videolaryngoscope, the tip of the tube should be in-
pared with first-generation devices.182 Several second-generation
troduced into the oropharynx under direct vision because failure
SADs have been described,183–191 and it is likely that during the
to do so has been associated with airway trauma.163–167
lifetime of these guidelines many similar devices will appear.
The ideal attributes of a SAD for airway rescue are reliable
Tracheal intubation and confirmation first-time placement, high seal pressure, separation of gastro-
intestinal and respiratory tracts, and compatibility with fibre-op-
Difficulty with tracheal intubation is usually the result of a poor
tically guided tracheal intubation. These attributes are variably
laryngeal view, but other factors, such as tube impingement, can
combined in different devices.182 Of those currently available,
hinder the passage of the tube into the trachea.
only the i-gel™ (Intersurgical, Wokingham, UK), the Proseal™
Once tracheal intubation has been achieved, correct placement
LMA® (PLMA; Teleflex Medical Europe Ltd, Athlone, Ireland),
of the tube within the trachea must be confirmed. This should in-
and the LMA Supreme™ (SLMA; Teleflex Medical Ltd) have
clude visual confirmation that the tube is between the vocal cords,
large-scale longitudinal studies,192–195 literature reviews,196 or
bilateral chest expansion, and auscultation and capnography.
meta-analyses in adults197–200 supporting their use. A number
A continuous capnography waveform with appropriate inspired
of studies have compared second-generation SADs,201–224 but it
and end-tidal values of CO2 is the gold standard for confirming
is important to recognize that the experience of the operator
ventilation of the lungs. Capnography should be available in
with the device also influences the chance of successful
every location where a patient may require anaesthesia.2 168
insertion.225
Absence of exhaled CO2 indicates failure to ventilate the
lungs, which may be a result of oesophageal intubation or com-
plete airway obstruction (rarely, complete bronchospasm).2 In Limiting the number of insertion attempts
such situations, it is safest to assume oesophageal intubation. Repeated attempts at inserting a SAD increases the likelihood of
Videolaryngoscopy, examination with a fibrescope, or ultrasound airway trauma and may delay the decision to accept failure and
can be used to verify that the tube is correctly positioned.169–171 move to an alternative technique to maintain oxygenation.
Successful placement is most likely on the first attempt. In
one series, insertion success with the PLMA™ was 84.5% on the
Plan B. Maintaining oxygenation: supraglottic
first attempt, decreasing to 36% on the fourth attempt.193 In the
airway device insertion series of Goldmann and colleagues,194 only 4.2% of devices
In these guidelines (Fig. 2), the emphasis of Plan B (Table 2) is on were placed on the third or fourth attempt. Three studies report
maintaining oxygenation using an SAD. that a third insertion attempt increased overall success rate by
 Difficult Airway Society 2015 guidelines | 833

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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.

Even supraglottic airways can fail.227 228 If effective oxygen-

Table 2 Key features of Plan B. ation has not been established after three attempts, Plan C
SAD, supraglottic airway device
should be implemented.

Guided supraglottic airway device placement

• Failed intubation should be declared
• The emphasis is on oxygenation via a SAD Bougie-aided placement of the PLMA has been described as im-
• Second-generation SADs are recommended proving first-time placement.229 In comparison studies, the bou-
• A maximum of three attempts at SAD insertion are gie-guided technique was 100% effective at achieving first-time
recommended placement and more effective than digital insertion or insertion
• During rapid sequence induction, cricoid pressure should with the introducer tool.230 231 Bougie-aided placement provides
be removed to facilitate insertion of a SAD better alignment of the drain port and a better fibre-optic view of
• Blind techniques for intubation through a SAD are not the cords through the PLMA than the introducer tool method.232
recommended
Patients with a history of difficult tracheal intubation or predicted
difficulty were excluded from these studies, making it unclear
how effective this technique would be in this situation. The tech-
nique has been used effectively in a simulated difficult airway
in patients wearing a hard collar,233 but again patients with pre-
more than 5%; however, one was conducted with operators who dicted difficulty were excluded. A comparative study between
had minimal experience, and the other two used the Baska® the i-gel and the PLMA using a guided technique with a duo-
mask (Baska Versatile Laryngeal Mask, Pty Ltd, Strathfield, NSW, denal tube234 showed both devices to have a first-time insertion
Australia).189 214 226 Changing to an alternative SAD has been success rate of >97%. An orogastric tube has also been used
shown to be successful.192 193 211 216 218 223 224 A maximum of effectively to facilitate PLMA placement in 3000 obstetric
three attempts at SAD insertion is recommended; two with the patients.235 Despite the apparent benefit, bougie- and gastric
preferred second-generation device and another attempt with tube-guided placement of second-generation devices are not
an alternative. An attempt includes changing the size of the SAD. guaranteed to be successful.193 221 The technique requires
834 | Frerk et al.

