Recommendations for the evaluation and management of the anticipated and non-anticipated difficult airway of the Societat Catalana d’Anestesiologia, Reanimació i Terapèutica del Dolor, based on the adaptation of clinical practice guidelines and expert consensus | Revista Española de Anestesiología y Reanimación (English Edition)

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(B) Pre-oxygenation is recommended in patients who require optimised airway management, combining the previous position and oxygen delivery through nasal cannula and a properly sealed face mask." ] ] ] "textoCompleto" => "In 2016, the Airway Group (SEVA, in its Spanish acronym) of the Catalan Society of Anaesthesiology and Pain Therapy (SCARTD, in its Spanish acronym) decided to update the current difficult airway (DA) evaluation and management algorithm in order include the latest knowledge and innovations in airway management techniques that had emerged since the algorithm was approved and published in 2007.<a class="elsevierStyleCrossRef" href="#bib0560">1</a> Following the recent publication of several international guidelines based on an extensive and systematic review of the evidence, SEVA experts agreed to select and subsequently adapt these recommendations to the needs and characteristics of our setting.<a class="elsevierStyleCrossRef" href="#bib0565">2</a> For this purpose, the 2013 version of the AGREE II instrument<a class="elsevierStyleCrossRef" href="#bib0570">3</a> was applied to existing guidelines using ADAPTE<a class="elsevierStyleCrossRef" href="#bib0575">4</a> and Delphi<a class="elsevierStyleCrossRef" href="#bib0580">5</a> methodology.Field of application, scope and objectives of the guidelinesThese guidelines are intended for licensed and trained anaesthesiologists responsible for intra- and out-of-hospital airway management in our setting. The objective is to update the recommendations for the pre-anaesthesia evaluation and management of anticipated and unanticipated difficult airway by developing a series of recommendations for each specific sub-field of airway management (paediatrics, obstetrics, emergency medicine and critical care).MethodologyThe following is a summary of the procedure used to develop the recommendations presented in this document:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.A small group of experts in airway management from the SCARTD was appointed to prepare the list of clinical questions to be answered in the different sections and subsections of this guideline.</li><li class="elsevierStyleListItem" id="lsti0010">2.Airway management guidelines published after 2007 were critically analysed to determine whether they met the criteria defined in the AGREE instrument. Five guidelines that both answered the questions posed and presented an average AGREE score of 85.5 (73.7–95.2) were selected and included in the analysis.<a class="elsevierStyleCrossRefs" href="#bib0585">6–11</a></li><li class="elsevierStyleListItem" id="lsti0015">3.All anaesthesiology services in university, public and private hospitals in Catalonia were invited to take part in the project, and an expert panel was formed of representatives from the 19 service that agreed to participate (SEVA Group).</li><li class="elsevierStyleListItem" id="lsti0020">4.Thematic working groups were created to formulate consensus proposals for each question that met the particular requirements of our setting. These proposals were formulated by comparing the recommendations included in the accepted guidelines, reviewing the supporting evidence, and evaluating the articles published after the aforementioned guidelines. The first step involved creating a shared electronic bibliographic database.</li><li class="elsevierStyleListItem" id="lsti0025">5.In the case of controversial recommendations in the guidelines reviewed that were supported by weak evidence or that did not achieve consensus, the working group drew up proposals and prepared a Delphi questionnaire that was sent to the experts in the participating services using the “e-Delphi” technique.</li><li class="elsevierStyleListItem" id="lsti0030">6.After analysing the responses, the experts were sent a second and third questionnaire containing the proposals that had not reached a consensus of 80% or more in the previous round.</li><li class="elsevierStyleListItem" id="lsti0035">7.The draft document with the initial recommendations was published on the SCARTD website and all members were invited to comment on the content and send suggestions before the final recommendations were drawn up. The final consensus document and infographics (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1–3</a>) were published on the SCARTD website.<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0040">8.The consensus document was sent to external experts for independent evaluation.</li><li class="elsevierStyleListItem" id="lsti0045">9.The final version was then approved by the SCARTD.</li></ul>Consensus documentThe SCARTD consensus document for DA management is described below. The statements included in the e-Delphi questionnaire appear followed by the percentage of consensus (in parentheses) reached among the experts polled.Definition of the difficult airwayDifficult airway. The airway is defined as difficult if a fully trained anaesthesiologist encounters a situation that fulfils any of the following criteria<a class="elsevierStyleCrossRefs" href="#bib0585">6,9</a>: (a) suspicion or evidence of difficulty due to a compatible medical history and/or physical examination that calls for airway management in spontaneous ventilation (93%); (b) difficulty (more than 2 attempts or a change of device or operator) encountered during one of the steps involved in establishing the airway (92.5%); (c) Difficulty that leads to a significant decrease in O2 saturation with or without complications, or causes airway device-related injuries (90%).<a class="elsevierStyleCrossRef" href="#bib0590">7</a>The difficulty in each of the following procedures must be specified, assuming that sufficient depth of anaesthesia and neuromuscular blockade have been achieved, the patient is correctly positioned and the resources used are adequate.Difficult ventilation. Insufficient or impossible facial mask (FM) ventilation that fulfils any of the following criteria: (a) excessive leakage or air flow resistance; (b) absence of chest movement and capnography curve on the monitor, or appearance of gastric distension (92.5%)<a class="elsevierStyleCrossRef" href="#bib0600">9</a>; (c) manoeuvres to improve ventilation are required, such as optimising the patient's position, use of oral/nasal cannulas, four-hand ventilation, or deepening of neuromuscular block (95%); (d) inability to maintain oxygenation and elimination of CO2 (100%).<a class="elsevierStyleCrossRefs" href="#bib0590">7,12,13</a>Difficult laryngoscopy. No full or partial view of the glottis (Cormack Lehane 3 or 4), despite the use of adjunct manoeuvres such as external laryngeal manipulation (BURP) or change of position (the type of laryngoscope or video laryngoscope [VLS] used must be specified) (100%).<a class="elsevierStyleCrossRefs" href="#bib0625">14–16</a>Difficult intubation. More than 2 attempts required by one or more than one operator to advance the tracheal tube, or need for a bougie or change of technique (100%).<a class="elsevierStyleCrossRefs" href="#bib0590">7,17</a>Difficult ventilation with supraglottic airway device (SAD). Two aspects must be considered: (a) more than 2 manoeuvres or more than 2 attempts needed to position the SAD; and/or (b) insufficient oxygenation or CO2 elimination due to leakage or obstruction once the device is in place, requiring a change in SAD or technique (100%).<a class="elsevierStyleCrossRefs" href="#bib0645">18,19</a>Difficult surgical access. Difficulty in (a) locating the cricothyroid membrane; and/or (b) more than one attempt or excessive time needed to perform the puncture or insert the cannula that does not prevent functional repercussions (95%).<a class="elsevierStyleCrossRef" href="#bib0590">7</a>Difficult extubation in the DA patient. Suspected (a) difficulty in maintaining adequate ventilation/oxygenation after extubation and/or (b) subsequent difficulty in managing the airway using any of the above modalities (95%).<a class="elsevierStyleCrossRef" href="#bib0655">20</a>Pre-anaesthesia evaluationAll patients should undergo an airway evaluation before an anaesthetic procedure.<a class="elsevierStyleCrossRefs" href="#bib0585">6,8–11,20,21</a>The evaluation should take into account potential difficulties in all aspects of management: ventilation, intubation, SAD placement, and surgical access.<a class="elsevierStyleCrossRefs" href="#bib0585">6,10,11,21</a>It is essential to take a directed medical history in order to obtain relevant information on the patient's airway (previous difficulties, associated pathologies, etc.).<a class="elsevierStyleCrossRefs" href="#bib0585">6,8,9,11</a> The existence of a prior difficulty in airway management is an independent criterion if the conditions that caused it persist, so the patient's records must be checked for a difficult airway alertcardor report detailing previous difficulties in airway management (95%).<a class="elsevierStyleCrossRef" href="#bib0665">22</a>The pre-anaesthesia evaluation also includes an exploration to identify the physical characteristics, signs and symptoms known to be risk factors for DA (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) (100%).