Nej MR A 1916801

The n e w e ng l a n d j o u r na l of m e dic i n e
Review Article
Dan L. Longo, M.D., Editor
Management of the Difficult Airway

Thomas Heidegger, M.D.
M
From the Department of Anesthesia, anagement of the difficult airway is one of the most rele-
Spital Grabs, Grabs, and the Department vant issues for practicing emergency physicians, intensivists, and anes-
of Anesthesiology and Pain Medicine,
Bern University Hospital, University of thesiologists, since airway loss in an unconscious patient can lead to
Bern, Bern — both in Switzerland; and brain damage or even death. Despite revolutionary innovations in airway manage-
the Private University of the Principality ment, such as the laryngeal mask airway and video laryngoscopy, and despite
of Liechtenstein, Triesen, Liechtenstein.
Address reprint requests to Dr. Heidegger major efforts in monitoring, education, and training, it is still unclear whether
at the Department of Anesthesia, Spital safety in airway management has improved during the past decade.
Grabs, Spitalstrasse 44, 9472 Grabs, Swit- The Fourth National Audit Project (NAP4) of the Royal College of Anaesthetists
zerland, or at thomas.heidegger@srrws.ch.
and the Difficult Airway Society in the United Kingdom showed that 1 of 22,000
N Engl J Med 2021;384:1836-47. cases of tracheal intubation was associated with severe adverse airway manage-
DOI: 10.1056/NEJMra1916801
Copyright © 2021 Massachusetts Medical Society.
ment events in the operating room, such as death, brain damage, need for an
emergency surgical airway, or unplanned intensive care unit (ICU) admission.1
However, the number of cases may have been underreported, and the true inci-
dence of severe events might actually have been 4 times as high (1 of 5500 cases).1,2
Thus, vigilance in airway management remains essential.
A subsequent analysis estimated that the incidence of adverse events associated
with airway management in the emergency department was higher by a factor of
35 than the incidence of adverse events associated with airway management in
patients under anesthesia, and the incidence of adverse events in the ICU was
higher by a factor of 55.3,4 Recent results of the new U.S. closed-claims analysis
with regard to difficult tracheal intubation have yielded worrisome figures as
well.5 Although claims related to difficult tracheal intubation in perioperative loca-
tions (operating or recovery rooms) were similarly distributed between two time
periods — 1993 to 1999 and 2000 to 2012 — the incidence of brain damage or
death at induction of anesthesia was higher by a factor of 5.5 in the latter period.
In healthy patients who undergo anesthesia for elective procedures, complications
associated with airway management are still the leading cause of death or perma-
nent brain damage.6
Considering that more than 320 million surgical procedures annually would be
needed to address the burden of disease for a population of around 7 billion (data
from 2010),7 and further considering that 20 to 40% of the more than 5 million
patients who are admitted annually to ICUs in the United States require mechanical
ventilation, it is evident that even small changes in the practice of airway manage-
ment are highly relevant to outcomes (https://www.sccm.org/Communications/
Critical-Care-Statistics).8
This review provides an overview of the definition, incidence, and prediction of
a difficult airway; management of unanticipated and anticipated difficult airways;
management of tracheal extubation of a difficult airway in the operating room, the
ICU, and the emergency department; and human factors in airway management.
1836 n engl j med 384;19 nejm.org May 13, 2021
The New England Journal of Medicine

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Copyright © 2021 Massachusetts Medical Society. All rights reserved.
Defini t ion, Incidence , a nd whereas with hyperangulated-blade video laryn-