experience, it may cause trauma,150 and it is not listed in the cur- 128 patients with a 93% success rate through a classic Laryngeal
rent PLMA instruction manual.236 Mask Airway.255 The patients in whom the technique was suc-
cessful included 90.8% with a grade 3 or 4 Cormack and Lehane
view at direct laryngoscopy and three patients in whom mask
Successful supraglottic airway device insertion and
ventilation was reported to be impossible.
effective oxygenation established: ‘stop and think’ Aintree Intubation Catheter™-facilitated intubation has also
Clinical examination and capnography should be used to confirm been described with the PLMA256 257 and the i-gel.258 Aintree In-
ventilation. If effective oxygenation has been established tubation Catheter™-guided intubation through an LMA Su-
through a SAD, it is recommended that the team stop and take preme™ has been reported,259 but it is unreliable260 and cannot
the opportunity to review the most appropriate course of action. be recommended.261
There are four options to consider: wake the patient up; at-
tempt intubation via the SAD using a fibre-optic scope; proceed Proceed with surgery using the supraglottic airway

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with surgery using the supraglottic airway; or (rarely) proceed
device
to tracheostomy or cricothyroidotomy.
Patient factors, the urgency of the surgery, and the skill set of the This should be considered as a high-risk option reserved for spe-
operator all influence the decision, but the underlying principle is to cific or immediately life-threatening situations and should in-
maintain oxygenation while minimizing the risk of aspiration. volve input from a senior clinician. The airway may already be
traumatized from several unsuccessful attempts at intubation
and may deteriorate during the course of surgery because of de-
Wake the patient up vice dislodgement, regurgitation, airway swelling, or surgical fac-
If the surgery is not urgent then the safest option is to wake the tors. Rescue options are limited given that tracheal intubation is
patient up, and this should be considered first. This will require already known to have failed.
the full antagonism of neuromuscular block. If rocuronium or ve- Although waking a patient up after failed intubation is most
curonium has been used, sugammadex is an appropriate choice often in their best interest, this is a difficult decision for an anaes-
of antagonistic agent. If another non-depolarizing neuromuscu- thetist to take, especially during a crisis.241 262
lar blocking agent has been used then anaesthesia must be main-
tained until paralysis can be adequately antagonized. Surgery Proceed to tracheostomy or cricothyroidotomy
may then be postponed or may continue after awake intubation
In rare circumstances, even when it is possible to ventilate
or under regional anaesthesia.
through a SAD, it may be appropriate to secure the airway with
If waking the patent up is inappropriate (for example, in the
a tracheostomy or cricothyroidotomy.
critical care unit, in the emergency department, or where life-
saving surgery must proceed immediately), the remaining op-
tions should be considered. Plan C. Final attempt at face-mask ventilation
If effective ventilation has not been established after three SAD
Intubation via the supraglottic airway device insertion attempts, Plan C (Table 3) follows on directly. A number
of possible scenarios are developing at this stage. During Plans A
Intubation through a SAD is only appropriate if the clinical situ-
and B, it will have been determined whether face-mask ventila-
ation is stable, oxygenation is possible via the SAD, and the anaes-
tion was easy, difficult, or impossible, but the situation may
thetist is trained in the technique. Limiting the number of airway
have changed if attempts at intubation and SAD placement
interventions is a core principle of safe airway management; re-
have traumatized the airway.
peated attempts at intubation through a SAD are inappropriate.
If face-mask ventilation results in adequate oxygenation, the
Intubation through an intubating laryngeal mask airway
patient should be woken up in all but exceptional circumstances,
(iLMA™; Teleflex Medical Ltd) was included in the 2004 guide-
and this will require full antagonism of neuromuscular block.
lines.1 Although an overall success rate of 95.7% has been re-
If it is not possible to maintain oxygenation using a face mask,
ported in a series of 1100 patients using a blind technique,237
ensuring full paralysis before critical hypoxia develops offers a
first-attempt success rates are higher using fibre-optic guid-
final chance of rescuing the airway without recourse to Plan D.
ance,238 239 and a guided technique has been shown to be of bene-
fit in patients with difficult airways.240 The potential for serious
adverse outcomes associated with blind techniques remains.241
Table 3 Key features of Plan C.
With the need for repeated insertion attempts to achieve suc-
CICO, can’t intubate can’t oxygenate; SAD, supraglottic airway
cess238 and a low first-time success rate240 242 (even with se- device
cond-generation devices243), the blind technique is redundant.
Direct fibre-optically guided intubation has been described via
a number of SADs, although this may be technically challen-
ging.244–248 Fibre-optically guided tracheal intubation through • Failed SAD ventilation should be declared
• Attempt to oxygenate by face mask
the i-gel has been reported with a high success rate.249 250 Se-
• If face-mask ventilation is impossible, paralyse
cond-generation SADs specifically designed to facilitate tracheal
• If face-mask ventilation is possible, maintain oxygenation
intubation have been described,190 251 252 but data regarding their
and wake the patient up
efficacy are limited.
• Declare CICO and start Plan D
The use of an Aintree Intubation Catheter™ (AIC; Cook Medic-
• Continue attempts to oxygenate by face mask, SAD, and
al, Bloomington, USA) over a fibre-optic scope allows guided in- nasal cannulae
tubation through a SAD where direct fibre-optically guided
intubation is not possible.248 253 The technique is described on
the DAS website.254 Descriptions of AIC use include a series of
 Difficult Airway Society 2015 guidelines | 835

