title: Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults.
abstract: These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. They are founded on published evidence. Where evidence is lacking, they have been directed by feedback from members of the Difficult Airway Society and based on expert opinion. These guidelines have been informed by advances in the understanding of crisis management; they emphasize the recognition and declaration of difficulty during airway management. A simplified, single algorithm now covers unanticipated difficulties in both routine intubation and rapid sequence induction. Planning for failed intubation should form part of the pre-induction briefing, particularly for urgent surgery. Emphasis is placed on assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions. It is recommended that the number of airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video- or fibre-optically guided intubation. If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Second-generation devices have advantages and are recommended. When both tracheal intubation and supraglottic airway device insertion have failed, waking the patient is the default option. If at this stage, face-mask oxygenation is impossible in the presence of muscle relaxation, cricothyroidotomy should follow immediately. Scalpel cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. The plans outlined are designed to be simple and easy to follow. They should be regularly rehearsed and made familiar to the whole theatre team.
authors.affiliation: Department of Anaesthesia, Northampton General Hospital, Billing Road, Northampton NN1 5BD, UK chris.frerk@ngh.nhs.uk.
authors.forename: C
authors.initials: C
authors.lastname: Frerk
authors.affiliation: Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London NW1 2BU, UK.
authors.forename: V S
authors.initials: VS
authors.lastname: Mitchell
authors.affiliation: Department of Anaesthesia, NHS Lothian, Crewe Road South, Edinburgh EH4 2XU, UK.
authors.forename: A F
authors.initials: AF
authors.lastname: McNarry
authors.affiliation: Department of Anaesthesia, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK.
authors.forename: C
authors.initials: C
authors.lastname: Mendonca
authors.affiliation: Department of Anaesthesia, Barts Health, West Smithfield, London EC1A 7BE, UK.
authors.forename: R
authors.initials: R
authors.lastname: Bhagrath
authors.affiliation: Department of Anaesthesia, The Royal National Throat Nose and Ear Hospital, 330 Grays Inn Road, London WC1X 8DA, UK.
authors.forename: A
authors.initials: A
authors.lastname: Patel
authors.affiliation: Department of Anaesthesia, St James's Hospital, PO Box 580, James's Street, Dublin 8, Ireland.
authors.forename: E P
authors.initials: EP
authors.lastname: O'Sullivan
authors.affiliation: Department of Anaesthesia, The Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich NR4 7UY, UK.
authors.forename: N M
authors.initials: NM
authors.lastname: Woodall
authors.affiliation: Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London SE1 9RT, UK.
authors.forename: I
authors.initials: I
authors.lastname: Ahmad
mesh_terms: D058109:Airway Management / Q000592:standards*; D006801:Humans; D017410:Practice Guidelines as Topic
keywords: airway obstruction; complications; intubation; intubation, endotracheal; intubation, transtracheal; ventilation