ASA Difficult Airway Management Guidelines: What's New?

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September 1, 2013 Volume 77, Number 9
ASA Difficult Airway Management Guidelines: What's New? Carin A. Hagberg, M.D.

Management of the difficult airway remains one of the most relevant and challenging tasks for anesthesiologists. A major factor for this concern is the serious consequence of inadequate oxygenation and ventilation. Airway complications remain high on the list of categories in the ASA Closed Claims Database as a cause of death or permanent neurologic injury (Figure 1).1


ASA Difficult Airway Management Guidelines Fig 1

Figure 1: Most common damaging events, 1990 or later (n = 5,230)
Used by permission:  Metzner J, Posner KL, Lam MS, Domino KB.
Closed claims analysis. Best Pract Res Clin Anaesthesiol. 25(2):263-76, 2011. doi:10.1016/j.bpa.2011.02.007. Review.


In a review of anesthesiology closed claims cases in 1990, the leading causes of respiratory-related complications were inadequate ventilation, esophageal intubation and difficult intubation.2 Although esophageal intubation has nearly disappeared with the adoption of end-tidal capnography, difficult intubation remains a concern and represented 27 percent of all adverse respiratory events in 1991-2007 (Figure 2).3 While inadequate oxygenation and ventilation has decreased in the operating room with the adoption of pulse oximetry as a standard for intraoperative monitoring,4 it has risen in non-operating room locations, secondary to over-sedation and inadequate monitoring of ventilation.5,6 Also of significance is that pulmonary aspiration is the third most common respiratory event following inadequate oxygenation ventilation and difficult intubation.1 The Fourth National Audit Project (NAP4) of the Royal College of Anesthetists and the Difficult Airway Society revealed aspiration of gastric contents as second only to failed intubation in frequency of reported adverse events during anesthesia in the United Kingdom.7

In order to facilitate management of the difficult airway and reduce the likelihood of adverse outcomes, a Difficult Airway Task Force was formed by ASA. After extensive deliberation and review, the task force formulated and published the first guidelines on management of the difficult airway in 1993.8 The guidelines have served several purposes over time, most notably the concept of organized, preplanning strategies, including identification of the difficult airway. Since there is not one universal test that reliably predicts difficulty in airway management, it is important to conduct a thorough airway assessment that takes into account any characteristics of a patient that could lead to difficulty in airway management. Physician anesthesiologists should identify patients with individual predictors and determine any combinations of predictors that may lead to difficulty. If any additional testing or preoperative consultation is necessary, it should be obtained and an appropriate plan(s) should be formulated. In theory, the ability to better accurately predict possible difficulties should reduce the number of adverse outcomes and improve the safety of airway management.

Ten years after the first guidelines were introduced, the task force reconvened and published revised guidelines following a thorough review of new research and clinical experience.9 These guidelines also include data and recommendations for a more extensive range of management techniques than was previously addressed. Inclusion of the laryngeal mask airway (LMA), either as a ventilatory device or as a conduit for intubation, was the most significant modification of the 2003 revised guidelines. Changes in these guidelines also included the removal of the option for “one more intubation attempt” in the emergency pathway and the addition of the rigid bronchoscope as an option for emergency noninvasive ventilation. Additionally, in regard to preoperative assessment and management choices, “possible difficulties with bag mask ventilation” now moved up to be first and foremost, and the “assessment for possible difficult tracheostomy” was added. Finally, “Awake intubation attempts after induction of anesthesia” should be considered before “noninvasive vs. invasive techniques as the initial approach to intubation.”


ASA Difficult Airway Management Guidelines Fig 2


Figure 2: Changes in respiratory events over time. *p < 0.001, 1970-89; **p < 0.05, 1970-89 vs. 1970-07. Excerpted from ref.3  New trends in adverse respiratory events, ASA Newsl. 2011 75(2):28-29. A copy of the full text can be obtained from ASA, 520 N. Northwest Highway, Park Ridge, Illinois 60058-2573. Used by permission:  Metzner J, Posner KL, Lam MS, Domino KB. Closed claims analysis. Best Pract Res Clin Anaesthesiol. 25(2):263-76, 2011. doi: 10.1016/j.bpa.2011.02.007. Review.


There have been many alternative airway devices introduced into our clinical practice since the development of the last difficult airway guidelines and, as such, the guidelines were once again revised. In 2011, the ASA Committee on Standards and Practice Parameters requested a re-evaluation of the updated guidelines adopted in 2003. The most recent update of the ASA Practice Guidelines for Management of the Difficult Airway evaluated the literature published since completion of the first update and the latest survey findings of expert consultants and ASA members. These guidelines were adopted by ASA in 2012 and published in February 2013.10 They are also available on the ASA website in the “Standards, Guidelines and Statements” section.

The following changes were made regarding the 2013 ASA Difficult Airway Management Algorithm, as compared to the 2003 algorithm.

1. Addition of definitions related to difficult supraglottic airway (SGA) ventilation or placement.

a. Difficult face mask or SGA ventilation: It is not possible for the anesthesiologist to provide adequate ventilation due to one or more of the following problems: inadequate mask or supraglottic airway seal, excessive gas leak, or excessive resistance to the ingress or egress of gas.

b. Difficult SGA placement: SGA placement requires multiple attempts, in the presence or absence of tracheal pathology.

2. The anesthesiologist should have a preformulated strategy for intubation of the difficult airway. This strategy will depend, in part, on the anticipated surgery, the condition of the patient, and the skills and preferences of the anesthesiologist. The recommended strategy for intubation of the difficult airway includes: Consideration of difficulty with SGA placement when performing a preoperative assessment.