Sugammadex has been used to antagonize neuromuscular

block during the CICO situation but does not guarantee a patent Table 4 Key features of Plan D.
CICO, can’t intubate can’t oxygenate
and manageable upper airway.34 263–266 Residual anaesthesia,
trauma, oedema, or pre-existing upper airway pathology may
all contribute to airway obstruction.33
• CICO and progression to front-of-neck access should be
declared
Plan D: Emergency front-of-neck access • A didactic scalpel technique has been selected to promote
A CICO situation arises when attempts to manage the airway by standardized training
tracheal intubation, face-mask ventilation, and SAD have failed • Placement of a wide-bore cuffed tube through the
cricothyroid membrane facilitates normal minute
(Table 4). Hypoxic brain damage and death will occur if the situ-
ventilation with a standard breathing system
ation is not rapidly resolved.
• High-pressure oxygenation through a narrow-bore

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Current evidence in this area comes either from scenario-
cannula is associated with serious morbidity
based training using manikin, cadaver, or wet lab facilities or
• All anaesthetists should be trained to perform a surgical
from case series, typically in out-of-hospital or emergency de-
airway
partment settings.267–272 None of these completely replicates • Training should be repeated at regular intervals to ensure
the situation faced by anaesthetists delivering general anaesthe- skill retention
sia in a hospital setting.
NAP4 provided commentary on a cohort of emergency surgi-
cal airways and cannula cricothyroidotomies performed when
other methods of securing the airway during general anaesthesia
recommended in these guidelines is a modification of previously
had failed.2 The report highlighted a number of problems, includ-
described techniques.
ing decision-making (delay in progression to cricothyroidotomy),
Airway rescue via the front of neck should not be attempted
knowledge gaps (not understanding how available equipment
without complete neuromuscular block. If sugammadex has
worked), system failures (specific equipment not being available),
been administered earlier in the strategy, a neuromuscular block-
and technical failures (failure to site a cannula in the airway).
ing agent other than rocuronium or vecuronium will be required.
After NAP4, discussion largely focused on the choice of tech-
Oxygen (100%) should be applied to the upper airway through-
nique and equipment used when airway rescue failed, but the re-
out, using a SAD, a tightly fitting face mask, or nasal insufflation.
port also highlighted the importance of human factors.2 273–275
The use of the ‘laryngeal handshake’ as described by Levi-
Regular training in both technical and non-technical ele-
tan281 (Fig. 3) is recommended as the first step because it pro-
ments is needed in order to reinforce and retain skills. Success
motes confidence in the recognition of the three-dimensional
depends on decision-making, planning, preparation, and skill ac-
anatomy of the laryngeal structures; the conical cartilaginous
quisition, all of which can be developed and refined with re-
cage consisting of the hyoid, thyroid, and cricoid. The laryngeal
peated practice.276 277 Cognitive processing and motor skills