<a class="elsevierStyleCrossRefs" href="#bib0585">6,8,9,11,23</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Complementary imaging studies should not be performed routinely, but should be considered when they can provide essential information in the presence of local pathology (100%).<a class="elsevierStyleCrossRef" href="#bib0585">6</a>Although evidence and experience supporting the use of ultrasound is still limited and the technique requires prior training, in expert hands it can be used to locate the cricothyroid membrane faster and more accurately than palpation, especially in women and in patients with anatomical difficulties. In patients with anticipated DA, it is recommended to locate the cricothyroid membrane with ultrasound and mark its position in hyperextension before starting airway management (80%).<a class="elsevierStyleCrossRefs" href="#bib0675">24,25</a>The combination of multiple variables increases the predictive capacity with respect to isolated parameters. However, the predictive value of multivariate indices remains low and insufficient,<a class="elsevierStyleCrossRefs" href="#bib0585">6,8,9,11,26</a> and there is evidence that a systematic evaluation using multivariate indices is not superior to routine evaluation by an experienced anaesthesiologist,<a class="elsevierStyleCrossRefs" href="#bib0690">27–29</a> and does not improve adherence to airway management algorithms.<a class="elsevierStyleCrossRef" href="#bib0705">30</a> Much of the evidence for predicting DA is based on conventional laryngoscopy and tracheal intubation, and evidence for predicting SAD difficulty or failure is based primarily on first-generation or unspecified devices. These studies do not reflect current practice in our setting, where VLSs and second generation SADs are widely available and have substantially improved the estimated success rate in these techniques.The aim of the airway evaluation is to identify patients who are at high risk for failure of the techniques described above, and therefore, severe oxygenation impairment. Once the patient-related factors have been evaluated, the experience of the anaesthesiologist, the availability of material resources and the characteristics of the setting should also be considered (82.8%).<a class="elsevierStyleCrossRef" href="#bib0595">8</a>The DA has been classified into 3 categories in order to simplify the parameters evaluated in the different studies and guidelines<a class="elsevierStyleCrossRefs" href="#bib0585">6,8–13,21,31–33</a> (91.4%):Obvious or known difficult airwayIf one of the following conditions is met:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0050">(A)History of DA, if the criteria or causative factors persist (100%).</li><li class="elsevierStyleListItem" id="lsti0055">(B)Presence of obvious difficulty, such as deformities or neck and face trauma (100%).</li><li class="elsevierStyleListItem" id="lsti0060">(C)Presence of any of the following difficulty criteria, common to all airway management techniques:</li><li class="elsevierStyleListItem" id="lsti0065">•Interdental distance <3cm (100%).</li><li class="elsevierStyleListItem" id="lsti0070">•Neck mobility <80° (94.3%).</li><li class="elsevierStyleListItem" id="lsti0075">•Radiation changes to face and neck affecting tissue plasticity (94.3%).</li><li class="elsevierStyleListItem" id="lsti0080">•Obstructive pathology or airway deformation (100%).</li><li class="elsevierStyleListItem" id="lsti0085">(D)Presence of more than 3 criteria or pathologies with a high risk of difficulty (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) (100%).</li></ul>Potentially difficult airwayThe likelihood of difficulty increases with the number and severity of the risk criteria present. If the patient presents one or more ventilation and intubation difficulty criteria, but these are inconclusive, other factors or safety criteria should be considered individually in order to plan management.<a class="elsevierStyleCrossRefs" href="#bib0595">8,9,11</a>:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0090">•Patient status: risk of aspiration, low tolerance to apnoea, lack of collaboration, emergency situation (100%).</li><li class="elsevierStyleListItem" id="lsti0095">•Experience of the anaesthesiologist in routine and rescue techniques (100%).</li><li class="elsevierStyleListItem" id="lsti0100">•Environment factors: material resources and help available (100%).</li></ul>Airway with no anticipated difficultyPatients who do not present high-risk criteria and less than 3 minor airway-related criteria (88.6%).Pre-airway management preparationCareful planning and preparation can prevent or reduce the severity of complications from airway manipulation. Routine application of the following measures is recommended before starting anaesthesia induction or airway management in spontaneous ventilation.PlanningEstablish an action strategy based on the difficulties envisaged, the type of intervention, the patient's preferences, the experience of the anaesthesiologist, the setting and the resources available.<a class="elsevierStyleCrossRefs" href="#bib0585">6,8,10,11,34</a>CommunicationAll information must be transmitted clearly and promptly to:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0105">•The patient, if any difficulty is foreseen (100%).<a class="elsevierStyleCrossRefs" href="#bib0585">6,8,9</a></li><li class="elsevierStyleListItem" id="lsti0110">•The assistant, specifying the planned strategy, the fallback options if the primary approach fails, and the material resources needed (plan B, C and D) (94.8%).<a class="elsevierStyleCrossRefs" href="#bib0605">10,35</a></li><li class="elsevierStyleListItem" id="lsti0115">•Other experts who can provide competent help, if necessary, in patients with anticipated difficult airway (100%).<a class="elsevierStyleCrossRefs" href="#bib0585">6,8</a></li><li class="elsevierStyleListItem" id="lsti0120">•The surgical team responsible for the patient (culture of patient safety).</li></ul>MaterialBefore starting, make sure the following resources are available:<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0125">•Material needed for the initial plan.</li><li class="elsevierStyleListItem" id="lsti0130">•Immediate access to ventilation and oxygenation devices in the operating room (FM, cannulas, SAD) (100%).<a class="elsevierStyleCrossRef" href="#bib0610">11</a></li><li class="elsevierStyleListItem" id="lsti0135">•Rescue materials and advanced airway management devices needed to implement each step of the algorithm (DA cart).<a class="elsevierStyleCrossRefs" href="#bib0585">6,8–11</a></li></ul>PositionThe position of the patient will determine the effectiveness of spontaneous or assisted ventilation and airway management techniques. Proper positioning of the patient's head, neck, and chest optimises respiratory mechanics, increases airway patency, improves axis alignment,<a class="elsevierStyleCrossRefs" href="#bib0595">8–11</a> and exposes the neck for palpation and localisation of the cricothyroid membrane. Two positions are recommended, depending on the scenario:<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0140">1.Sniffing position: slight cervical flexion and maximum cephalic extension, placing an 8–10cm cushion under the neck. This position improves laryngoscopic vision, intubation, and SAD placement (92.1%).<a class="elsevierStyleCrossRefs" href="#bib0735">36–38</a></li><li class="elsevierStyleListItem" id="lsti0145">2.Chest elevation+sniffing position (HELP: Head elevated laryngoscopy position<a class="elsevierStyleCrossRef" href="#bib0750">39</a> or ramped position), which consists in placing the external auditory canal and the sternum at the same level in the horizontal plane (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>A). This position is best suited for patients with anticipated ventilation difficulties and/or low tolerance to apnoea (obese patients, with obstructive sleep apnoea [OSA] syndrome, previous hypoxaemia, etc.) (100%).<a class="elsevierStyleCrossRefs" href="#bib0735">36,40–42</a><elsevierMultimedia ident="fig0020"></elsevierMultimedia></li></ul>Pre-oxygenationPre-oxygenation before anaesthesia induction delays arterial oxygen desaturation induced by apnoea during attempts to secure the airway. It is recommended in all patients<a class="elsevierStyleCrossRefs" href="#bib0585">6,8,11</a> (100%) after ensuring an airtight FM seal, using either the traditional (100% oxygen, tidal volume, for 3–5min)<a class="elsevierStyleCrossRef" href="#bib0770">43</a> or fast (100% oxygen, maximum capacity, for 60s) method if pressed for time, and monitoring the efficiency of pre-oxygenation with EtO2 >90%.<a class="elsevierStyleCrossRef" href="#bib0775">44</a> The use of positive pressure CPAP should be considered in patients with anticipated difficult airway and/or reduced functional residual capacity.Intraoperative oxygenationIt is important to guarantee patient oxygenation by all available means during airway manipulation. In case of anticipated or unanticipated difficulties, the following are recommended:<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0150">•Administer supplemental oxygen continuously via nasal cannula<a class="elsevierStyleCrossRef" href="#bib0780">45</a> at a rate of 15 l/min (NODESAT) (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>B), or use humidified high-flow nasal oxygen systems at body temperature.<a class="elsevierStyleCrossRefs" href="#bib0585">6,8–10,46,47</a> These measures must be started during or after pre-oxygenation in order to prolong apnoea tolerance time, and should continue until the airway has been secured (85.7%).