Pr edic t ion of a Difficult A irwa y goscopes, tube delivery must occur around a
curve, which may make it more challenging.14,15
Definition Therefore, with video laryngoscopy, it makes
The term “difficult airway” covers a spectrum sense to describe the view of the glottis (full,
ranging from problems in ventilating a patient’s partial, or none) and the ease of tracheal intuba-
lung with a face mask or supraglottic airway to tion (easy, difficult, or unachievable) and to note
problems in intubating (and strictly speaking, the device used to facilitate tracheal intubation.16
also extubating) a patient’s trachea. A standard
definition of the difficult airway cannot be iden- Incidence
tified in the available literature.9 A recent guide- The difficult airway is a rare phenomenon. The
line update defines the difficult airway as an incidence of difficult face-mask ventilation rang-
airway for which an experienced practitioner es from 1.4 to 5.0%, and the incidence of impos-
anticipates or encounters difficulty with face- sible ventilation from 0.07 to 0.16%.17,18 The inci-
mask ventilation, tracheal intubation, or supra- dence of difficult tracheal intubation ranges from
glottic airway use or recognizes the need for an 5 to 8%, and failed tracheal intubation from 0.05
emergency surgical airway.10 The following scale to 0.35%.15 The success rate for tracheal intuba-
is useful for classifying the difficulty of face- tion with video laryngoscopes is between 97.1
mask ventilation: grade 1 — ventilation by mask and 99.6% overall and between 95.8 and 100%
can be performed without any problems; grade when a difficult airway is predicted.19,20 The in-
2 — ventilation by mask is possible with an oral cidence of failed tracheal intubation in obstetrics
airway or another adjuvant; grade 3 — mask ranges from 0.15 to 0.6%.21 Maternal mortality
ventilation is difficult, defined as inadequate, from failed tracheal intubation is approximately
unstable, or requiring two providers; grade 4 — 4 times as high as mortality from failed tracheal
mask ventilation is impossible.11 This informa- intubation in the general population, according
tion, whether it has been determined with or to the NAP4 report.22,23
without administration of a muscle relaxant to
the patient, is useful.12 Ideally, ventilation should Prediction
be confirmed by observation of a rise in the chest, To maximize patient safety, it is reasonable to try
by a capnographic tracing, and by an increase in to predict a difficult airway and to adjust man-
oxygen saturation.13 agement of it accordingly. We must determine
Difficult tracheal intubation must be distin- whether airway management is planned after in-
guished from difficult laryngoscopy, especially duction of general anesthesia, whether tracheal
since the introduction of video laryngoscopy intubation is warranted while the patient is awake,
into airway management.14 A poorly visualized or whether additional help is needed from the
larynx may not be indicative of difficult tracheal beginning. We also try to predict whether fall-
intubation, especially if an adjunct such as a back techniques such as face-mask ventilation or
styleted tube is used. A poorly visualized larynx a surgical airway will succeed or fail.
on direct laryngoscopy (classified as grade 3 or If airway difficulty is predicted but does not
4 on the Cormack–Lehane grading scale, on which occur (a false positive result), there are almost
grades range from 1 to 4, with higher grades no consequences. The positive predictive value,
indicating poorer visibility) might be more suc- which is the probability that a positive test re-
cessfully visualized by using a different device, sult, such as the thyromental distance, is correct
such as a flexible bronchoscope or a video laryn- (difficulty predicted and actually encountered),
goscope, and this in turn may allow for easy will always be low as long as the prevalence of
tracheal intubation. But in some instances (e.g., the phenomenon — a difficult airway — is low.24
the use of video laryngoscopy with a hyperangu- On the other hand, if an easy airway is predicted
lated blade), tracheal intubation may still be but a difficult airway is encountered (a false
challenging.14,15 With direct laryngoscopy, there negative result, which is rare), there may be con-
is a straight pathway from teeth to larynx, gen- sequences. The negative predictive value, which
erally allowing for straightforward tube delivery, is the probability that a negative test result is
n engl j med 384;19 nejm.org May 13, 2021 1837