handshake is performed with the non-dominant hand, identify-
decline under stress. A simple plan to rescue the airway using fa-
ing the hyoid and thyroid laminae, stabilizing the larynx between
miliar equipment and rehearsed techniques is likely to increase
thumb and middle finger, and moving down the neck to palpate
the chance of a successful outcome. Current evidence indicates
the cricothyroid membrane with the index finger.
that a surgical technique best meets these criteria.2 269 273 278
Standardization is useful in rarely encountered crisis situa-
A cricothyroidotomy may be performed using either a scalpel
tions. It is recommended that the technique described below is
or a cannula technique. Anaesthetists must learn a scalpel tech-
adopted. The technique relies on the correct equipment being
nique and have regular training to avoid skill fade.279
immediately available. Operator position and stabilization of
the hands is important.
Scalpel cricothyroidotomy
Scalpel cricothyroidotomy is the fastest and most reliable meth- Equipment
od of securing the airway in the emergency setting.269 278 280 A 1. Scalpel with number 10 blade; a broad blade (with the same
cuffed tube in the trachea protects the airway from aspiration, width as the tracheal tube) is essential.
provides a secure route for exhalation, allows low-pressure ven- 2. Bougie with coude (angled) tip.
tilation using standard breathing systems, and permits end-tidal 3. Tube, cuffed, size 6.0 mm.
CO2 monitoring.
A number of surgical techniques have been described, but Patient positioning
there is a lack of evidence of the superiority of one over an- The sniffing position used for routine airway management does
other.268 281–283 The techniques all have steps in common: neck not provide optimal conditions for cricothyroidotomy; in this
extension, identification of the cricothyroid membrane, incision situation, neck extension is required. In an emergency, this
through the skin and cricothyroid membrane, and insertion of a may be achieved by pushing a pillow under the shoulders, drop-
cuffed tracheal tube. In some descriptions, the skin and crico- ping the head of the operating table, or by pulling the patient up
thyroid membrane are cut sequentially; in others, a single inci- so that the head hangs over the top of the trolley.
sion is recommended. Many include a placeholder to keep the
incision open until the tube is in place. Some use specialist equip- Cricothyroid membrane palpable: scalpel technique (Fig. 4;
ment (cricoid hook, tracheal dilators etc). ‘stab, twist, bougie, tube’)
A single stab incision through the cricothyroid membrane is 1. Continue attempts at rescue oxygenation via upper airway
appealing in terms of its simplicity, but this approach may fail (assistant).
in the obese patient or if the anatomy is difficult, and a vertical 2. Stand on the patient’s left-hand side if you are right handed
skin incision is recommended in this situation. The approach (reverse if left handed).
836 | Frerk et al.

A B C

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Fig 3 The laryngeal handshake. () 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. () The fingers and thumb slide down over the thyroid laminae. () Middle finger and
thumb rest on the cricoid cartilage, with the index finger palpating the cricothyroid membrane.

