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UK: results of the Fourth National Audit Project of the Royal 15. ANZCA working party. Ed. L. Watterson. Transition for
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British Journal of Anaesthesia 115 (6): 812–14 (2015)

Advance Access publication 10 November 2015 . doi:10.1093/bja/aev404

Difficult Airway Society 2015 guidelines for the

management of unanticipated difficult intubation
in adults: not just another algorithm
C. A. Hagberg1, *, Joseph C. Gabel1 and R. T. Connis2
1
Department of Anesthesiology, 6431 Fannin Street, MSB 5.020, Houston, TX, USA, and
2
ASA Headquarters, 1061 American Lane, Schaumburg, Il, USA
*Corresponding author. E-mail: [email protected]

Since the first iteration of the ASA Difficult Airway Practice Guide- techniques, including emergency invasive airway access, is not
lines for the management of the difficult airway was published in only considered essential but expected.
1993 (updated in 2013),1 a number of national societies have gen- Practice guidelines rely on scientific literature to supply evi-
erated practice guidelines for difficult airway management, dence in support of clinical recommendations. Evaluation of lit-
including the Difficult Airway Society (DAS).2 erature includes identifying whether the topic addressed is
Unlike the ASA guidelines, which address both the antici- relevant and determining whether the methodology used has re-
pated and the unanticipated difficult airway, the DAS guidelines sulted in the minimization of potential bias in findings. Numer-
focus on the unanticipated difficult airway, an unpredictable ous sources of bias may occur during the development of a
problem. The new 2015 DAS guidelines differ from the original guideline, including article selection bias, reviewer bias, report-
2004 DAS guidelines in that they are more concise and more prag- ing bias, bias associated with study design, and subjective
matic, with considerable emphasis placed on preparedness and weighting or grading of studies.3 Steps to mitigate bias should
accountability of the practitioner by optimizing conditions and be a vital part of an evidence-based process.4–6
minimizing patient morbidity in a difficult airway situation. Difficult airway literature generally focuses on airway manage-
Training of physicians with alternative airway devices and ment devices and techniques. Airway management techniques
 Editorials | 813

often use a protocol or algorithm that includes a combination of Given that repeated instrumentation of the airway may lead
choices that depend on the patient’s condition at some point dur- to airway trauma and deterioration of the ability to ventilate,
ing a procedure.1 2 The use of algorithms can be studied, but from the number of laryngoscopy attempts with any particular device
these studies one cannot determine the impact of the individual should be limited. In attempts to secure the airway, there is no
components of the algorithm; these must be assessed individually single technique that is better than others in all situations. Prac-
with an appropriate research design, preferably a randomized con- titioners involved in airway management should be familiar with
trolled trial. several different devices and techniques, because if a difficult air-
Devices to manage the difficult airway are varied, but most way problem develops, it should be managed expeditiously and
have the intent of quickly establishing a patent airway. An appro- safely. Each device has unique properties that may be advanta-
priate airway device should provide adequate ventilation and geous in certain situations, yet limiting in others.
oxygenation while causing minimal airway morbidity and keep- For other difficult airway interventions, controlled studies
ing the risk of aspiration to a minimum. Several factors should be with difficult airway subjects are not easy to conduct, primarily
taken into consideration when determining which type of airway because of the emergent nature of difficult airway patency. In
device should be used in any given situation, including, but not these situations, studies must rely on surrogate outcome mea-
limited to, patient anatomy, clinical situation, provider skill sures or non-difficult airway patients to serve as subjects for con-
level, and equipment availability. trolled clinical trials. Successful intubation must be inferred
The introduction of new airway devices into clinical practice rather than genuinely observed. Although these studies are indir-
accounted for the most significant changes in the ASA Difficult ect assessments, they can nonetheless be valuable for identifica-