correct (no difficulty predicted and none en- lation, difficult laryngoscopy, and difficult tra-
countered), is usually very high.25 cheal intubation.30,31 Obesity or a thick neck also
A Cochrane systematic review of data from predicts difficult identification of the landmarks
844,206 study participants concluded that none for cricothyrotomy.32,33 Physiological threats such
of the current bedside screening tests, alone or as reduced functional residual capacity and, par-
in any combination, were well suited to detect- ticularly, the resulting decrease in the manageable
ing an unanticipated difficult airway, because duration of apnea must be considered as well.34
they missed a large number of people with diffi-
cult airways.26 The upper-lip bite test performed M a nagemen t of Difficult
best, even though it was not widely used, with a A irwa ys
sensitivity of approximately 60% for the detec-
tion of difficulty in tracheal intubation.27 Most airway management practitioners and most
A complete airway assessment includes, besides national professional societies recommend dis-
bedside screening tests, consideration of ana- tinguishing between management of the unan-
tomical and physiological features, as well as ticipated difficult airway and management of
contextual issues that may affect the approach to the anticipated difficult airway.35,36 These recom-
airway management (Tables 1 and 2). Irrespec- mendations are based on the best available pub-
tive of the importance we attribute to screening lished evidence. When high-quality evidence is
tests in predicting difficulty, and regardless of lacking, recommendations are based on group
whether a preoperative airway assessment predicts consensus statements.37 There are inherent dif-
no difficulty or fails to predict difficulty,25,29 ficulties in conducting adequately powered, ran-
performing an airway examination is a strategy domized, controlled studies for special airway
that requires a clinician to use cognitive skills in scenarios, as well as problems justifying such
deducing how to approach unanticipated diffi- studies from an ethical point of view.38 However,
culty.28 However, airway examination is only one the information available from database analysis
aspect of difficult airway management. The other and cohort studies is just as useful as data from
aspects are technical skills and human factors. randomized, controlled trials.4 In a cohort study
involving 188,064 patients, there were 3391 diffi-
Predictors of Difficulty cult tracheal intubations and 857 cases of difficult
Predictors of difficulty with airway management mask ventilation, confirming that difficult tra-
can be categorized as anatomical, physiological, cheal intubation and difficult mask ventilation
or contextual. Anatomical predictors can be fur- are rare events. Of the 3391 difficult tracheal
ther divided into predictors of difficult direct or intubations, 3154 (93%) were unanticipated.39 Like-
video laryngoscopy, difficult face-mask ventila- wise, difficult mask ventilation was unanticipated
tion, difficult supraglottic airway insertion or use, in 808 of 857 cases (94%). The clinician should
and difficult front-of-neck airway access (Table 1).28 be prepared with a good approach to difficulty
Obesity is a significant predictor of airway going into every case and should attain and
difficulty because of a combination of anatomi- maintain competence in required techniques.9,40,41
cal and physiological factors.1 Obese patients are
twice as likely to have a severe airway complica- Unanticipated Difficulty
tion as those who are not obese, and patients If airway assessment predicts no difficulty, or in
with a body-mass index (the weight in kilograms some circumstances even if difficulty is predict-
divided by the square of the height in meters) ed, management will most often occur after the
that is higher than 40 (i.e., those who are mor- induction of general anesthesia. This is common
bidly obese) are 4 times as likely to have a severe practice, regardless of whether the situation has
complication.1 In the recent anesthesia closed- been judged to be easy or difficult.
claims analysis, obesity was a factor in 68% of
claims involving difficult tracheal intubation.5 Difficult or Failed Face-Mask Ventilation
The anatomical changes that accompany obe- Difficult airway management is frequently and
sity, such as a neck circumference of more than inappropriately focused on tracheal intubation
40 cm, are associated with difficult mask venti- only. Face-mask ventilation is usually the first

Table 1. Anatomical and Physiological Predictors of Difficulty with Airway Management.*
Type of Predictor Specific Predictor

