1. Assess the likelihood and clinical impact of basic management problems:
1. Difficult Ventilation
2. Difficult Intubation
3. Difficulty with Patient Cooperation or Consent
4. Difficult Tracheostomy
2. Actively pursue opportunities to deliver supplemental oxygen throughout the process of difficult airway management
3. Consider the relative merits and feasibility of basic management choices:
1. Awake Intubation
   vs.
   Intubation Attempts After Induction of General Anesthesia
2. Non-Invasive Technique for Initial Approach to Intubation
   vs.
   Invasive Technique for Initial Approach to Intubation
3. Preservation of Spontaneous Ventilation
   vs.
   Ablation of Spontaneous Ventilation
4. Develop primary and alternative strategies:

1. Difficult Ventilation
2. Difficult Intubation
3. Difficulty with Patient Cooperation or Consent
4. Difficult Tracheostomy

1. Awake Intubation
   vs.
   Intubation Attempts After Induction of General Anesthesia
2. Non-Invasive Technique for Initial Approach to Intubation
   vs.
   Invasive Technique for Initial Approach to Intubation
3. Preservation of Spontaneous Ventilation
   vs.
   Ablation of Spontaneous Ventilation

Invasive Airway Access^(b)*

NON-EMERGENCY PATHEAY
Ventilation Adequate, Intubation Unsuccessful

EMERGENCY PATHWAY
Ventilation Not Adequate, Intubation Unsuccessful

IF BOTH FACE MASK AND LMA VENTILATION BECOME INADEQUATE

^* Confirm ventilation, tracheal intubation, or LMA placement with exhaled CO₂

a. Other options include (but are not limited to): surgery utilizing face mask or LMA anesthesia, local anesthesia infiltration or regional nerve blockade. Pursuit of these options usually implies that mask ventilation will not be problematic. Therefore, these options may be of limited value if this step in the algorithm has been reached via the Emergency Pathway.

b. Invasive airway access includes surgical or percutaneous tracheostomy or cricothyrotomy.

c. Alternative non-invasive approaches to difficult intubation include (but are not limited to): use of different laryngoscope blades, LMA as an intubation conduit (with or without fiberoptic guidance), fiberoptic intubation, intubating stylet or tube changer, light wand, retrograde intubation, and blind oral or nasal intubation.

d. Consider re-preparation of the patient for awake intubation or canceling surgery.

e. Options for emergency non-invasive airway ventilation include (but are not limited to): rigid bronchoscope, esophageal-tracheal combitube ventilation, or transtracheal jet ventilation.

End

A. AWAKE INTUBATION

B. INTUBATION ATTEMPTS AFTER INDUCTION GENERAL ANESTHESIA

Airway Approached by Non-Invasive Intubation

Invasive Airway Access^(b)*

Succeed^*

FAIL

Cancel Case

Consider Feasibility of Other Options^(a)

Invasive Airway Access^(b)*

Invasive Airway Access^(b)*

Consider Feasibility of Other Options^(a)

Awaken Patient^(d)

CONSIDER / ATTEMPT LMA

LMA ADEQUATE^*

LMA NOT ADEQUATE OR NOT FEASIBLE

Call for help

Emergency Non-Invasive Airway Ventilation^(e)

Emergency Invasive Airway Access^(b)*

Successful Ventilation^*

FAIL

Invasive Airway Access^(b)*

Consider Feasibility of Other Options^(a)

Awaken Patient^(d)

Emergency Invasive Airway Access^(b)*

Initial Intubation Attempts Successful^*

Initial Intubation Attempts UNSUCCESSFUL
FROM THIS POINT ONWARDS CONSIDER:

1. Calling for help
2. Returning to Spontaneous Ventilation
3. Awakening the Patient

FACE MASK VENTILATION ADEQUATE

FACE MASK VENTILATION NOT ADEQUATE

Alternative Approaches to Intubation^(c)

Successful Intubation^*

FAIL After Multiple Attempts

If Both Face Mask and LMA Ventilation Become Inadequate