ASA difficult airway algorithm: Adults

ASA: American Society of Anesthesiologists; CO₂: carbon dioxide.
* The airway manager's choice of airway strategy and techniques should be based on their previous experience; available resources, including equipment, availability and competency of help; and the context in which airway management will occur.
¶ Low- or high-flow nasal cannula, head elevated position throughout procedure. Noninvasive ventilation during preoxygenation.
Δ Awake intubation techniques include flexible bronchoscope, videolaryngoscopy, direct laryngoscopy, combined techniques, and retrograde wire-aided intubation.
◊ Invasive airway techniques include surgical cricothyrotomy, needle cricothyrotomy with a pressure-regulated device, large-bore cannula cricothyrotomy, or surgical tracheostomy. Elective invasive airway techniques include the above and retrograde wire-guided intubation and percutaneous tracheostomy. Also consider rigid bronchoscopy and extracorporeal membrane oxygenation.
§ Other options include, but are not limited to, alternative awake technique, awake elective invasive airway, alternative anesthetic techniques, induction of anesthesia (if unstable or cannot be postponed) with preparations for emergency invasive airway, and postponing the case without attempting the above options.
¥ Consideration of size, design, positioning, and first versus second generation supraglottic airways may improve the ability to ventilate.
‡ Includes postponing the case or postponing the intubation and returning with appropriate resources (eg, personnel, equipment, patient preparation, awake intubation).
† Alternative difficult intubation approaches include but are not limited to video-assisted laryngoscopy, alternative laryngoscope blades, combined techniques, intubating supraglottic airway (with or without flexible bronchoscopic guidance), flexible bronchoscopy, introducer, and lighted stylet or light wand. Adjuncts that may be employed during intubation attempts include tracheal tube introducers, rigid stylets, intubating stylets, or tube changers and external laryngeal manipulation.
** Other options include, but are not limited to, proceeding with procedure utilizing face mask or supraglottic airway ventilation. Pursuit of these options usually implies that ventilation will not be problematic.