Anatomical
Predictors of difficult direct laryngoscopy Limited mouth opening
Blood or emesis in the oropharynx
Narrow dental arch
Limited mandibular protrusion
Short thyromental distance
Poor submandibular compliance
Modified Mallampati class III or IV†
Limited head and upper neck extension
Increased neck circumference
Obesity
Adverse dentition
Difficult face-mask ventilation
Operator inexperience with direct laryngoscopy
Predictors of difficult video laryngoscopy Limited mouth opening
Blood or emesis in the oropharynx
Short thyromental distance
History of neck irradiation or neck surgery, neck disease, limited neck
mobility, thick neck
Obesity
Known Cormack–Lehane grade 3 or 4 during direct laryngoscopy‡
Operator inexperience with video laryngoscopy
Predictors of difficult face-mask ventilation Beard or other factor affecting mask seal
Male sex
Lack of teeth
Age >50 yr
Modified Mallampati class III or IV†
BMI >26
History of snoring or obstructive sleep apnea
History of neck irradiation
Difficult intubation
Predictors of difficult SGA insertion or use Limited mouth opening
Obstructing or distorting lesion in the upper airway
Fixed neck-flexion deformity
Applied cricoid pressure
BMI >29
Predictors of difficult front-of-neck airway Female sex
access Age <8 yr
Thick neck
Obesity
Displaced trachea
Overlying disorder (e.g., irradiation damage or other tissue induration)
Fixed neck-flexion deformity
Physiological Full stomach
Rapid oxygen desaturation and the onset of apnea due to reduced
functional residual capacity or increased oxygen consumption (e.g.,
obese, septic, or pregnant patients)
Large minute ventilation (e.g., compensatory for metabolic acidosis)
Hemodynamic instability: shock states, including hypovolemia and
right ventricular failure
* The information in the table is adapted from Law and Heidegger.28 BMI denotes body-mass index (the weight in kilo-
grams divided by the square of the height in meters), and SGA supraglottic airway.
† The modified Mallampati classification is used to evaluate the visibility of oropharyngeal structures. Class III denotes
visibility only of the soft palate and the base of the uvula, and class IV denotes no visibility of the soft palate.
‡ The Cormack–Lehane grading scale ranges from grades 1 to 4, with grade 1 indicating full view of the glottis and grade 4
indicating no view of the epiglottis.

Table 2. Contextual Issues that May Affect the Approach to Airway Management.*
Issue Explanation
Experience and skills of primary When difficulty is predicted, the clinician must be sufficiently experienced in the
clinician or team planned technique to achieve acceptable success rates.
Availability of skilled help Rendering a patient apneic when the potential for technical difficulty in securing
the airway has been identified can be stressful for both the patient and the
care team. Having a colleague stand by during the process or even knowing
that a colleague is nearby and could be called on, should serious difficulty be
encountered, can alleviate such stress. When difficulty is predicted, the ab-
sence of readily available help may affect the decision about how to proceed
by elevating the advisability of tracheal intubation while the patient is awake.
Availability of appropriate equipment When difficulty is predicted, the necessary equipment to expeditiously manage
the airway after induction of general anesthesia or in the awake state (flexible
bronchoscope) should be available.
Behavior of the patient Although tracheal intubation while the patient is awake may have been identified
as the safest approach after assessment of anatomical predictors of technical
difficulty, this may be precluded by a patient who does not respond appropri-
ately to instructions.
High urgency A high-urgency situation during resuscitation may preclude tracheal intubation
while the patient is awake because of the need to rapidly move on to other
resuscitation priorities.
* The information in the table is adapted from Law and Heidegger.28
step in airway management in an unconscious factors. If none of these factors is responsible

patient and is an integral part of difficult airway and ventilation and oxygenation still fail, tracheal
management. It is a commonly used rescue ma- intubation or face-mask ventilation should be
neuver between unsuccessful attempts at tracheal attempted. In addition to its use in primary air-
intubation or supraglottic airway insertion. way management, a supraglottic airway is an
Effective face-mask ventilation can be con- established rescue device when tracheal intuba-
firmed by observation of a rise in the chest, a tion has failed (Fig. 1).9,10,40 Further information
capnographic tracing, and an increase in oxygen on supraglottic airway devices can be found else-
saturation. Appropriate aids are an oropharyn- where.45,46
geal or nasopharyngeal airway and modified,
two-handed face-mask ventilation with an exag- Difficult or Failed Laryngoscopy or Tracheal
A video showing gerated jaw lift.42 A video demonstrating modi- Intubation
a technique for
fied, two-handed face-mask ventilation can be Difficulty in visualizing the larynx can some-
performing face-
mask ventilation viewed at NEJM.org. For effective face-mask times be overcome by means of simple mea-
is available at ventilation, it is crucial to open the airway, usu- sures, such as improving the anesthesia level
NEJM.org ally by performing jaw-thrust and chin-lift ma- and inducing relaxation in case of inability to
neuvers, and to keep the airway open. It is gen- open the mouth or changing the position of the
erally accepted that mask ventilation improves head and neck if the view of the glottis is im-
after the establishment of neuromuscular block- paired.47,48
ade, as noted in guidelines regarding airway If difficult or even failed laryngoscopy occurs
management.10,40,43,44 but oxygenation through a face mask or supra-
glottic airway ventilation is possible, there is time
Difficult or Failed Ventilation with a Supraglottic to consider different options (Fig. 1). If tracheal
Airway Device intubation is necessary, up to two further opti-
Supraglottic airway devices such as the laryngeal mized attempts at tracheal intubation are valid
mask airway are an integral part of routine air- before an alternative strategy is considered. There
way management and are recommended by almost is a strong association between multiple tracheal
all airway guidelines.35,36,38 Difficult or failed intubation attempts and adverse outcomes, such as
ventilation with a supraglottic airway and subse- hypoxemia, airway trauma, or cardiac arrest.5,10,49-56
quent, inadequate oxygenation may be due to light A study that involved 1828 orotracheal intuba-
anesthesia, incorrect positioning, or anatomical tions in an emergency department showed that