3. Perform a laryngeal handshake to identify the laryngeal Equipment, patient, and operator position are as for the scalpel
anatomy. technique (Fig. 5)
4. Stabilize the larynx using the left hand. 1. Continue attempts at rescue oxygenation via upper airway
5. Use left index finger to identify the cricothyroid membrane. (assistant).
6. Hold the scalpel in your right hand, make a transverse stab in- 2. Attempt to identify the laryngeal anatomy using a laryngeal
cision through the skin and cricothyroid membrane with the handshake.
cutting edge of the blade facing towards you. 3. If an ultrasound machine is immediately available and switched
7. Keep the scalpel perpendicular to the skin and turn it through on, it may help to identify the midline and major blood vessels.
90° so that the sharp edge points caudally (towards the feet). 4. Tension skin using the left hand.
8. Swap hands; hold the scalpel with your left hand. 5. Make an 8–10 cm midline vertical skin incision, caudad to
9. Maintain gentle traction, pulling the scalpel towards you (lat- cephalad.
erally) with the left hand, keeping the scalpel handle vertical 6. Use blunt dissection with fingers of both hands to separate
to the skin (not slanted). tissues and identify and stabilize the larynx with left hand.
10. Pick the bougie up with your right hand. 7. Proceed with ‘scalpel technique’ as above.
11. Holding the bougie parallel to the floor, at a right angle to the
trachea, slide the coude tip of the bougie down the side of the Note that a smaller cuffed tube (including a Melker) can be used
scalpel blade furthest from you into the trachea. provided it fits over the bougie. The bougie should be advanced
12. Rotate and align the bougie with the patient’s trachea and ad- using gentle pressure; clicks may be felt as the bougie slides
vance gently up to 10–15 cm. over the tracheal rings. ‘Hold-up’ at less than 5 cm may indicate
13. Remove the scalpel. that the bougie is pre-tracheal.
14. Stabilize trachea and tension skin with left hand.
15. Railroad a lubricated size 6.0 mm cuffed tracheal tube over the Cannula techniques
bougie.
Narrow-bore (<4 mm) cannula
16. Rotate the tube over the bougie as it is advanced. Avoid exces-
Cannula techniques were included in the 2004 guidelines and
sive advancement and endobronchial intubation.
have been advocated for a number of reasons, including the
17. Remove the bougie.
fact that anaesthetists are much more familiar with handling
18. Inflate the cuff and confirm ventilation with capnography.
cannulae than scalpels. It has been argued that reluctance to
19. Secure the tube.
use a scalpel may delay decision-making and that choosing a
cannula technique may promote earlier intervention.268
If unsuccessful, proceed to scalpel–finger–bougie technique
Whilst narrow-bore cannula techniques are effective in the
(below).
elective setting, their limitations have been well described.2 284
285
Impalpable cricothyroid membrane: scalpel–finger–bougie Ventilation can be achieved only by using a high-pressure
technique source, and this is associated with a significant risk of
This approach is indicated when the cricothyroid membrane is barotrauma.2 268 286 Failure because of kinking, malposition, or
impalpable or if other techniques have failed. displacement of the cannula can occur even with purpose-
 Difficult Airway Society 2015 guidelines | 837

A B C

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D E

Fig 4 Cricothyroidotomy technique. Cricothyroid membrane palpable: scalpel technique; ‘stab, twist, bougie, tube’. () Identify cricothyroid membrane. () Make
transverse stab incision through cricothyroid membrane. () Rotate scalpel so that sharp edge points caudally. () Pulling scalpel towards you to open up the
incision, slide coude tip of bougie down scalpel blade into trachea. () Railroad tube into trachea.