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Airway Practice Guidelines throughout the past two decades. tion of a difficult airway before a procedure.
From 1993 to 2003, it was the introduction of the laryngeal The increasing demands for evidence-based medicine encour-
mask airway and from 2003 to 2013, it was the introduction of age us to determine the effectiveness of new approaches and how
the video laryngoscope. Both of these devices have also been they compare with traditional techniques. For video-assisted
incorporated into the new DAS guidelines for good reason, laryngoscopy (VAL), the standard of care is traditional direct laryn-
because randomized controlled trials have been successfully goscopy. Thus far, there is insufficient evidence to indicate that
conducted on patients with a history of difficult intubation, and VAL should replace direct laryngoscopy in patients with normal
intubation success with these patients has been appropriately or difficult airways.9 10 Nonetheless, as more video laryngoscopes
assessed. are introduced into clinical practice and as more practitioners be-
After an unsuccessful initial intubation attempt, restoration come increasingly skilled with the technique of VAL, it could well
of ventilation is the priority, by either a non-invasive [i.e. supra- become the standard for both routine and difficult intubations.
glottic airway (SGA)] or an invasive intervention, or by awakening Similar to recommendations by other national societies, the
the patient. Repeated attempts at intubation should not delay new DAS guidelines incorporate the use of VAL for management
non-invasive airway ventilation (i.e. SGA) or emergency invasive of the difficult airway. Multiple reports have demonstrated im-
airway access. The new DAS guidelines favour the use of second- proved glottic visualization and visual confirmation of tube
generation SGAs in this situation, because they have specifically placement, in addition to better team coordination during airway
designed features to reduce the risk of aspiration and provide a management with VAL. These devices should not only be imme-
better airway seal. The Fourth National Audit Project study re- diately available, but the practitioner should become proficient in
vealed that 56% of the airway complications involved the use of their use.11 12
an SGA and that these devices were often used inappropriately.7 The use of cricoid pressure (CP) in difficult intubation has not
Numerous aspiration events occurred when a first-generation been extensively studied. Although the new DAS guidelines rec-
SGA was used in patients with clearly identifiable risk factors ommend the use of CP during rapid sequence induction, the ap-
for aspiration.8 Although these events were no’t as evident in plication of CP during rapid sequence induction remains a matter
the use of the second-generation devices, second-generation de- of debate; some believe in its effectiveness in preventing pul-
vices were used less commonly at the time (10% of SGA use). None- monary aspiration, whereas others believe it should be aban-
theless, recommendations were made to use second-generation doned because of the paucity of scientific evidence of benefit
SGA’s rather than first-generation devices, because they are con- and possible complications.13 14 The literature does demonstrate
sidered to provide better airway protection. that the use of CP is likely to make airway interventions, such as
Conclusive evidence demonstrating better safety of one de- mask ventilation, SGA insertion, direct laryngoscopy, and intub-
vice compared with another regarding aspiration can only ation more difficult.15 16
come from formal studies of several million patients, because As a result of the lack of sufficient scientific evidence that CP
harmful aspiration events occur infrequently. These studies reduces regurgitation, in addition to evidence that it may inter-
may be impractical. Thus, safety data must be acquired by ana- fere with airway management, the Scandinavian practice guide-
lysing the design features of airway devices, appropriate bench lines leave its use up to individual judgement rather than making
models, and surrogate measures of airway safety, such as seal its use mandatory.17 The use of CP has been removed as a level I
pressures and laryngeal view. recommendation in both the 2010 American Heart Association
Although all second-generation SGAs have features designed Guidelines18 and the Eastern Society for the Surgery of Trauma
to lessen the likelihood of gastric insufflation, regurgitation, and (EAST) practice management guideline for emergency tracheal
aspiration, currently there is little or no scientific evidence to intubation.19 Despite these trends, the use of CP remains in the
support their performance in improving such outcomes for diffi- new DAS guidelines. Nonetheless, the guidelines recommend
cult airway patients. Of the second-generation devices currently that if initial attempts at laryngoscopy are difficult with the appli-
available, only the i-gel, the Proseal LMA, and the LMA Supreme cation of CP, it should be released under vision with suction avail-
have large-scale longitudinal studies in adults that support their able; it should be re-applied if regurgitation occurs. It should
use. There is little robust evidence to inform the practitioner of remain off during insertion of an SGA.
the safety and efficacy of each SGA or which device to use in a Although controlled scientific research in the management of
given situation. the unanticipated difficult airway is sparse, the new DAS
814 | Editorials