Patient requires airway management
Does airway assessment (history, anatomical, physiological,

or contextual issues) predict easy airway management?
Yes No
Airway management Anticipated difficult

(e.g., tracheal intubation or SGA) airway management
after induction of general
anesthesia
Unanticipated difficulty is Low risk of failed oxygenation High risk of failed oxygenation
encountered in the if management is after induction if management is after induction
unconscious patient of general anesthesia of general anesthesia
Can patient oxygenation be Difficulty is Is tracheal intubation or FONA

maintained with FMV, SGA, encountered in the feasible in a patient who
or apneic oxygenation? unconscious patient is awake?
Yes No
Tracheal intubation or Preparation for immediate

Yes, can oxygenate No, cannot oxygenate
FONA in a patient who cricothyrotomy; ensure
is awake presence of second
clinician with airway
In parallel with preparations management expertise
for emergency FONA,
Try the intended technique make a single final attempt
≤2 more times: at any untried technique:
Different device FMV, SGA, or tracheal
Different operator intubation; ensure
neuromuscular blockade
Fails (but patient still oxygenated)
Stop and think about your Fails

options
Awaken patient (only if
feasible)
Temporize or proceed with Emergency FONA
SGA
Intubate if intended tech-
nique was SGA
FONA (rarely)
Figure 1. Airway Management Algorithm.

Practitioners performing airway management should call for help when they have difficulty with maintenance of patient oxygenation.
Front-of-neck airway (FONA) access while the patient is awake or sufficiently conscious and breathing spontaneously is rarely practiced
but is not unusual in situations such as those involving a high risk of failed oxygenation if airway management is performed after induc-
tion of general anesthesia or a high risk that tracheal intubation in a patient who is awake might fail (e.g., in a patient with a massive tu-
mor in the supraglottic region). Adapted from Law and Heidegger.28 FMV denotes face-mask ventilation, and SGA supraglottic airway.
even in cases requiring two attempts, the inci- management of a difficult airway is persevera-
dence of one or more adverse events, such as de- tion, defined as the repeated application of any
saturation or esophageal intubation, was 47%, as airway management technique or tool in three
compared with 14% in cases with one attempt.57 or more attempts without deviation or change.5
A major contribution to a bad outcome in the Besides changing the operator, which should