designed cannulae, such as the Ravussin™ (VBM, Sulz, Further evidence of the efficacy of this technique in human
Germany).2 268 High-pressure ventilation devices may not be practice is needed before widespread adoption can be
available in all locations, and most anaesthetists do not use recommended.
them regularly. Their use in the CICO situation should be limited
to experienced clinicians who use them in routine clinical practice. Wide-bore cannula over guidewire
Experience of training protocols carried out using high-fidel- Some wide-bore cannula kits, such as the Cook Melker® emer-
ity simulation with a live animal model (wet lab) suggest that per- gency cricothyrotomy set, use a wire-guided (Seldinger) tech-
formance can be improved by following didactic teaching of nique.289 This approach is less invasive than a surgical
rescue protocols.287 Wet lab high-fidelity simulation is unique be- cricothyroidotomy and avoids the need for specialist equipment
cause it provides a model that bleeds, generates real-time stress, for ventilation. The skills required are familiar to anaesthetists
and has absolute end-points (end-tidal CO2 or hypoxic cardiac ar- and intensivists because they are common to central line inser-
rest) to delineate success or failure. After observation of >10 000 tion and percutaneous tracheostomy; however, these techniques
clinicians performing infraglottic access on anaesthetized require fine motor control, making them less suited to stressful
sheep,268 288 Heard has recommended a standard operating pro- situations. Whilst a wire-guided technique may be a reasonable
cedure with a 14 gauge Insyte™ (Becton, Dickinson and Com- alternative for anaesthetists who are experienced with this
pany) cannula technique, with rescue oxygenation delivered method, the evidence suggests that a surgical cricothyroidotomy
via a purpose-designed Y-piece insufflator with a large-bore ex- is both faster and more reliable.288
haust arm (Rapid-O2™ Meditech Systems Ltd UK). This is fol-
lowed by insertion of a cuffed tracheal tube using the Melker® Non-Seldinger wide-bore cannula
wire-guided kit. An algorithm, a structured teaching programme, A number of non-Seldinger wide-bore cannula-over-trochar de-
competency-based assessment tools, and a series of videos have vices are available for airway rescue. Although successful use
been developed to support this methodology and to promote has been reported in CICO, there have been no large studies of
standardized training.287 these devices in clinical practice.275 The diversity of
838 | Frerk et al.

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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.

commercially available devices also presents a problem because not delay airway access.171 291 292 Airway evaluation using ultra-
familiarity with equipment that is not universally available chal- sound is a valuable skill for anaesthetists,292 and training in its
lenges standardization of training. use is recommended.273 293

The role of ultrasound Postoperative care and follow-up

It is good practice to attempt to identify the trachea and the crico- Difficulties with airway management and the implications for
thyroid membrane during the preoperative assessment.273 If this postoperative care should be discussed at the end of the proced-
is not possible with inspection and palpation alone, it can often ure during the sign-out section of the WHO checklist.294 In add-
be achieved with ultrasonography.171 290 The role of ultrasound ition to a verbal handover, an airway management plan should
in emergency situations is limited. If immediately available and be documented in the medical record. Many airway guidelines
switched on it may help to identify key landmarks but should and airway interest groups169 295 296 (including the DAS
 Difficult Airway Society 2015 guidelines | 839

Extubation and Obstetric Guidelines4 5) recommend that patients guidelines may be loosely followed in the management of
should be followed up by the anaesthetist in order to document patients with a known or suspected difficult airway, and in
and communicate difficulties with the airway. There is a close re- these circumstances a suitably experienced surgeon with appro-
lationship between difficult intubation and airway trauma;297 298 priate equipment could be immediately available to perform the
patient follow-up allows complications to be recognized and surgical airway on behalf of the anaesthetist.
treated. Any instrumentation of the airway can cause trauma Complications related to airway management are not limited
or have adverse effects; this has been reported with videolaryn- to situations where the primary plan has been tracheal intub-
goscopes,163 166 second-generation supraglottic devices,192 193 195 ation; 25% of anaesthesia incidents reported to NAP4 started
and fibre-optic intubation.299 The American Society of Anesthe- with the intention of managing the airway using a SAD. Whilst
siologists closed claims analysis suggests that it is the pharynx the key principles and techniques described in these guidelines
and the oesophagous that are damaged most commonly during are still appropriate in this situation, it is likely that at the point
difficult intubation.298 Pharyngeal and oesophageal injury are dif- of recognizing serious difficulty the patient may not be well oxy-
ficult to diagnose, with pneumothorax, pneumomediastinum, or