An assessment of the likelihood and anticipated clinical impact of six basic problems that may occur alone or in combination: 1) difficulty with patient cooperation or consent, 2) difficult mask ventilation, 3) difficult supraglottic airway placement, 4) difficult laryngoscopy, 5) difficult intubation and 6) difficult surgical airway access.

The use of a laryngeal mask airway in the algorithm has been replaced with supraglottic airway or SGA, which may include the LMA, intubating LMA and the laryngeal tube. Although the Esophageal Tracheal Combitube is no longer specifically mentioned, it can still be considered. Also, it should be noted that although the laryngeal tube is now included as an alternative SGA, the literature is insufficient to evaluate the efficacy of the laryngeal tube or laryngeal tube suction in providing adequate ventilation for difficult airway patients.

As previously mentioned, the anesthesiologist should ascertain whether or not there may be difficulty in the performance of laryngoscopy or a surgical airway. Risk factors for difficulty in the performance of either procedure should be ascertained during the history and physical examination of the patient.

3. Videolaryngoscopy can and should be considered both as an initial approach to intubation (awake or following induction of general anesthesia) and following failed intubation in which face mask ventilation is adequate.

a. A consideration of the relative clinical merits and feasibility of four basic management choices: 1) awake intubation versus intubation after induction of general anesthesia, 2) noninvasive techniques versus invasive techniques (i.e., surgical or percutaneous airway) for the initial approach to intubation, 3) video-assisted laryngoscopy as an initial approach to intubation, and 4) preservation versus ablation of spontaneous ventilation.

b. Under strategies for noninvasive intubation of the difficult airway, interventions intended to manage a difficult airway include, but are not limited to: 1) awake intubation, 2) video-assisted laryngoscopy, 3) intubating stylelets or tube-changers, 4) supraglottic airway for ventilation (e.g., laryngeal mask airway, LMA; laryngeal tube, laryngeal tube suction), 5) supraglottic airway for intubation (e.g., intubating LMA, ILMA), 6) rigid laryngoscope blades of varying design and size, 7) fiberoptic-guided intubation, and 8) lighted stylets or light wands.

c. The rigid bronchoscope is no longer mentioned as an emergency non-invasive airway technique. Additionally, jet ventilation and retrograde intubation are now considered invasive airway techniques and are listed as such, along with surgical or percutaneous airway. Finally, a video laryngoscope was added and retrograde intubation was removed from the list of suggested contents of the portable storage unit for difficult airway management.

Extubation, particularly of the difficulty airway, is not without risk and should be taken seriously, as reflected in the last ASA Closed Claims analysis in which 12 percent of claims involving airway management are associated with this process.2 The physician anesthesiologist needs to consider many factors, including the ease of the initial intubation, the patient’s medical status, the surgical procedure, the setting in which the extubation is going to occur and, finally, the practitioner’s skills and preferences. The 2013 ASA Guidelines for Management of the Difficult Airway remain the same regarding extubation:

1. Consideration of the risk-to-benefits of awake extubation versus extubation in the deeply anesthetized state.

2. Careful evaluation of factors that could impair ventilation after extubation.

3. The formation of a plan to immediately repair control of the airway in the event that adequate ventilation is not achieved after extubation.

4. Consideration of the short-term use of a stylet to act as a bridge to aid in re-intubation and/or ventilation if extubation is not successful.

There is really not an optimum technology solution for management of the difficult airway. Each device has unique properties that may be advantageous in certain situations, yet limiting in others. Specific airway management techniques are greatly influenced by individual disease and anatomy, and successful management may require a combination of devices and techniques. Nonetheless, clinical judgment born from experience is crucial to their application. Any strategy chosen by the clinician should be well rehearsed in patients with non-problematic airways prior to implementation in those patients likely to be difficult.

Carin A. Hagberg, M.D. is Joseph C. Gabel Professor and Chair, UTHealth, The University of Texas Health Science Center at Houston, Medical School, Department of Anesthesiology, Houston, Texas. She is Executive Director, Society of Airway Management.


1. Metzner J, Posner KL, Lam MS, Domino KB. Closed claims’ analysis. Best Pract Res Clin Anaesthesiol 25(2):263-76, 2011.

2. Caplan RA, Posner KL, Ward RJ, et al. Adverse respiratory events in anesthesia: A closed claims analysis. Anesthesiology 72:828-33, 1990.

3. Baille R, Posner KL. New trends in adverse respiratory events. ASA Newsletter 75:28-29, 2011.

4. Cheney FW, Posner KL, Lee LA, et al. Trends in anesthesia-related death and brain damage: a closed claims analysis. Anesthesiology 105:1081-1086, 2006.

5. Bhananker SM, Posner KL, Cheney FW, et al. Injury and liability associated with monitored anesthesia care: a closed claims analysis. Anesthesiology 1045:228-234, 2006.

6. Metzner J, Posner KL, Domino KB. The risk and safety of anesthesia at remote locations: the US closed claims analysis. Current Opinion Anaesthesiology 22:502-508, 2009.

7. Cook TM, Woodall N, Frerk C. Major complications of airway management in the UK: Results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society Part 1: anaesthesia. Br J Anaesth 106(5):617-31.

8. American Society of Anesthesiologists Task Force on Management of the Difficult Airway: Practice Guidelines for Management of the Difficult Airway: A Report. Anesthesiology 78:597-602,1993.

9. 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 98:1269-77, 2003.

10. 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 118:251-70, 2013.