always be considered, changing to video laryn- When ventilation and oxygenation are possi-
goscopy is a valid alternative for a second or ble but tracheal intubation with direct or video
third attempt58 and may be considered the tech- laryngoscopy has failed after a maximum of
nique of first choice for tracheal intubation, as three attempts, it is time to stop and think about
recommended by the recently updated guidelines the options. These are awakening the patient
of the Canadian Airway Focus Group.10 The first- (usually not an option in the emergency depart-
attempt or overall success rate for tracheal intu- ment or ICU), temporizing or proceeding with a
bation facilitated by video laryngoscopy is rarely supraglottic airway, intubating if the intended
lower and is often higher than the rate for tra- technique was insertion of a supraglottic airway,
cheal intubation facilitated by direct laryngos- making a further attempt at tracheal intubation
copy.10,59-61 However, video laryngoscopy is not a (e.g., with the use of a flexible bronchoscope),69
panacea,62 and the data are still conflicting. or on rare occasions, using front-of-neck airway
In a multicenter study involving 720 patients access (Fig. 1).28
with simulated limited mouth opening and re-
stricted neck movement,63 the primary outcome “Cannot Intubate, Cannot Oxygenate” Situation
for each of the six video laryngoscopes used was If oxygenation is impaired and oxygen satura-
that the lower limit of the 95% confidence inter- tion is declining, an emergency situation must
val for the rate of a successful first attempt within be declared, with immediate preparation for
180 seconds was 90% or higher. However, when front-of-neck airway access. In parallel, a final
this model is used for trauma patients, the amount attempt at any untried technique is recommend-
of time taken is a concern. With 60 seconds as a ed (Fig. 1), and neuromuscular blockade should
more reasonable cutoff time, the first-attempt be established (or reestablished).43,44
success rate was less than 70%. A Cochrane re- If a “cannot intubate, cannot oxygenate” situ-
view comparing video laryngoscopy with direct ation persists, establishment of front-of-neck
laryngoscopy in the operating room, ICU, and airway access must be attempted immediately.
emergency department concluded that video Most airway societies recommend a scalpel–bou-
laryngoscopy may reduce the number of failed gie–tube approach for cricothyrotomy, but a
tracheal intubations, particularly among patients cannula-based technique can be considered by
with a difficult airway, but that there was insuf- physicians who are experienced in its use.70
ficient evidence that the use of a video laryngo-
scope reduces the number of tracheal intubation Anticipated Difficulty
attempts or the incidence of hypoxia or respira- When no technical difficulty is predicted, airway
tory complications. In addition, mostly because management generally occurs after the induc-
of a lack of standardization of outcome mea- tion of general anesthesia.28 This affords opti-
sures, there was no evidence that the use of a mized conditions for technical management
video laryngoscope affects the time required for mainly because of the administration of medica-
tracheal intubation.64 tions, including neuromuscular blocking agents.
A systematic review and two meta-analyses of The use of general anesthesia with neuromuscu-
studies conducted in ICUs suggest that video lar blockade for airway management is more
laryngoscopy does not perform better than tradi- comfortable for the patient and the clinician
tional direct laryngoscopy across a wide range of than management while the patient is awake
conditions, even if video laryngoscopy can offer and is most often safe. Since the patient is un-
better visualization of the glottis.65-67 However, conscious and often apneic, however, airway
published data on video laryngoscopy in criti- patency and gas exchange must be addressed
cally ill patients are generally of poor quality.68 while the airway is being secured.
The Difficult Airway Society of the United King- Even when laryngoscopy or tracheal intuba-
dom states that a video laryngoscope should be tion is predicted to be difficult but airway man-
available and considered as an option for all in- agement during general anesthesia is considered
tubations of critically ill patients, provided that to be safe, the induction of general anesthesia can
the physician is appropriately trained in the use be attempted as long as a strategy for addressing
of this device.68 difficulty or failure is available (Fig. 1).14,71 The

goal should be to achieve first-pass success, since T r ache a l E x t ub at ion of the

