Difficult Airway Management

Airway management is usually an uncomplicated and safe intervention; however, when problems arise with the primary airway technique, the clinical situation can rapidly deteriorate, resulting in significant patient harm. Videolaryngoscopy has been shown to improve patient outcomes when compared with direct laryngoscopy, including improved first-pass success at tracheal intubation, reduced difficult laryngeal views, reduced oxygen desaturation, reduced airway trauma, and improved recognition of oesophageal intubation. The shared view that videolaryngoscopy affords may also facilitate superior teaching, training, and multidisciplinary team performance. As such, its recommended role in airway management has evolved from occasional use as a rescue device (when direct laryngoscopy fails) to a first-intention technique that should be incorporated into routine clinical practice, and this is reflected in recently updated guidelines from a number of international airway societies. However, currently, overall videolaryngoscopy usage is not commensurate with its now widespread availability. A number of factors exist that may be preventing its full adoption, including perceived financial costs, inadequacy of education and training, challenges in achieving deliverable decontamination processes, concerns over sustainability, fears over "de-skilling" at direct laryngoscopy, and perceived limitations of videolaryngoscopes. This article reviews the most up-to-date evidence supporting videolaryngoscopy, explores its current scope of utilisation (including specialist techniques), the potential barriers preventing its full adoption, and areas for future advancement and research.

Videolaryngoscopy has significantly improved the management of unanticipated difficult airways and replaced other intubation techniques. The goal of this study was to identify the indications for using videolaryngoscopy and fiberoptic bronchoscopy for adult patients, where direct laryngoscopy is the standard intubation technique. Over a one-year period from January to December 2018, anesthesiologists were surveyed on their reasons for using a videolaryngoscope or fiberoptic bronchoscope for tracheal intubations. Additionally, retrospective data on all direct laryngoscopy intubations were collected for the same period from the anesthesia information management system. Out of 6251 tracheal intubations with direct laryngoscopy and 502 with videolaryngoscopy or fiberoptic bronchoscopy, data from 450 (89.6%) cases were collected. We excluded 46 cases where videolaryngoscopy and fiberoptic bronchoscopy were used for non-airway management reasons, resulting in 404 cases for analysis. Videolaryngoscopy was initially used in 356 (88.1%) patients. The primary reasons for using videolaryngoscopy or fiberoptic bronchoscopy were anticipated difficult intubation (218, 54.0%) and cervical pathology (109, 27.0%). Among the 42 cases of unanticipated failed direct laryngoscopy, videolaryngoscopy was used in 41 cases and fiberoptic bronchoscopy in 1 case. The overall rate of unanticipated failed direct laryngoscopy was 0.7%. The routine use of videolaryngoscopy and fiberoptic bronchoscopy for anticipated difficult tracheal intubations led to a very low incidence of unanticipated failed tracheal intubations with direct laryngoscopy. Therefore, routinely using more expensive videolaryngoscopes for all intubations would prevent only very small numbers of unanticipated failed direct laryngoscopic intubations and is not financially justified.

Difficult airway management poses a great challenge for clinicians, especially if it is unanticipated. Numerous guidelines and a wide array of devices constitute the anesthesiologist's armamentarium for managing the airway. When the use of individual devices fails, the use of combination techniques is advised. We present a case of difficult intubation in a 50-year-old male patient scheduled for aortic valve replacement. He had no prior history of difficult airway management, and no abnormalities were detected on preoperative airway assessment. Body mass index was 29 kg/m2. After the separate use of direct laryngoscopy, videolaryngoscopy and a BONFILS intubation endoscope (BIE) had failed, we resorted to a combination technique, combining videolaryngoscopy and BIE. While the videolaryngoscope provided the space needed for BIE and visual guidance through copious secretions, the BIE served as a stylet for endotracheal tube guidance, leading to successful intubation. Since the technique requires costly equipment, experience in handling it and at least two operators, it is more appropriate as a rescue measure than an elective procedure. Given the potentially disastrous outcomes of failed intubation, mastering advanced airway management techniques remains of vital importance, and the combination technique is one of them.

The All India Difficult Airway Association 2025 Adult guideline provides guidance for the management of an unanticipated difficult airway under general anaesthesia. The American Heart Association (AHA) Class of Recommendation and Level of Evidence was used. In addition, for interventions where the evidence was absent or weak, a Delphi process among airway experts was convened to generate expert consensus statements. The most significant difference from the 2016 guidelines is providing guidance for a failed supraglottic airway (SGA) insertion, tracheal intubation, face mask ventilation, or other strategies commonly used as part of the primary airway plan under general anaesthesia, not restricting to a failed intubation. Airway assessment should be routinely performed to identify an anatomical as well as the physiologically difficult airway. Peri-intubation oxygenation with pre-oxygenation and apnoeic oxygen with nasal oxygen (10-15 L/min) or high-flow nasal oxygen increases the safe apnoea time. Videolaryngoscopy and adjuncts such as stylets and bougies improve first pass intubation success. Tracheal tube position should be confirmed by waveform capnography. If the primary airway plan fails, activate 'Code D' as the hospital emergency code to call for help. Airway rescue should then be attempted with any of the three devices (tracheal tube, SGA, or face mask), and switching promptly between them as needed, with no hierarchy, until effective ventilation and adequate oxygen saturation (SpO₂) are achieved. Optimise patient position, ensure neuromuscular blockade, and consider changing the tools, technique, or operator. Allow up to three failed attempts with these devices provided the SpO2 remains ≥95%. Complete ventilation failure (ventilation using a tracheal tube, SGA, and face mask have all failed, even if oxygenation may be maintained) is the trigger to perform an emergency cricothyroidotomy, preferably by a surgical approach. Team debriefing, team support, patient and family counselling, and documentation are paramount after encountering an unanticipated difficult airway.