</li><li class="elsevierStyleListItem" id="lsti0155">•Use ventilation devices if necessary (FM+laryngeal cannula or SAD).</li></ul>These rescue devices must be immediately available in all operating rooms. This recommendation extends to extubation and recovery of stable spontaneous ventilation (100%).Alveolar recruitment: There is evidence that pre-oxygenation with O2 100% causes reabsorption atelectasis. The risk/benefit of this strategy, therefore, should be evaluated in each case, and recruitment and prevention measures should be applied once the airway has been secured<a class="elsevierStyleCrossRef" href="#bib0795">48</a> (100%).MonitoringMonitoring ventilation, oxygenation and verifying the effectiveness of tracheal intubation (see below) are essential for good airway management. Pulse oximetry and capnography, in addition to standard monitoring techniques, must be connected and working.<a class="elsevierStyleCrossRefs" href="#bib0585">6,8–11</a>Unanticipated difficult airwayIn the apnoeic patient airway management can be difficult from the start, become complicated at any point in the process, or rapidly evolve to a critical situation. It is important to optimise the initial strategy in all patients and adapt alternative techniques to the context at all times.Plan AThe first attempt at laryngoscopy and intubation should be performed under optimal conditions<a class="elsevierStyleCrossRefs" href="#bib0585">6,8,10,11</a>:<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0160">•Apply the aforementioned recommendations for positioning and pre-oxygenation, and choose the most appropriate material (right sized blade and laryngoscope, etc.).<a class="elsevierStyleCrossRefs" href="#bib0585">6,8–11</a></li><li class="elsevierStyleListItem" id="lsti0165">•Correctly titre drugs and monitor their effect to achieve an optimal anaesthetic depth and neuromuscular blockade that facilitates ventilation, intubation, or SAD insertion (97.1%).<a class="elsevierStyleCrossRefs" href="#bib0595">8,10,11</a> There is no evidence to justify the confirmation of ventilation before administering the neuromuscular block (64.7%).<a class="elsevierStyleCrossRefs" href="#bib0800">49–51</a></li><li class="elsevierStyleListItem" id="lsti0170">•Apply external laryngeal pressure (BURP: back, up, rightpressure), as this can improve laryngoscopic vision.<a class="elsevierStyleCrossRefs" href="#bib0590">7,9,10</a></li><li class="elsevierStyleListItem" id="lsti0175">•Use a VLS on the first attempt if it more likely to be successful than conventional laryngoscopy (100%).<a class="elsevierStyleCrossRefs" href="#bib0585">6,7,10,11,52–54</a></li></ul>If, despite these measures, intubation is unsuccessful, re-ventilate with an FM and assess the difficulty of maintaining adequate ventilation/oxygenation.The second attempt should significantly improve the chances of success compared to the first:<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0180">•Improve intubation conditions: optimise positioning, and depth of anaesthesia or neuromuscular block, if necessary (100%).</li><li class="elsevierStyleListItem" id="lsti0185">•Change the technique according to the difficulty detected. In patients with Cormack grade 2, bougies and VLS can resolve the problem (97%). In Cormack grade 4, however, neither bougies nor other blind intubation attempts are recommended.<a class="elsevierStyleCrossRef" href="#bib0605">10</a> VLS can improve vision in these cases (97%).<a class="elsevierStyleCrossRef" href="#bib0830">55</a></li><li class="elsevierStyleListItem" id="lsti0190">•Change operator if one with more experience is available (92.1%).</li></ul>Repeated airway manipulation can cause mucosal oedema and hamper or entirely prevent ventilation. Therefore, no more than 2 attempts at laryngoscopy intubation should be made at this stage (77.5%).<a class="elsevierStyleCrossRefs" href="#bib0835">56,57</a>Plan BIf intubation has not been successful after 2 attempts in the best possible conditions, a situation of unanticipated difficult airway should be declared, help should be sought and the DA cart brought in.If FM ventilation is still possible, an alternative intubation technique may be considered:<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0195">•VLS, if this has not already been attempted, if a different VLS is used, or if a more experienced anaesthesiologist can take over.<a class="elsevierStyleCrossRef" href="#bib0845">58</a> VLSs significantly improve laryngoscopic vision compared to conventional laryngoscopes.<a class="elsevierStyleCrossRefs" href="#bib0820">53,55,59</a> Despite better vision, intubation may be complicated due to difficulty directing or advancing the tube between the vocal cords<a class="elsevierStyleCrossRefs" href="#bib0585">6,7,9–11</a> (100%). When a VLS without a channel is used, care must be taken to choose the right curvature for the blade. Injury to the oropharyngeal mucosa has been described during blind tube insertion,<a class="elsevierStyleCrossRefs" href="#bib0855">60,61</a> so the tip of the tube should be introduced under direct vision<a class="elsevierStyleCrossRef" href="#bib0605">10</a> until it is visible on the screen. A bougie with a flexible tip can facilitate insertion by reducing the risk of mucosal injury.</li><li class="elsevierStyleListItem" id="lsti0200">•SADs can be used to deliver ventilation and also as a conduit for fibreoptic intubation (FOI).<a class="elsevierStyleCrossRefs" href="#bib0585">6,7,9–11,21</a> The latest, second generation devices that incorporate a large bore gastric channel give higher sealing pressure and allow direct endotracheal intubation (Ambu AuraGain or LMA Protector) are the most suitable,<a class="elsevierStyleCrossRefs" href="#bib0865">62–64</a> although there is still not enough evidence to demonstrate their superiority over other devices (90%). Second generation devices (i-gel, LMA Proseal and LMA Supreme) are preferable<a class="elsevierStyleCrossRef" href="#bib0880">65</a> (84.3%) to devices that do not have a gastric canal (such as AML Fastrach) (60.6%). If ventilation is adequate, the following alternatives should be considered, depending on the context: make an additional attempt at FOI, continue the procedure with these devices,<a class="elsevierStyleCrossRefs" href="#bib0885">66,67</a> or wake the patient.<a class="elsevierStyleCrossRefs" href="#bib0585">6,7,9–11</a> Correct SAD placement must be verified by capnography, by checking for obstruction, leakage and correct insertion of the gastric tube (through the channel), and by pulmonary auscultation (97.2%).<a class="elsevierStyleCrossRefs" href="#bib0600">9,68</a> Over-inflation of the cuff may worsen ventilation and increase the risk of oropharyngeal morbidity; therefore, pressure should not exceed 60 cmH2O.<a class="elsevierStyleCrossRefs" href="#bib0900">69,70</a> SAD insertion can be facilitated and malposition avoided by inserting a suction tube through the gastric canal to the distal end of the device.</li><li class="elsevierStyleListItem" id="lsti0205">•FOI through an anaesthetic FM that permits non-invasive ventilation.</li></ul>No more than 2 attempts at intubation should be made at this stage, and no more than 3 overall (plan A+plan B). A fourth attempt would only be justified if performed by an expert anaesthesiologist (67%).<a class="elsevierStyleCrossRefs" href="#bib0590">7,56,57</a>If none of these alternatives are available, or if the level of expertise is inadequate, the patient should be woken up while maintaining FM or SAD ventilation.<a class="elsevierStyleCrossRefs" href="#bib0585">6,7,9–11</a>If all attempts at intubation with different techniques have failed, but FM or SAD ventilation is still effective, it is time to stop, think and decide the next step by consensus with the team (90.9%).<a class="elsevierStyleCrossRefs" href="#bib0590">7,10</a>Plan CWhen FM ventilation/oxygenation is difficult or insufficient, the anaesthesiologist should:<ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0210">1.Take all possible measures to optimise FM ventilation<a class="elsevierStyleCrossRef" href="#bib0910">71</a>:</li></ul><ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0215">•Raise the base of the tongue and open the upper airway with the following manoeuvres: raise the chest, place patient in the sniffing position, perform jaw thrust (if not contraindicated), use oral or nasal cannulas, resize the FM if necessary, and perform 4-handed ventilation.<a class="elsevierStyleCrossRefs" href="#bib0590">7,9–11</a></li><li class="elsevierStyleListItem" id="lsti0220">•When faced with severe ventilation difficulties,<a class="elsevierStyleCrossRef" href="#bib0915">72</a> ensure complete neuromuscular block using fast-acting drugs<a class="elsevierStyleCrossRefs" href="#bib0590">7,9–11</a> (88.3%). Consider using rocuronium, as this can be reverse with sugammadex if the patient is awakened once effective oxygenation has been restored<a class="elsevierStyleCrossRefs" href="#bib0920">73–75</a> (97.1%).</li></ul><ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0225">2.Insert a SAD if this has not already been attempted, or change device if the first SAD is ineffective. A more experienced anaesthesiologist should make the second attempt, if available (100%).