rescue techniques are much more likely to fail.72 Difficult A irwa y
However, when tracheal intubation is predicted to
be very difficult or fallback techniques are pre- As compared with tracheal intubation, relatively
dicted to be difficult, or both, an extra margin of little has been published about tracheal extuba-
safety might be afforded by performing tracheal tion, which is a tricky part of airway manage-
intubation while the patient is awake.73 ment.84 Since planned tracheal extubation is al-
ways an elective procedure, there should be time
Tracheal Intubation while the Patient Is Awake for careful preparation.
Tracheal intubation while the patient is awake or The Difficult Airway Society of the United
sufficiently conscious and breathing spontaneously Kingdom has published guidelines for the man-
involves securing the airway and applying topi- agement of tracheal extubation.85 Even though
cal airway anesthesia, with or without the use of they were developed for the perioperative period,
sedation.73,74 However, a patient’s responsiveness the basic principles can readily be applied in the
to stimuli, airway reflexes, and ability to main- ICU as well.68,86 The guidelines define the main
tain spontaneous ventilation may be impaired by goals of safe extubation as ensuring uninter-
deep sedation.75,76 The device typically used to per- rupted oxygen delivery and having a backup plan
form tracheal intubation while the patient is for tracheal reintubation, should tracheal extu-
awake is a flexible bronchoscope, although in bation fail. The crucial consideration is whether
selected cases, a video laryngoscope can be used. the patient will be at risk after tracheal extuba-
Tracheal intubation while the patient is awake tion (Fig. 2). Patients may be at risk either be-
might be indicated, especially when there is a high cause they cannot withstand tracheal extubation
risk of failed oxygenation after the induction of or because of the potential difficulty of tracheal
general anesthesia (e.g., in patients with morbid reintubation. Risk factors for unsuccessful tra-
obesity or tumors in the oropharyngeal region).10,69 cheal extubation are functional airway obstruc-
Airway management techniques for patients who tion such as muscle weakness or impaired cog-
are awake have been underused in cases of a dif- nitive status, anatomical airway obstruction such
ficult airway that is clearly recognizable.1,5 as airway edema or secretion overload, and car-
diopulmonary issues such as fluid overload or
Airway Management in Obese Patients compromised functional residual capacity. Risk
On the basis of the increased incidence of bad factors for difficult reintubation include known
outcomes of airway management in obese pa- difficult tracheal intubation or upper airway
tients,1 airway societies have begun declaring such surgery. A detailed list of all factors that put
patients to be at elevated risk, and management patients at risk after tracheal extubation can be
of the anticipated difficult airway should be un- found elsewhere.73,85,87
dertaken accordingly.73 Basically, the same prin- The key questions are whether it is safe to re-
ciples of airway management in patients with an move the tube, to postpone extubation, or to per-
anticipated difficult airway (described above) can form a tracheotomy (Fig. 2). Different advanced
be used for airway management in obese patients. techniques are available, and recommendations
However, since obesity is a significant predictor vary among professional societies.73,85,87 However,
of airway difficulty and of increased risk related none of the techniques cover all clinical scenarios,
to apnea, as noted above,1,34 special considerations and none of the techniques are without risk.
must be addressed to maximize safety, such as The use of an airway exchange catheter for ex-
tracheal intubation while the patient is awake or tubation in an at-risk patient in whom reintuba-
general anesthesia with attention to the details tion might be difficult is recommended, but the
of implementation (e.g., apneic oxygenation) and practitioner must be experienced in this tech-
arrangement for the presence of a second clini- nique.73,85,87 The patient’s trachea can be immedi-
cian.73,77,78 Because obese patients are at particu- ately reintubated through this placeholder in the
larly high risk for airway obstruction,79-81 there is case of a failed extubation. In this case, reintuba-
still controversy regarding the benefit of apneic tion can be improved by using a video laryngo-
oxygenation.79,82,83 scope.88 A catheter of the appropriate size is

Guidelines for Tracheal Extubation of the Difficult Airway
Step 1
Assess airway risk factors (e.g., uncertain
Plan Tracheal Extubation ability to oxygenate, potentially
difficult tracheal intubation)
and general risk factors
Step 2
Prepare for Tracheal Extubation Optimize patient factors
Cardiovascular
Respiratory
Metabolic
Neuromuscular
Optimize other factors
Location
Skilled help or assistance
Monitoring
Equipment
Key question: Is it safe to remove the tube?
Step 3
Perform Tracheal Extubation
Yes No
Tracheal extubation in Advanced techniques Postpone tracheal

Tracheotomy
patient who is awake Airway exchange extubation
catheter
Step 4
Postextubation Care Postanesthesia care unit, intermediate care unit, or ICU
Safe transfer
Handover and communication
Oxygen and airway management
Observation and monitoring
Analgesia
Staffing
Monitoring
Equipment
Documentation
General medical and surgical management
Figure 2. Guidelines for Tracheal Extubation of the Difficult Airway.

