Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

Abstract

Purpose Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the published airway management literature has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This second of two articles addresses airway evaluation, decision-making, and safe implementation of an airway management strategy when difficulty is anticipated. Source Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence is lacking, statements are based on group consensus. Findings and key recommendations Prior to airway management, a documented strategy should be formulated for every patient, based on airway evaluation. Bedside examination should seek predictors of difficulty with face-mask ventilation (FMV), tracheal intubation using video- or direct laryngoscopy (VL or DL), supraglottic airway use, as well as emergency front of neck airway access. Patient physiology and contextual issues should also be assessed. Predicted difficulty should prompt careful decision-making on how most safely to proceed with airway management. Awake tracheal intubation may provide an extra margin of safety when impossible VL or DL is predicted, when difficulty is predicted with more than one mode of airway management (e.g., tracheal intubation and FMV), or when predicted difficulty coincides with significant physiologic or contextual issues. If managing the patient after the induction of general anesthesia despite predicted difficulty, team briefing should include triggers for moving from one technique to the next, expert assistance should be sourced, and required equipment should be present. Unanticipated difficulty with airway management can always occur, so the airway manager should have a strategy for difficulty occurring in every patient, and the institution must make difficult airway equipment readily available. Tracheal extubation of the at-risk patient must also be carefully planned, including assessment of the patient’s tolerance for withdrawal of airway support and whether re-intubation might be difficult.

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient

“…While plentiful, most systematic reviews and meta-analyses comparing DL with VL combine various VL blade types (HA-VL and Mac-VL), patient populations, clinical contexts, airway manager experience, and measured outcomes. 141 Nevertheless, compared with DL, the first-attempt and overall success rates of tracheal intubation using VL (Mac-VL or HA-VL) are rarely worse, and are often better. 105 , 113 , 114 , 142 – 153 …”

“…A successful exit strategy tracheal intubation should prompt the airway manager to carefully consider a safe tracheal extubation strategy (see companion article). 8 Conversely, failure of an exit strategy tracheal intubation attempt should prompt re-consideration of other exit strategy options, including awakening the patient, temporizing with an SGA, or proceeding to FONA.…”

“…To this end, thorough patient airway evaluation should be made, followed by appropriate decision-making and safe implementation of the plan. These aspects of safe management of a patient with a difficult airway are addressed further in the companion article 8 , as is advice on tracheal extubation of the difficult airway patient.…”

“…Significant difficulty with airway management in the unconscious patient can often be avoided by careful airway evaluation before the induction of general anesthesia. In part 2 of these updated recommendations, 8 we have addressed decision-making and implementation of the planned airway strategy for the patient with an anticipated difficult airway. Recommendations in both articles are meant to be broadly applicable to all specialties involved in airway management.…”

Editors’ note: 2021 Special Issue on airway management

“…In the centre of this Special Issue—the Journal’s first since April 2018—are, after their last iteration in 2013 2 , 3 the two-part 2021 updated consensus-based recommendations for management of the difficult airway by the Canadian Airway Focus Group (CAFG). 4 , 5 These take into consideration the body of airway management literature that has appeared since the last update as well as the evolution in equipment and practice patterns—including in particular the increasing penetration of videolaryngoscopy.…”