</li></ul>When airway management becomes complicated, a SAD should be inserted without delay (97.1%). When correctly used, these devices can restore effective ventilation in patients with difficult airway management when other methods have failed. Second-generation SADs should be immediately available in all areas<a class="elsevierStyleCrossRefs" href="#bib0600">9,11</a> (94.1%). Restoring oxygenation gives the team time to think and prepare for the next step<a class="elsevierStyleCrossRefs" href="#bib0585">6,7,9–11</a>:<ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0230">•Wake up the patient and restore spontaneous ventilation if possible, after reversing muscle relaxants and other drugs using antagonists (97%).</li><li class="elsevierStyleListItem" id="lsti0235">•Attempt FOI through the SAD, if not attempted before (90%).</li><li class="elsevierStyleListItem" id="lsti0240">•Continue the procedure with the SAD if ventilation is sufficient and the intervention cannot be postponed (87%).</li><li class="elsevierStyleListItem" id="lsti0245">•Perform front-of-neck access (95%) if the possibility of rapidly recovering effective spontaneous ventilation has been ruled out.</li></ul>Do not make more than 2 ventilation attempts with a SAD at this stage. If the airway has not been secured but oxygenation is maintained (with FM or SAD), waking the patient must be given priority (80%). Otherwise, proceed immediately to plan D.At this stage, any device that incorporates a gastric channel and allows direct endotracheal intubation should be used (91.1%). Check that the device is correctly placed, as indicated above.Plan DAn emergency (CICO) must be declared if SAD or FM oxygenation is insufficient and awaking the patient is not an option, or if oxygenation progressively worsens. In this situation, surgical access is required.<a class="elsevierStyleCrossRefs" href="#bib0590">7,10,21</a>Efforts to restore and maintain oxygenation through the FM, high flow nasal cannulas/SAD must be continued until an effective subglottic airway has been established (97%). It is recommended to ensure complete neuromuscular block to facilitate ventilation and the performance of the technique (90%).<a class="elsevierStyleCrossRefs" href="#bib0595">8,10,21</a>TechniquesThere is insufficient evidence or consensus to recommend any particular technique. Therefore, the anaesthesiologist should choose the best technique in each case, or the one he or she is most familiar with (68%).<a class="elsevierStyleCrossRefs" href="#bib0585">6,7,10</a> The SEVA expert group has listed these techniques in order of preference:<ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0250">•Surgical (68%): a skin incision is made with a scalpel (no. 10), the cricothyroid membrane is located by palpation and dissected, the incision is enlarged by rotating the scalpel 90° and removing it to insert a narrow bore (5 or 6mm) tracheal tube. Insertion can be made easier by using an introducer (Frova, Eschmann). All the materials needed are standard issue in all operating rooms.<a class="elsevierStyleCrossRefs" href="#bib0605">10,76</a></li><li class="elsevierStyleListItem" id="lsti0255">•Wide bore cannula-over-needle technique (27.3%): needle puncture+guide wire (Seldinger technique) followed by insertion of a dilator+>4mm bore cannula, usually with a cuff.<a class="elsevierStyleCrossRefs" href="#bib0935">76,77</a></li><li class="elsevierStyleListItem" id="lsti0260">•Small-bore cannula (4.5%): needle puncture+dilator+cannula in one step. The use of intravenous cannulas for this purpose is not recommended, due to the high risk of collapse and displacement.</li></ul>All these techniques have their advantages and risks,<a class="elsevierStyleCrossRefs" href="#bib0945">78,79</a> and all require practice; therefore, specific and regular training is essential.<a class="elsevierStyleCrossRef" href="#bib0955">80</a>Surgical access is fast, more reliable, but also more invasive, and could delay the decision to perform cricothyrotomy.<a class="elsevierStyleCrossRef" href="#bib0960">81</a>The narrow-bore cannula technique (<4mm) is fast and more intuitive for anaesthesiologists, but has the highest complication and failure rate, and is only effective if a high pressure or high flow ventilation system is available.<a class="elsevierStyleCrossRef" href="#bib0590">7</a>If the cricothyroid membrane cannot be located by palpation, a vertical skin incision should be made in the midline to locate the membrane and proceed with the surgical technique (84.9%).<a class="elsevierStyleCrossRef" href="#bib0605">10</a>If cricothyrotomy is not an option, an emergency surgical tracheostomy will be needed (82.3%).<a class="elsevierStyleCrossRef" href="#bib0610">11</a>The cricothyroid membrane can be located faster and more accurately with ultrasound than with palpation in patients with anatomical difficulties,<a class="elsevierStyleCrossRef" href="#bib0675">24</a> but the technique requires training and the scanner must be immediately available and prepared. Therefore, in cases of unanticipated DA, the scanner should be requested together with the DA cart at the first sign of difficulty (84.9%).<a class="elsevierStyleCrossRef" href="#bib0675">24</a>These techniques restore oxygenation, but are not appropriate to maintain ventilation during the surgical procedure, except in emergent situations. It is best to postpone surgery and wake the patient if it is not possible to establish intubation or perform a tracheostomy.Check the position of the tracheal tube or cannulaIt is important to check that the tube or cannula is correctly placed in the trachea after insertion. This can be done by chest inspection and auscultation, and also by observing the capnography curve (100%),<a class="elsevierStyleCrossRef" href="#bib0965">82</a> which is the gold standard and must be available wherever anaesthesia is administered. If FOI has been performed, the bronchoscope can be used to confirm the position of the tip of the tube tip in the trachea (100%). Ultrasound can also be used to confirm correct intubation by observing the symmetrical movement of the lungs or the diaphragm when the other options do not give immediate confirmation of intubation (78.9%).<a class="elsevierStyleCrossRef" href="#bib0970">83</a>Anticipated difficult airwayWhen a difficult airway is anticipated, the anaesthesiologist has 2 options: either proceed with anaesthesia induction or maintain spontaneous ventilation. The choice will depend on both the degree of likelihood of intubation difficulty or failure and safety considerations (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).<elsevierMultimedia ident="fig0025"></elsevierMultimedia>In either case, management of the anticipated difficult airway requires special preparation in addition to all the recommendations already set forth above.<a class="elsevierStyleCrossRefs" href="#bib0585">6,8,9,11</a> The patient should be informed of the cause of the potential difficulty, the options available, the details of the chosen procedure, and the need for collaboration. It is important to reassure the patient and gain their trust (100%).<a class="elsevierStyleCrossRef" href="#bib0585">6</a> The DA cart, including oxygenation rescue devices and supplies, must be available immediately.<a class="elsevierStyleCrossRefs" href="#bib0585">6,8</a>Preparations for airway management under spontaneous ventilation include correct positioning (94.4%) (chest elevation+sniffing position, if not contraindicated), pre-oxygenation and/or continuous oxygenation, continuous pulse oximetry and capnography monitoring, and individual drug titration. Patients should receive an antisialagogue (atropine)+topical nasal/oral anaesthesia+individually titrated sedation to maintain spontaneous ventilation, protective reflexes, and muscle tone (100%). The goal is to keep the patient calm and cooperative.<a class="elsevierStyleCrossRef" href="#bib0975">84</a>Potentially difficult airwayPatients with DA risk criteria who meet the following safety criteria:<ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0265">•Can be ventilated with FM or SAD.</li><li class="elsevierStyleListItem" id="lsti0270">•Low risk of aspiration.</li><li class="elsevierStyleListItem" id="lsti0275">•Low risk of rapid desaturation.</li><li class="elsevierStyleListItem" id="lsti0280">•High probability of successful VLS intubation (if available).</li><li class="elsevierStyleListItem" id="lsti0285">•Expert help and sufficient material for rescue techniques available.</li></ul>In these cases, anaesthesia induction would be justified if the expert anaesthesiologist believes that the probability of first-attempt success is high, the risk of oxygenation failure is low, and an alternative plan can be implemented quickly and efficiently (95.5%).<a class="elsevierStyleCrossRefs" href="#bib0595">8,11</a>Plan AA VLS should be used if tracheal intubation is anticipated (maximum 2 attempts) (94.4%).<a class="elsevierStyleCrossRefs" href="#bib0980">85,86</a>If tracheal intubation is not required and SAD is planned,<a class="elsevierStyleCrossRef" href="#bib0595">8</a> a second generation SAD should be used.Plan BIf the first attempt fails, the previously planned alternative strategy should be implemented according to the recommendations described for unanticipated difficult airway (FOI under assisted ventilation, intubation with SAD, awakening).If the above criteria are not met, or when in doubt, the recommendations for obvious or known DA should be followed (97.2%).Obvious, known, or anticipated difficult airwayIn these cases, intubation should be performed under spontaneous ventilation, regardless of the technique chosen (100%).Plan AThe following options are recommended:<ul class="elsevierStyleList" id="lis0085"><li class="elsevierStyleListItem" id="lsti0290">•Nasal or oral FOI: this is the technique of choice, particularly when the difficulty is due to serious anatomical alterations, limited mouth opening or cervical mobility, obstruction, or airway stenosis. It is associated with a success rate of 88–100%,<a class="elsevierStyleCrossRef" href="#bib0990">87</a> and can be used in combination with VLS and SAD (100%).