Recommendations for Unanticipated and Emergency Difficult Airway Management 2022

Recommendations for Unanticipated and Emergency Difficult Airway Management

 • Call for help.

• Optimize oxygenation. Examples include low or high flow nasal oxygen during efforts securing a tube.

• When appropriate, refer to an algorithm and/or cognitive aid.

• Upon encountering an unanticipated difficult airway:

o Determine the benefit of waking and/or restoring spontaneous breathing.

o Determine the benefit of a noninvasive versus invasive approach to airway management.

o If a noninvasive approach is selected, identify a preferred sequence of noninvasive devices to use for airway management.

Noninvasive devices include rigid laryngoscopic blades of alternative design and size (with adequate face mask ventilation after induction); adjuncts (e.g., introducers, bougies, stylets, alternative tracheal tubes, and supraglottic airways), video/video-assisted laryngoscopy; flexible intubation scopes; supraglottic airway devices (SGAs); lighted or optical stylets; alternative optical laryngoscopes; and rigid bronchoscopes.

 If difficulty is encountered with individual techniques, combination techniques may be performed.

 Be aware of the passage of time, number of attempts, and oxygen saturation.

 Provide and test mask ventilation after each attempt, when feasible.

 Limit the number of attempts at tracheal intubation or SGA placement to avoid potential injury and complications.

• If an invasive approach to the airway is necessary (i.e., cannot intubate, cannot ventilate), identify a preferred intervention.

Invasive interventions may include surgical cricothyrotomy (e.g., scalpel-bougie technique), surgical tracheostomy, needle cricothyrotomy with pressure regulated ventilation (e.g., transtracheal jet ventilation or other pressure regulated techniques), and large bore cannula cricothyrotomy (including Seldinger guided techniques).

o Assure that an invasive airway is performed by an individual trained in invasive airway techniques, whenever possible.

o Assure that an invasive airway is performed as rapidly as possible.

o If the selected invasive approach fails or is not feasible, identify an alternative invasive intervention.

 Initiate Extracorporeal Membrane Oxygenation (ECMO) when/if appropriate and available.

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