This document outlines an algorithm for managing a difficult airway. It begins with evaluating the airway and informing the patient. It considers performing awake intubation versus intubation after induction of general anesthesia. The algorithm involves developing primary and alternative airway strategies, with pathways for when mask ventilation is adequate or not adequate. It emphasizes optimizing oxygenation throughout and calling for help if initial intubation attempts are unsuccessful. The goal is to preserve spontaneous ventilation when possible and consider invasive access or awakening the patient if other options fail.

1. ASA DIFFICULT AIRWAY ALGORITHM
Dr Murugesh Sukumar MD
Sr Consultant
Anaesthesia and ICU
Khawla Hospital Muscat

2. Basics
Evaluation of the
Airway
Informing the
patient/Bystander
Availability of
equipment
Availability of a
Trained Assistant
Optimise the
position /
Preoxygenation

3. From: Practice Guidelines for Management of the Difficult Airway:An Updated Report by the American Society of Anesthesiologists Task Force
on Management of the Difficult Airway
Anesthesiology. 2013;118(2):251-270. doi:10.1097/ALN.0b013e31827773b2

4. Assess the basic management problems
• Difficulty
with patient
cooperation
or consent
• Difficult
mask
ventilation
• Difficult
supraglottic
airway
placement
• Difficult
laryngoscopy
• Difficult
intubation
• Difficult
surgical
airway access

5. Consider the basic management choices
• Awake Intubtn vs. Intubtn after
induction of GA
• Non-Inv. vs. Inv. Techniques initial
approach
• VAL as an initial approach to
intubation
• Preservation vs. ablation of spont.
ventilation

6. Throughout the process of difficult airway
 Actively deliver supplemental OXYGEN

7. Develop primary and alternative strategies
AWAKE INTUBATION
INTUBATION AFTER INDUCTION OF GA

8. AWAKE INTUBATION
Airway approached by
NON Invasive Airway Access
Invasive Airway Access
Succeed Fail
Cancel case
Consider feasibility of other options
Invasive airway access

9. INTUBATION AFTER INDUCTION OF GA
INITIAL INTUBATION ATTEMPTS SUCCESSFUL
INITIAL INTUB UNSUCCESSFUL
FROM THIS POINT ONWARDS CONSIDER
1.CALL FOR HELP
2.Return to spont ventilation
3.Awaken

10. INITIAL INTUBATION ATTEMPTS UNSUCCESSFUL
FACE MASK VENTILATION ADEQUATE FACE MASK VENTILATION NOT ADEQUATE

11. FACE MASK VENTILATION ADEQUATE
NONEMERGENCY PATHWAY
Ventilation adequate, intubation unsuccessful
Alternative approaches to intubation
SUCCESSFUL INTUBATION FAIL AFTER MULTIPLE ATTEMPTS
INVASIVE AIRWAY ACCESS CONSIDER FEASIBILTY OF OTHER OPTIONS AWAKEN THE PATIENT

12. FACE MASK VENTILATION NOT ADEQUATE
CONSIDER/ATTEMPT SGA
SGA ADEQUATE
SGA NOT ADEQUATE OR NOT FEASIBLE
EMERGENCY PATHWAY
Ventilation not adequate, intubation unsuccessful
Call for help
Emergency NON invasive airway ventilation
Successful ventilation
FAIL
Emergency invasive airway access
Invasive airway access
Consider feasibility of other options
Awaken the patient

13. From: Practice Guidelines for Management of the Difficult Airway:An Updated Report by the American Society of Anesthesiologists Task Force
on Management of the Difficult Airway
Anesthesiology. 2013;118(2):251-270. doi:10.1097/ALN.0b013e31827773b2

14. Follow-up Care
Extuabation strategy
• Postextubation care and counselling
• Documentation of a difficult airway
• Registration with notification service

15. Thank you !