<a class="elsevierStyleCrossRef" href="#bib0595">8</a></li><li class="elsevierStyleListItem" id="lsti0295">•VLS: can be as effective as FOI under spontaneous ventilation when mouth opening and cervical mobility is not severely limited and the oropharynx is not obstructed (89.5%).<a class="elsevierStyleCrossRefs" href="#bib0995">88,89</a></li><li class="elsevierStyleListItem" id="lsti0300">•SAD with intubation capability: can be effective in difficult intubation+ventilation. Awake SAD insertion is tolerated as well or even better than laryngoscopy. FOI is recommended when intubating through these devices (86.1%).<a class="elsevierStyleCrossRefs" href="#bib1005">90,91</a></li></ul>In cases of airway obstruction/stenosis, the indication for intubation should be evaluated individually. If the obstruction is severe and is accompanied by symptoms of dyspnoea, dysphonia, and hypoxaemia that can worsen with topical anaesthesia or endoscope insertion, surgical techniques (plan B) should be considered as the first option (88.6%).<a class="elsevierStyleCrossRefs" href="#bib0595">8,11,92,93</a>If the patient is not cooperative, inhalation induction under spontaneous ventilation and fibreoptic, VLS or SAD intubation can be considered. All the material required for cricothyrotomy should be immediately available (94.4%).<a class="elsevierStyleCrossRef" href="#bib0595">8</a>If the procedure does not require tracheal intubation, consider inserting a SAD under spontaneous ventilation<a class="elsevierStyleCrossRefs" href="#bib1025">94,95</a> following the same pre-operative preparation and verification steps described above (88.5%). Preferably use a second generation SAD that provide high sealing pressure and allow direct endoscopic intubation in case the technique needs to be converted (94.6%).Plan BWhen plan A is not feasible or fails:<ul class="elsevierStyleList" id="lis0090"><li class="elsevierStyleListItem" id="lsti0305">•Establish a surgical airway (cricothyrotomy and percutaneous or surgical tracheotomy) under spontaneous ventilation. This is the first option in the following cases: if difficult FOI is anticipated due to obstruction, severe stenosis or serious tracheal lesions (93.6%), or if tracheostomy is expected in the postoperative period (97.2%).</li><li class="elsevierStyleListItem" id="lsti0310">•Consider other options, such as locoregional anaesthesia or cancel surgery, depending on the procedure (91.6%).</li></ul>Risk of bronchoaspirationSpecial precautions must be taken with patients with risk criteria for regurgitation.If DA (difficult ventilation or intubation) and/or low tolerance to apnoea are suspected in addition to the risk of bronchoaspiration, tracheal intubation should be performed under spontaneous ventilation (90%).If DA is not anticipated, the degree of aspiration risk should be assessed on the basis of the cause and the patient's clinical status. Consider using gastric ultrasound, if available, to assess the type of content (liquid, solid, or mixed) and estimate the approximate volume<a class="elsevierStyleCrossRef" href="#bib1035">96</a> (taking into account the limitations inherent to the technique and formulas used to determine intragastric volume) (86.4%). The approach taken will depend on whether the risk of aspiration is high or moderate:<ul class="elsevierStyleList" id="lis0095"><li class="elsevierStyleListItem" id="lsti0315">(a)High risk of bronchoaspiration (gastric bloating, ileus, intestinal obstruction, solid content or estimated volume >1.5ml/kg):</li></ul><ul class="elsevierStyleList" id="lis0100"><li class="elsevierStyleListItem" id="lsti0320">•Place a gastric tube prior to rapid sequence induction. Connect to suction and maintain continuous aspiration (90%).<a class="elsevierStyleCrossRefs" href="#bib0605">10,97,98</a> The same procedure is followed in patients with an existing gastric tube.</li><li class="elsevierStyleListItem" id="lsti0325">•If the gastric tube cannot be inserted, consider performing intubation under spontaneous ventilation or proceed to rapid sequence induction, depending on which has the greatest likelihood of first-attempt success (87.2%).</li></ul><ul class="elsevierStyleList" id="lis0105"><li class="elsevierStyleListItem" id="lsti0330">(b)Moderate risk of bronchoaspiration: proceed to rapid sequence tracheal intubation using the Sellick manoeuvre (apply pressure to the cricoid cartilage to occlude the proximal oesophagus) (96.6%).</li></ul>PreparationThe general preparations described above should be made for airway management under spontaneous ventilation and for rapid sequence induction:<ul class="elsevierStyleList" id="lis0110"><li class="elsevierStyleListItem" id="lsti0335">•Consider administering drugs to reduce gastric pH and accelerate emptying.</li><li class="elsevierStyleListItem" id="lsti0340">•Maintain chest elevation+sniffing position to facilitate spontaneous and/or assisted ventilation and improve glottic vision (96.6%).</li><li class="elsevierStyleListItem" id="lsti0345">•It is essential to maximise pre-oxygenation in patients at risk of aspiration in order to avoid the need for assisted ventilation. Apnoeic oxygenation with high-flow nasal cannula should be used to prolong apnoea time (93.3%).<a class="elsevierStyleCrossRef" href="#bib1050">99</a></li><li class="elsevierStyleListItem" id="lsti0350">•If rapid sequence induction is performed in patients with limited apnoea tolerance, administer low pressure FM ventilation (<20cm H20) and apply cricoid pressure of 30N before intubation to delay oxygen desaturation (80%).<a class="elsevierStyleCrossRef" href="#bib0605">10</a></li></ul>Despite the controversy over the efficacy of the Sellick manoeuvre, it is recommended during rapid sequence induction (92%).<a class="elsevierStyleCrossRefs" href="#bib0595">8,10,11,46</a> This manoeuvre can impede FM ventilation, SAD placement, and laryngoscopic vision. Obstructed glottic vision can delay tracheal tube insertion, and thus increase the risk of bronchoaspiration. If the manoeuvre obstructs the glottis, the pressure should be partially released while maintaining direct vision and aspiration.<a class="elsevierStyleCrossRef" href="#bib1055">100</a> If regurgitation occurs, re-apply pressure immediately and aspirate (92.4%).<a class="elsevierStyleCrossRef" href="#bib0605">10</a>If intubation fails during rapid sequence induction, low pressure (<20cm H2O) FM ventilation should be started immediately while maintaining appropriate cricoid pressure (30N) (100%). If ventilation is insufficient, the pressure should be gradually released (83.7%).<a class="elsevierStyleCrossRefs" href="#bib0595">8,11</a> If FM ventilation is not effective, a second generation SAD should be inserted immediately<a class="elsevierStyleCrossRef" href="#bib0605">10</a> together with a tube to aspirate the gastric contents. The Sellick manoeuvre should be partially released if it prevents SAD placement (96.7%).Extubation in the difficult airway patientThe incidence of morbidity and mortality associated with complications arising both during and after extubation has remained constant in recent years. The tracheal tube is removed at the discretion of the anaesthesiologist, and can therefore be postponed until the conditions are appropriate (96.7%). It is always necessary to establish an extubation strategy.<a class="elsevierStyleCrossRefs" href="#bib0585">6,8–10,20,101</a>EvaluationThe first step is to identify patients with DA criteria who are also at risk of poor oxygenation after extubation<a class="elsevierStyleCrossRefs" href="#bib0670">23,102</a>:<ul class="elsevierStyleList" id="lis0115"><li class="elsevierStyleListItem" id="lsti0355">•Patients with a history of anticipated or unanticipated difficult airway management (who might also present airway lesions, oedema, etc.) (100%).</li><li class="elsevierStyleListItem" id="lsti0360">•Surgical procedures that carry a risk of anatomical or functional airway alteration (extensive or complex surgery involving the head and neck surgery, thyroid, maxilla, etc.) (96.6%).</li><li class="elsevierStyleListItem" id="lsti0365">•Patients with DA criteria and risk of post-intubation hypoventilation (limited tolerance of apnoea, airway hyperresponsiveness, vocal cord oedema, vocal cord dysfunction, etc.) (96.6%).<a class="elsevierStyleCrossRef" href="#bib1065">102</a></li></ul>In these patients, the extent and severity of the changes (trauma, bleeding, oedema) should be assessed.<ul class="elsevierStyleList" id="lis0120"><li class="elsevierStyleListItem" id="lsti0370">•Upper airway examination (96.7%).</li><li class="elsevierStyleListItem" id="lsti0375">•Cuff leak test: check for audible leakage (or by spirometry) around the tube during ventilation after the sealing balloon cuff has been deflated. No leakage (<10% of tidal volume) indicates risk of obstruction due to airway oedema after extubation (93.4%).<a class="elsevierStyleCrossRefs" href="#bib1070">103,104</a></li><li class="elsevierStyleListItem" id="lsti0380">•Respiratory function and general status (100%).