guidelines provide valuable consensus from an expert panel that 5. Apfelbaum JL, Connis RT, Nickinovich DG. 2012 Emery
has drawn extensively on the experience of international experts. A. Rovenstine Memorial Lecture: the genesis, development,
They are successful in their aim to provide a structured approach and future of the American Society of Anesthesiologists evi-
to a potentially life-threatening clinical situation and take into dence-based practice parameters. Anesthesiology 2013; 118:
account current practice and recent developments. The authors 767–8
note that these guidelines should not constitute a minimum 6. Nickinovich DG, Connis RT, Caplan RA, Arens JF,
standard of practice, nor be regarded as a substitute for good clin- Apfelbaum JL. Evidence-based practice parameters: the ap-
ical judgement. They also acknowledge that the guideline recom- proach of the American Society of Anesthesiologists. In:
mendations may not be suitable in all circumstances; separate Fleisher LA, ed. Evidence-Based Practice of Anesthesiology, 3rd
guidelines exist for paediatric and obstetric patients and for Edn. Philadelphia: W.B. Saunders Co., 2013; 2–6
extubation. 7. Cook TM, Woodall N, Frerk C; Fourth National Audit
Most importantly, the new DAS guidelines emphasize that Project. Major complications of airway management in
in order to be most effective, our profession must address the the UK: results of the Fourth National Audit Project of
impact of environmental, technical, psychological, and physio- the Royal College of Anaesthetists and the Difficult
logical factors on our performance. We must also consider Airway Society. Part 1: anaesthesia. Br J Anaesth 2011;
human factor issues at individual, team, and organizational 106: 617–31
levels to optimize these guidelines. At both individual and soci- 8. Woodall N, Frerk C, Cook TM. Can we make airway manage-
etal levels, we have the responsibility to provide optimal patient ment (even) safer?–lessons from national audit. Anaesthesia

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care. Although there is not enough scientific literature to sup- 2011; 66(Suppl 2): 27–33
port every recommendation made concerning airway manage- 9. Niforopoulou P, Pantazopoulos I, Demestiha T, Koudouna E,
ment in these guidelines, we must provide guidance based Xanthos T. Video laryngoscopes in the adult airway manage-
on the best available evidence we have, including expert ment: a topical review of the literature. Acta Anesthesiol Scand
consensus. 2010; 54: 1050–61
Difficult airway guidelines must be updated continuously to 10. Levitan RM. Video laryngoscopy, regardless of blade shape,
reflect the most current evidence and should be reviewed regu- still requires a backup plan. Ann Emerg Med 2013; 61: 421–2
larly for their content and continued relevance. There has been 11. Griesdale DEG, Liu D, McKinney J, Choi PT. Glidescope® video
a tremendous growth in the literature on the management of laryngoscopy versus direct laryngoscopy for endotracheal in-
the difficult airway in anaesthesia practice. The new DAS guide- tubation: a systematic review and meta-analysis. Can J
lines are not just another algorithm but rather an evolutionary Anaesth 2012; 59: 41–52
advancement in how to address management of the unantici- 12. Aziz MF, Dillman D, Fu R, Brambrink AM. Comparative effect-
pated difficult airway in adults. The burden is now upon us to im- iveness of the C-MAC video laryngoscope versus direct laryn-
plement the guidelines in the most appropriate manner to goscopy in the setting of the predicted difficult airway.
maximize the safety of our patients. Anesthesiology 2012; 116: 629–36
13. Shorten GD, Alfille PH, Gliklich RE. Airway obstruction follow-
ing application of cricoid pressure. J Clin Anesth 1991; 3: 403–5
Declaration of interest 14. Neilipovitz DT, Crosby ET. No evidence for decreased inci-
None declared. dence of aspiration after rapid sequence induction. Can J
Anaesth 2007; 54: 748–64
15. Shorten GD. Airway obstruction from cricoid pressure. Anesth
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