Tracheal extubation of the difficult airway is associated with the following airway risk factors: preexisting airway dif-
ficulties (e.g., obesity and risk of aspiration), perioperative airway deterioration (e.g., edema resulting from surgery),
restricted airway access (e.g., cervical spine fixation and mandibular wiring), and general risk factors (e.g., impaired
respiratory function and cardiovascular instability). Adapted from Popat et al.85 ICU denotes intensive care unit.
placed and secured above the carina before the should be administered by means of a face mask
tube is removed. These catheters are usually not or high-flow nasal cannulae.90
problematic and can be left in situ until tracheal
reintubation is unlikely to be needed. However, Hum a n Fac t or s a nd Erg onomic s
since severe barotrauma and subsequent death in A irwa y M a nagemen t
have been reported after continuous application
of oxygen through an airway exchange catheter,89 The study of human factors is the discipline that
routine oxygen insufflation through this device applies theoretical principles, data, and methods
is discouraged.73 Instead, supplemental oxygen to design in order to optimize human well-being

and overall system performance, including pa- and planning, decision making, situational aware-
tient safety.91 In the NAP4 study, human factors ness, avoidance of perseveration, communication,
contributed to 40% of serious airway complica- and teamwork, play an essential role in airway
tions and were major factors in 25% of these management safety.93,95,96 A detailed description
cases.1 A follow-up analysis showed that these can be found elsewhere.71,97-99
proportions were grossly underestimated.92 Poor
situational awareness (e.g., failure to anticipate C onclusions
a problem), job factors (e.g., task difficulty), and
personal factors (e.g., tiredness) had the greatest Management of the difficult airway is an impor-
influence.92,93 tant issue, since even small changes in the per-
Failure of judgment and a delay in attempting formance of airway management are highly rele-
a surgical airway in an emergency “cannot intu- vant to the outcome. Airway management is a
bate, cannot oxygenate” situation were common process that requires thorough preparation,
human factors in the U.S. closed-claims analy- which includes careful airway assessment, plan-
sis.5 An analysis of closed civil cases involving ning, and appropriate decision making. Manage-
anesthesiologists, reported by the Canadian Med- ment of the airway involves the use of appropri-
ical Protective Association, showed that 46 of the ate techniques and skills, an appropriate response
406 cases (11%) were related to problems with to difficulty or failure, and careful planning for
airway management.94 The outcomes were severe, tracheal extubation. Skills and human factors
with death or permanent brain damage occur- together are the key to successful airway man-
ring in two thirds of the 46 cases. Inadequate agement.
preoperative airway evaluation was the most Disclosure forms provided by the author are available with the
common judgment failure (accounting for 59% full text of this article at NEJM.org.
I thank Tim Cook for critical discussion and Jeannie Wurz
of the cases). for assistance with the editing of an earlier version of the manu-
Human factors, including adequate assessment script.
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The n e w e ng l a n d j o u r na l of m e dic i n e

Dan L. Longo, M.D., Editor

Management of the Difficult Airway

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The New England Journal of Medicine

Defini t ion, Incidence , a nd whereas with hyperangulated-blade video laryn-

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Table 1. Anatomical and Physiological Predictors of Difficulty with Airway Management.*

Type of Predictor Specific Predictor

n engl j med 384;19 nejm.org May 13, 2021 1839

* The information in the table is adapted from Law and Heidegger.28

step in airway management in an unconscious factors. If none of these factors is responsible

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The New England Journal of Medicine

Patient requires airway management

Does airway assessment (history, anatomical, physiological,

Airway management Anticipated difficult

Can patient oxygenation be Difficulty is Is tracheal intubation or FONA

Tracheal intubation or Preparation for immediate

Stop and think about your Fails

Figure 1. Airway Management Algorithm.

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goal should be to achieve first-pass success, since T r ache a l E x t ub at ion of the

n engl j med 384;19 nejm.org May 13, 2021 1843

Guidelines for Tracheal Extubation of the Difficult Airway

Key question: Is it safe to remove the tube?

Tracheal extubation in Advanced techniques Postpone tracheal

Figure 2. Guidelines for Tracheal Extubation of the Difficult Airway.

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The New England Journal of Medicine

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* The information in the table is adapted from Law and Heidegger.28