</li></ul>It is essential to evaluate the results of these examinations together with other clinical parameters before deciding on extubation.Preparing for extubation in the difficult airway patientIn addition to optimising the overall status of the patient (haemodynamic, respiratory, pharmacological), the pre-intubation preparations described above should also be made before extubation (100%):<ul class="elsevierStyleList" id="lis0125"><li class="elsevierStyleListItem" id="lsti0385">•Plan the strategy according to the difficulty anticipated.</li><li class="elsevierStyleListItem" id="lsti0390">•Check the availability of airway management resources (personnel and material).</li><li class="elsevierStyleListItem" id="lsti0395">•Pre-oxygenate.</li><li class="elsevierStyleListItem" id="lsti0400">•Optimise the patient's position to promote ventilation (raise chest+sniffing position).</li></ul>Extubation techniques in high-risk patientsDepending on the patient's status, the following alternatives can be applied:<ul class="elsevierStyleList" id="lis0130"><li class="elsevierStyleListItem" id="lsti0405">•Extubation with a tube exchanger or with specific extubation sets that allow rapid guided reintubation if necessary (96.5%).<a class="elsevierStyleCrossRefs" href="#bib0585">6,8–10,101,105</a></li><li class="elsevierStyleListItem" id="lsti0410">•Extubation with a SAD that replaces the tracheal tube (89.7%).<a class="elsevierStyleCrossRefs" href="#bib0585">6,9,10,102</a></li><li class="elsevierStyleListItem" id="lsti0415">•Tracheostomy (77%).</li></ul>Post-extubation follow-upOxygen delivery and monitoring must continue in the post-extubation period.<a class="elsevierStyleCrossRefs" href="#bib0585">6,8,9</a>The professionals involved in post-procedural care must be informed of the cause of the extubation difficulty and the risk of complications (100%). The patient must be continuously monitored for early signs and symptoms of deterioration, and the corresponding treatment strategies must be established in consensus with the treating teams (96.6%).<a class="elsevierStyleCrossRefs" href="#bib0600">9,106</a>DocumentationThe details of the airway management procedure must be documented and given to the patient in the form of a letter or airway management card. Although there is no evidence to support the effectiveness of these measures, they are recommended in the consensus guidelines consulted<a class="elsevierStyleCrossRefs" href="#bib0585">6,7,9–11,21</a>:<ul class="elsevierStyleList" id="lis0135"><li class="elsevierStyleListItem" id="lsti0420">1.The causes of the DA (history, anatomical characteristics) and the specific difficulty encountered during management (FM ventilation, SAD insertion, laryngoscopy or intubation; number of attempts and operators; types of devices used; possible future management options, etc.) should be noted in the patient's medical history (100%).</li><li class="elsevierStyleListItem" id="lsti0425">2.Fill in the SCARTD DA card (which describes the factors involved in the DA) and give it to the patient, their legal guardian and primary care doctor (100%). If the DA card is not available, provide a DA report containing the same information.</li><li class="elsevierStyleListItem" id="lsti0430">3.Assess and monitor the patient if complications have occurred during airway manipulation (oedema, bleeding, oesophageal or tracheal perforation, pneumothorax, or bronchial aspiration). The patient, their relatives and the primary care physician should be warned of the signs and symptoms of late complications (pharyngeal inflammation, pain or oedema of the face and neck, fever, chest pain, subcutaneous emphysema and difficulty swallowing), and the need to consult the medical team again if these occur (100%).</li></ul>The DA documentation should ideally include the diagnosis and treatment of possible complications and a guideline for airway management planning in any future interventions.DA cases reported in the corresponding registries must be periodically analysed by experts from the Service in order to determine and correct the causative factors.<a class="elsevierStyleCrossRef" href="#bib0605">10</a>The DA diagnosis should be included in the hospital discharge report or added as a risk factor for the patient (in the same way as allergies, etc.) (100%).The introduction of new technologies and inter-hospital databases, such as the Catalonia Shared Patient History (HCCC, in its Spanish acronym), allows this documentation to be accessed by any authorised healthcare professional in order to improve patient safety and the quality of care. Information related to the DA should be included in the HCCC (100%).EducationDA management requires clinicians to acquire and maintain specific knowledge and skills. The structure of both general and DA skills-specific continuous professional development courses needs to be clearly defined.<a class="elsevierStyleCrossRefs" href="#bib1090">107,108</a>The cornerstones of the successful implementation of a DA management algorithm are:<ul class="elsevierStyleList" id="lis0140"><li class="elsevierStyleListItem" id="lsti0435">(a)An institutional training programme that facilitates the acquisition and maintenance of DA management skills (100%).</li><li class="elsevierStyleListItem" id="lsti0440">(b)Commitment on the part of each anaesthesiologist to develop, maintain and self-evaluate their own competences throughout their professional life (100%).</li></ul>The programme should include the recommendations listed in the algorithm, and should facilitate:<ul class="elsevierStyleList" id="lis0145"><li class="elsevierStyleListItem" id="lsti0445">1.Acquisition of theoretical and practical knowledge (100%).</li><li class="elsevierStyleListItem" id="lsti0450">2.Development of the technical skills needed to perform all DA management techniques: FM ventilation, use of SADs, tracheal intubation (laryngoscopy, VLS and FOI) and surgical airway (96.6%).<a class="elsevierStyleCrossRef" href="#bib1100">109</a> These techniques should be taught in stages using mannequins or simulators before they are used in clinical practice.</li><li class="elsevierStyleListItem" id="lsti0455">3.Development of non-technical skills (decision making, leadership, etc.) in the management of critical airway situations (100%).</li></ul>Practical workshops should be organised that allow all team members to acquire technical skills using mannequins and non-technical skills in group simulation exercises (96.6%).<a class="elsevierStyleCrossRefs" href="#bib1105">110,111</a>A schedule of training activities in airway management should be drawn up (100%).Conflicts of interestThe authors declare that they have no conflict of interest." 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"identificador" => "sec0200" "titulo" => "Conflicts of interest" ] 17 => array:2 [ "identificador" => "xack477958" "titulo" => "Acknowledgements" ] 18 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-10-24" "fechaAceptado" => "2019-11-06" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1263650" "palabras" => array:5 [ 0 => "Recommendations" 1 => "Evaluation" 2 => "Anticipated difficult airway" 3 => "Non-anticipated difficult airway" 4 => "Difficult extubation" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1263651" "palabras" => array:5 [ 0 => "Recomendaciones" 1 => "Evaluación" 2 => "Vía aérea difícil prevista" 3 => "Vía aérea difícil imprevista" 4 => "Extubación difícil" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The Airway Division of the Catalan Society of Anaesthesiology, Intensive Care and Pain Management (SCARTD) presents its latest guidelines for the evaluation and management of the difficult airway. This update includes the technical advances and changes observed in clinical practice since publication of the first edition of the guidelines in 2008.The recommendations were defined by a consensus of experts from the 19 participating hospitals, and were adapted from 5 recently published international guidelines following an in-depth analysis and systematic comparison of their recommendations.The final document was sent to the members of SCARTD for evaluation, and was reviewed by 11 independent experts. The recommendations, therefore, are supported by the latest scientific evidence and endorsed by professionals in the field.This edition develops the definition of the difficult airway, including all airway management techniques, and places emphasis on evaluating and classifying the airway into 3 categories according to the anticipated degree of difficulty and additional safety considerations in order to plan the management strategy. Pre-management planning, in terms of preparing patients and resources and optimising communication and interaction between all professionals involved, plays a pivotal role in all the scenarios addressed.The guidelines reflect the increased presence of video laryngoscopes and second-generation devices in our setting, and promotes their routine use in intubation and their prompt use in cases of unanticipated difficult airway. They also address the increased use of ultrasound imaging as an aid to evaluation and decision-making.New scenarios have also been included, such as the risk of bronchoaspiration and difficult extubation Finally, the document outlines the training and continuing professional development programmes required to guarantee effective and safe implementation of the guidelines." