ASA difficult Airway Guidelines

Question 1

Evaluation of Airway : what 2 main areas for airway evaluation?

Answer 1

1. Risk assessment to predict a difficult airway or risk of aspiration.
2. Airway examination

Question 2

Airway evaluation: what relevant focused anaesthetic history would you ask?

Answer 2

Previous diffult airway
Prior surgical airway
Review anaesthetic chart

Question 3

Airway evaluation: what relevant focused medical history would you ask?

Answer 3

Syndromes : Downs, klippel-feil, crainiofascial

Medical : diabetes mellitus, RA,

Question 4

Airway evaluation: what relevant focused surgical history would you ask?

Answer 4

Facial burns
Submandibular/ rwtropharengial abscesses
Thyroid
Mediastinal mass

Question 5

Airway evaluation: what relevant focused physical exam would you perform

Answer 5

1. Look externally
2. Mallampati score
3. Measure thyromental distance, sternomental distance, hyomental, interincisor distance, hyomental distance ratio, neck circumference

Question 6

What is the acceptable mouth opening

Question 7

Which conditions would affect mouth opening?

Question 8

What is mallampati scoring and grades

Question 9

What’s is modified mallampati score?

Question 10

What does the mnemonic BONES stand for?

Answer 10

Beard
Obese
No teeth 
Elderly 
Snoring

Question 11

What does the mnemonic LEMONS stand for?

Answer 11

Look externally 
Examine 3:3:2
Mallampati 
Obstruction 
Neck mobility 
Surgical rescue ease

Question 12

What are the for Ds in airway assessment?

Answer 12

Distortion
Disproportion
Dysmobility
D

Question 13

What are the ASA recommendations on airway evaluation?

Answer 13

1. Before the initiation of anaesthetic careor airway management, ensure that an airway risk assessment is performed by the person responsible for airway management whenever feasible to identify patient, medical, surgical, environmental, and anaesthetic factors I. E risk of aspiration that may indicate the potential for difficult airway.
2. Before the initiation of anesthetic care or airway management, conduct an airway physical examination.

Question 14

What are the core steps to prepare for difficult airway?

Answer 14

1. Equipment availability
2. Informing patient of potential difficulty
3. Preoxygenation
4. Patient positioning
5. Sedative admin
6. Local anaesthesia
7. Supplimental oxygen
8. Patient monitoring
9. Human factors

Question 15

Which equipment should be prepared for difficult airway?

Question 16

Aim and end point of preoxygenation

Question 17

What is apneoic oxygenation?

Question 18

What is the ideal position of patient with diffult airway?

Question 19

What monitoring is required during airway management?

Question 20

What are the 3 ASA recommendations on preparation for difficult airway management?

Answer 20

1. If a difficult airway is known or suspected, ensure that a skilled individual is present or immediately available to assist with airway management. 17494*5001 2b.
2. If a difficult airway is known or suspected, inform the patient or responsible person of the special risks and procedures pertaining to management of the difficult airway. 17474*21311 2c.
3. If a difficult airway is known or suspected, administer oxygen before initiating management of the difficult airway and deliver supplemental oxygen throughout the process of difficult airway management, including extubation.

Question 21

What are the standards of difficult airway

Question 22

What are the options of Airway management for an anticipated difficult airway?

Answer 22

Awake tracheal intubation
Awake tracheostomy
Anaesthetised trachy/ET

Question 23

What airway maneuver can be used in difficult airway

Answer 23

Backward-upward-rightward pressure

Cricoid pressure

Question 24

Which none invasive airway device can be used?

Answer 24

Laryngoscopy blades
Adjuncts : introducer, bougie, stylet
Video Laryngoscopy
Flexible intubation scopes
Rigid bronch

Question 25

What is the combination technique in difficult airway management?

Answer 25

1. Direct/ video laryngoscopy with optic or video stylet, flexible scope, airway exchange catheter, retrograde placed guidewire,
2. supraglottic with optic or video stylet or flexible scope

Question 26

Which invasive airway intervention

Answer 26

Retrograde wire guided
Front of neck percutaneous cricothyrotomy
Surgical cricothyrotomy
ECMO

Question 27

What is the role of ECMO in difficult airway?

Question 28

How is awake intubation performed?

Question 29

Management strategies for adequate BMV but difficult intubation?

Question 30

Management strategies for can’t ventilate can’t intubate?

Question 31

Alternative approaches to airway management?