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genated or optimally positioned.
surgical emphysema present in only 50% of patients.5 Mediastini- These guidelines have been created for ‘unanticipated diffi-
tis after airway perforation has a high mortality, and patients culty’ with airway management, and it is important that what-
should be observed carefully for the triad of pain (severe sore ever the primary plan may be, a genuine attempt has been
throat, deep cervical pain, chest pain, dysphagia, painful swallow- made to identify possible difficulties with the generic Plans A,
ing), fever, and crepitus.297 300 They should be warned to seek med- B, C, and D. Assessing mouth opening, neck mobility, and the lo-
ical attention should delayed symptoms of airway trauma cation of the cricothyroid membrane before surgery will help to
develop. determine whether some rescue techniques are unlikely to be
Despite these recommendations, communication is often successful.
inadequate.301–304 The DAS Difficult Airway Alert Form is a stand- There are randomized controlled trials and meta-analyses
ard template with prompts for documentation and communica- supporting the use of some airway devices and techniques,197–200
tion.305 The desire to provide detailed clinical information but for others no high-grade evidence is available and recom-
must be balanced against the need for effective communication. mendations are necessarily based on expert consensus.8 In this
At present, there is no UK-wide difficult airway database, al- manuscript, individual techniques have not been listed against
though national systems such as Medic Alert have been advo- their levels of evidence, although other groups have taken this
cated306 and can be accessed for patients with ‘Intubation approach.309
Difficulties’.307 Implementation of the guidelines does not obviate the need
Coding is the most effective method of communicating im- for planning at a local level. The training required to develop
portant information to general practitioners; the code for ‘diffi- and maintain technical skills has been studied in relation to vari-
cult tracheal intubation’ is Read Code SP2y3303 308 and should ous aspects of airway management, including videolaryngo-
be included on discharge summaries. Read Codes in the UK will scopy and cricothyroidotomy.109 276 310–313 To achieve and
be replaced by the international SNOMED CT (Systematized maintain competence with devices such as videolaryngoscopes
Nomenclature of Medicine–Clinical Terms) by 2020. and second-generation SADs and drugs such as sugammadex,
Every failed intubation, emergency front-of-neck access, and they need to be available for regular use, and local training will
airway-related unplanned admission should be reviewed by de- be necessary. New airway devices will continue to be developed
partmental airway leads and should be discussed at morbidity and introduced into clinical practice; their place in these guide-
and mortality meetings. lines will need to be evaluated. Even when no single device or
technique has a clear clinical benefit, limiting choice simplifies
training and decision-making. In the area of airway rescue by
Discussion front-of-neck access, feedback from DAS members and inter-
Complications of airway management are infrequent. The NAP4 national experts suggested that there was a need to unify the
project estimated that airway management resulted in one ser- response of anaesthetists to the ‘CICO’ emergency and to recom-
ious complication per 22 000 general anaesthetics, with death mend a single pathway. While UK anaesthetists are required to
or brain damage complicating 1:150 000. It is not possible to revalidate every 5 yr and advanced airway management features
study such rare events in prospective trials, so our most in the Royal College of Anaesthetists CPD matrix314 (2A01), there
valuable insights come from the detailed analysis of adverse is currently no specific requirement for training or retraining in
events.2 241 262 cricothyroidotomy. A consistent local effort will be required to
Guidelines exist to manage complex emergency problems in ensure that all those involved in airway management are trained
other areas of clinical practice, with cardiopulmonary resuscita- and familiar with the technique. These guidelines recommend
tion guidelines being an obvious example. Standardized man- the adoption of scalpel cricothyroidotomy as a technique that
agement plans are directly transferable from one hospital to should be learned by all anaesthetists. This method was selected
another and make it less likely that team members will encoun- because it can be performed using equipment available at almost
ter unfamiliar techniques and equipment during an unfolding every location where an anaesthetic is performed and because
emergency. These guidelines are directed at anaesthetists with insertion of a large-bore cuffed tube provides protection against
a range of airway skills and are not specifically aimed at airway aspiration, an unobstructed route for exhalation and the ability
experts. Some anaesthetists may have particular areas of expert- to monitor end-tidal CO2. There are, however, other valid techni-
ise, which can be deployed to supplement the techniques ques for front-of-neck access, which may continue to be provided
described. in some hospitals where additional equipment and comprehen-
The guidelines are directed at the unanticipated difficult sive training programmes are available. It is incumbent on the
airway, where appropriately trained surgeons may not be imme- anaesthetic community to ensure that data from all front-of-
diately available, so all anaesthetists must be capable of perform- neck access techniques are gathered and are used to inform
ing a cricothyroidotomy. There are some situations where these change when these guidelines are next updated.
840 | Frerk et al.

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