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La Sección de Vía Aérea de la Sociedad Catalana de Anestesiología, Reanimación y Terapéutica del Dolor (SCARTD) presenta la actualización de las recomendaciones para la evaluación y manejo de la vía aérea difícil con el fin de incorporar los avances técnicos y los cambios observados en la práctica clínica desde la publicación de la primera edición en 2008.La metodología elegida fue la adaptación de 5 guías internacionales recientemente publicadas, cuyo contenido fue previamente analizado y comparado de forma estructurada, y el consenso de expertos de los 19 centros participantes.El documento final fue sometido a la valoración de los miembros de la SCARTD y a la revisión por parte de 11 expertos independientes. Estas recomendaciones están pues sustentadas en la evidencia científica actualmente disponible y en un amplio acuerdo de los profesionales de su ámbito de aplicación.En esta edición se amplía la definición de vía aérea difícil, abarcando todas las técnicas de manejo, y se hace mayor hincapié en la valoración de la vía aérea y en la clasificación en 3 categorías según el potencial grado de dificultad y las consideraciones de seguridad adicionales, que guiarán la planificación de la estrategia a seguir. La preparación previa al manejo de la vía aérea, no solo relativa al paciente y al material, sino también a la comunicación e interacción entre todos los agentes implicados, ocupa un lugar destacado en todos los escenarios incluidos en el presente documento. El texto refleja el aumento progresivo del uso de los videolaringoscopios y de los dispositivos de segunda generación en nuestro entorno y promueve tanto su uso electivo como el uso precoz en la vía aérea no prevista. También recoge la creciente utilización de la ecografía como herramienta de apoyo en la exploración y toma de decisiones.Se han abordado nuevos escenarios como el riesgo de broncoaspiración y la extubación considerada difícil. Finalmente, se trazan las líneas maestras de los programas de entrenamiento y formación continuada en vía aérea necesarios para garantizar la implementación efectiva y segura de las recomendaciones." ] ] "NotaPie" => array:2 [ 0 => array:3 [ "etiqueta" => "◊" "nota" => "The list of authors and members of the SCARTD Section of Via aèria (SEVA) is available in <a class="elsevierStyleCrossRef" href="#sec0210">Annex 1</a>." "identificador" => "fn0005" ] 1 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: López AM, Belda I, Bermejo S, Parra L, Áñez C, Borràs R, et al. Recomendaciones para la evaluación y manejo de la vía aérea difícil prevista y no prevista de la Societat Catalana d’Anestesiologia, Reanimació i Terapèutica del Dolor, basadas en la adaptación de guías de práctica clínica y consenso de expertos. Rev Esp Anestesiol Reanim. 2020;67:325–342." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "Pere Esquius, José Huesca Ranea, Jordi Llorca, Francesca Reguant (Althaia. Xarxa Assitencial Universitaria de Manresa); Silvia Bermejo, Jesús Carazo, Saida Sanchez (Consorci Mar Parc de Salut de Barcelona); Carmen Martin (Consorci Sanitari de Terrassa); Montse Bayo, Olaia Güenaga, Lourdes Parra, Pilar Santos, Meritxell Serra, Vanesa Tejedor, Ana Tejedor (Consorci Sanitari Integral); Mª Lluisa Martínez Villar (Fundació Hospital-Asil de Granollers); Daniel Hernando, Sergi Sabaté (Fundació Puigvert (IUNA)); Isabel Belda, Raquel Bergé, Mª José Carretero, Paola Hurtado, Ana López, Marta Magaldi, Julia Martínez, Ana Plaza, Eva Rivas, Ana Ruiz, Beatriz Tena, Ricard Valero (Hospital Clínic de Barcelona); Teresa Aberasturi (Hospital Comarcal de l’Alt Penedès); Josep Mª Soto (Hospital d’ Igualada; SEM); Josep Mª Gil, MªAngels Gil de Bernabé, Ignacio Hinojal (Hospital de la Santa Creu i Sant Pau); Josep Genis (Hospital d’Igualada); María Escobar (Hospital de Sta. Caterina; Girona); Lluis Martinez (Hospital Municipal de Badalona); Silvia Serrano (Hospital Sant Joan de Déu Barcelona); Maria Farré (Hospital Universitari Arnau de Vilanova); Enric Boza, M Jesus Castro Serrano, Maylin Koo Gomez, M Carmen Martin Castro, Victor Mayoral, Isabel Ornaque, Albert Pi, Rosa Villalonga (Hospital Universitari de Bellvitge); Alfred Muñoz (Hospital Universitari de Girona Doctor Josep Trueta); Cristòbal Áñez, Natalia Aragones, Luis Hernando Carrillo, Rocío Periñán (Hospital Universitari de Tarragona Joan XXIII); Teresa Planella, Julio Roza (Hospital Universitari de Vic); Rosa Borràs, Nuria Carbonell, Enric Monclús, Elena Sanchez (Hospital Universitari Dexeus); Carla Costa, Teresa Franco, Eva Massó, Pere Vila (Hospital Universitari Germans Trias i Pujol);Carme Colilles, Esteban García, Alberto Izquierdo, Silvia López, Jordi Pérez, Laura Ricol (Hospital Universitari Parc Taulí); Dolors del Pozo, Reis Drudis, Gregorio Marco (Hospital Universitari Santa Maria de Lleida); Erika Schmucker, Ivan Villaverde, Eva Andreu (Hospital Universitari Vall d’Hebró); Anna Casanovas (Parc Sanitari San Joan de Deu de Sant Boi); Josep Maria Serra (Pius Hospital de Valls)." "etiqueta" => "Annex 1" "titulo" => "List of authors and members of the Airway Group (SEVA) of the SCARTD" "identificador" => "sec0210" ] ] ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3814 "Ancho" => 2333 "Tamanyo" => 768634 ] ] "descripcion" => array:1 [ "en" => "Poster of SCARTD recommendations for the pre-anaesthetic evaluation of the airway." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 4341 "Ancho" => 2659 "Tamanyo" => 1476581 ] ] "descripcion" => array:1 [ "en" => "Poster of SCARTD recommendations for airway management." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 4445 "Ancho" => 3344 "Tamanyo" => 2317839 ] ] "descripcion" => array:1 [ "en" => "Flyer summarising the SCARTD recommendations." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1076 "Ancho" => 2175 "Tamanyo" => 156988 ] ] "descripcion" => array:1 [ "en" => "(A) Recommended position for airway management, combining chest elevation, slight neck flexion and head extension. (B) Pre-oxygenation is recommended in patients who require optimised airway management, combining the previous position and oxygen delivery through nasal cannula and a properly sealed face mask." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1288 "Ancho" => 2504 "Tamanyo" => 257260 ] ] "descripcion" => array:1 [ "en" => "Airway management flowchart according to the anticipated degree of difficulty." ] ] 5 => array:6 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "BMI: body mass index; DA: difficult airway; OSAS: obstructive sleep apnoea syndrome." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">High risk criteria or pathologies \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Additional difficulty criteria \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mallampati III–IV (94.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Protruding teeth (97.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Limited mandibular thrust (100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Edentation (80%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mandibular pathology (retrognathia, etc.) (97.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Symptoms: dyspnoea, dysphagia (90%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Interdental distance 3–4cm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Beard (90.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thyromental distance <6cm (97.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age >55 years (40%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neck mobility 80°–100° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BMI 30–40 (97.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">OSAS or severe daily snoring (95%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male gender (57%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BMI >40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Arched palate (100%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neck circumference >42cm (87.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DA-related pathology: thyroid mass, Ludwig's angina, acromegaly, tonsillar hypertrophy, etc. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2362059.png" ] ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:111 [ 0 => array:3 [ "identificador" => "bib0560" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evaluación y manejo de la vía aérea difícil prevista y no prevista: Adopción de guías de práctica" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0034-9356(08)70653-4" "Revista" => array:7 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2008" "volumen" => "55" "paginaInicial" => "563" "paginaFinal" => "570" "link" => array:1 [ …1] "itemHostRev" => array:3 [ …3] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0565" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The advantages and limitations of guideline adaptation frameworks" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/s13012-018-0763-4" "Revista" => array:5 [ "tituloSerie" => "Implement Sci" "fecha" => "2018" "volumen" => "13" "paginaInicial" => "72" "link" => array:1 [ …1] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0570" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Appraisal of guidelines for research & evaluation II. 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Recommendations for the evaluation and management of the anticipated and non-anticipated difficult airway of the Societat Catalana d’Anestesiologia, Reanimació i Terapèutica del Dolor, based on the adaptation of clinical practice guidelines and expert consensus