Question 32

Recommendation for anticipatex difficult airway

Answer 32

dentify a strategy for (1) awake intubation, (2) the patient who can be adequately ventilated but is difficult to intubate, (3) the patient who cannot be ventilated or intubated, and (4) alternative approaches to airway management failure.

Answer 33

When appropriate, perform awake intubation if the patient is suspected to be a difficult intubation and difficult ventilation (face mask/supraglottic airway) is anticipated. 1656822721 4b. When appropriate, perform awake intubation if the patient is suspected to be a difficult intubation and increased risk of aspiration is anticipated. 165423015112 4c. When appropriate, perform awake intubation if the patient is suspected to be a difficult intubation and anticipated to be incapable of tolerating a brief apneic episode. 1664434*1462 4d. When appropriate, perform awake intubation if the patient is suspected to be a difficult intubation and difficulty with emergency invasive airway rescue is anticipated.

Answer 34

5. If a noninvasive approach is selected, identify a preferred sequence of noninvasive devices to use for airway management. 1666329701 5a. If difficulty is encountered with individual techniques, combination techniques may be performed. 1676628511 5b. Be aware of the passage of time, the number of attempts, and oxygen saturation.166916201 5c. Provide and test mask ventilation between attempts.16758231361 5d. Limit the number of attempts at tracheal intubation or supraglottic airway placement to avoid potential injury and complications.

Answer 35

If an elective invasive approach to the airway (e.g., surgical cricothyrotomy, tracheostomy, or large-bore cannula cricothyrotomy) is selected, identify a preferred intervention. 1657221611
6a. Ensure that an invasive airway is performed by an individual trained in invasive airway techniques, whenever possible. 1668315201

6b. If the selected invasive ainvasive approach fails or is not feasible, identify an alternative invasive intervention.

Answer 36

• Call for help. • Optimize oxygenation.∥∥∥∥
• When appropriate, refer to an algorithm#### and/or cognitive aid.
• Upon encountering an unanticipated difficult airway:
◦ Determine the benefit of waking and/or restoring spontaneous breathing.
◦ Determine the benefit of a noninvasive versus invasive approach to airway management.
◦ If a noninvasive approach is selected, identify a preferred sequence of noninvasive devices to use for airway management.*****
▪ If difficulty is encountered with individual techniques, combination techniques may be performed.
▪ Be aware of the passage of time, the 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 supraglottic airway 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.††††† ◦ Ensure that an invasive airway is performed by an individual trained in invasive airway techniques, whenever possible.
◦ Ensure that an invasive airway is performed as rapidly as possible. ◦ If the selected invasive approach fails or is not feasible, identify an alternative invasive intervention. ▪ Initiate ECMO when/if appropriate and available.

Question 37

Algorithm for difficult airway.

Question 38

Confirmation of tracheal intubation?

Answer 38

• Confirm tracheal intubation using capnography or endtidal carbon dioxide monitoring. • When uncertain about the location of the tracheal tube, determine whether to either remove it and attempt ventilation or use additional techniques to confirm positioning of the tracheal tube.‡‡‡‡

Question 39

Extubation recommendation

Answer 39

Have a preformulated strategy for extubation and subsequent airway management. 13. Ensure that a skilled individual is present to assist with extubation. 14. Select an appropriate time and location for extubation when possible. 15. Assess the relative clinical merits and feasibility of the short-term use of an airway exchange catheter and/or supraglottic airway that can serve as a guide for expedited reintubation. 16. Before attempting extubation, evaluate the risks and benefits of elective surgical tracheostomy. 17. Evaluate the risks and benefits of awake extubation versus extubation before the return to consciousness. 18. Assess the clinical factors that may produce an adverse impact on ventilation after the patient has been extubated.

Question 40

Follow up recommendations

Answer 40

Inform the patient (or responsible person) of the airway difficulty that was encountered to provide the patient (or responsible person) with a role in guiding and facilitating the delivery of future care. 20. Document the presence and nature of the airway difficulty in the medical record to guide and facilitate the delivery of future care.

Question 41

Answer 42

Question 43

Way are the relevant human factors in airway management?

Answer 43

Question 44

Difficult airway info gram pediatric

Answer 44

Question 45

Difficult airway infograph adults

Answer 45

Question 46

ASA Pediatric difficult airway algorithm

Answer 46

Question 47

ASA adults difficult airway algorithm

Answer 47