Recomendaciones para la evaluación y manejo de la vía aérea difícil prevista y no prevista de la Societat Catalana d’Anestesiologia, Reanimació i Terapèutica del Dolor, basadas en la adaptación de guías de práctica clínica y consenso de expertos

A.M. Lópeza, I. Beldaa, S. Bermejoc, L. Parrab, C. Áñezd, R. Borràse, S. Sabatéf, N. Carbonelle, G. Marcog, J. Pérezh, E. Massói, J.Mª Sotoj, E. Bozak, J.M. Gill, M. Serrab, V. Tejedorb, A. Tejedorb, J. Rozam, A. Plazaa, B. Tenaa..., R. Valeroa,

Corresponding author

rvalero@clinic.cat

Corresponding author.

, Secció de via aèria (SEVA) de la SCARTD ◊Ver más

a Hospital Clínic de Barcelona, Barcelona, Spain

b Consorci Sanitari Integral, L’Hospitalet de Llobregat, Spain

c Consorci Mar Parc de Salut de Barcelona, Barcelona, Spain

d Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain

e Hospital Universitari Dexeus, Barcelona, Spain

f Fundació Puigvert (IUNA), Barcelona, Spain

g Hospital Universitari Santa Maria de Lleida, Lleida, Spain

h Hospital Universitari Parc Taulí, Sabadell, Spain

i Hospital Universitari Germans Trias i Pujol, Badalona, Spain

j Hospital d’ Igualada, SEM, Igualada, Spain

k Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Spain

l Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

m Hospital Universitari de Vic, Vic, Spain

Listado de autores y miembros de la Secció de via aèria (SEVA) de la SCARTD

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obstetrics&#44; emergency medicine and critical care&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methodology</span><p id="par0015" class="elsevierStylePara elsevierViewall">The following is a summary of the procedure used to develop the recommendations presented in this document&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0020" class="elsevierStylePara elsevierViewall">A small group of experts in airway management from the SCARTD was appointed to prepare the list of clinical questions to be answered in the different sections and subsections of this guideline&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Airway management guidelines published after 2007 were critically analysed to determine whether they met the criteria defined in the AGREE instrument&#46; 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or more in the previous round&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall">The draft document with the initial recommendations was published on the SCARTD website and all members were invited to comment on the content and send suggestions before the final recommendations were drawn up&#46; The final consensus document and infographics &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1&#8211;3</a>&#41; were published on the SCARTD website&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">The consensus document was sent to external experts for independent evaluation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">The final version was then approved by the SCARTD&#46;</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Consensus document</span><p id="par0065" class="elsevierStylePara elsevierViewall">The SCARTD consensus document for DA management is described below&#46; The statements included in the e-Delphi questionnaire appear followed by the percentage of consensus &#40;in parentheses&#41; reached among the experts polled&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Definition of the difficult airway</span><p id="par0070" class="elsevierStylePara elsevierViewall">Difficult airway&#46; The airway is defined as difficult if a fully trained anaesthesiologist encounters a situation that fulfils any of the following criteria<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;9</span></a>&#58; &#40;a&#41; suspicion or evidence of difficulty due to a compatible medical history and&#47;or physical examination that calls for airway management in spontaneous ventilation &#40;93&#37;&#41;&#59; &#40;b&#41; difficulty &#40;more than 2 attempts or a change of device or operator&#41; encountered during one of the steps involved in establishing the airway &#40;92&#46;5&#37;&#41;&#59; &#40;c&#41; Difficulty that leads to a significant decrease in O<span class="elsevierStyleInf">2</span> saturation with or without complications&#44; or causes airway device-related injuries &#40;90&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">7</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The difficulty in each of the following procedures must be specified&#44; assuming that sufficient depth of anaesthesia and neuromuscular blockade have been achieved&#44; the patient is correctly positioned and the resources used are adequate&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Difficult ventilation</span>&#46; Insufficient or impossible facial mask &#40;FM&#41; ventilation that fulfils any of the following criteria&#58; &#40;a&#41; excessive leakage or air flow resistance&#59; &#40;b&#41; absence of chest movement and capnography curve on the monitor&#44; or appearance of gastric distension &#40;92&#46;5&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">9</span></a>&#59; &#40;c&#41; manoeuvres to improve ventilation are required&#44; such as optimising the patient&#39;s position&#44; use of oral&#47;nasal cannulas&#44; four-hand ventilation&#44; or deepening of neuromuscular block &#40;95&#37;&#41;&#59; &#40;d&#41; inability to maintain oxygenation and elimination of CO<span class="elsevierStyleInf">2</span> &#40;100&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0590"><span class="elsevierStyleSup">7&#44;12&#44;13</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Difficult laryngoscopy</span>&#46; No full or partial view of the glottis &#40;Cormack Lehane 3 or 4&#41;&#44; despite the use of adjunct manoeuvres such as external laryngeal manipulation &#40;BURP&#41; or change of position &#40;the type of laryngoscope or video laryngoscope &#91;VLS&#93; used must be specified&#41; &#40;100&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">14&#8211;16</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Difficult intubation</span>&#46; More than 2 attempts required by one or more than one operator to advance the tracheal tube&#44; or need for a bougie or change of technique &#40;100&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0590"><span class="elsevierStyleSup">7&#44;17</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Difficult ventilation with supraglottic airway device</span> &#40;SAD&#41;&#46; Two aspects must be considered&#58; &#40;a&#41; more than 2 manoeuvres or more than 2 attempts needed to position the SAD&#59; and&#47;or &#40;b&#41; insufficient oxygenation or CO<span class="elsevierStyleInf">2</span> elimination due to leakage or obstruction once the device is in place&#44; requiring a change in SAD or technique &#40;100&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0645"><span class="elsevierStyleSup">18&#44;19</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Difficult surgical access</span>&#46; Difficulty in &#40;a&#41; locating the cricothyroid membrane&#59; and&#47;or &#40;b&#41; more than one attempt or excessive time needed to perform the puncture or insert the cannula that does not prevent functional repercussions &#40;95&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">7</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Difficult extubation in the DA patient</span>&#46; Suspected &#40;a&#41; difficulty in maintaining adequate ventilation&#47;oxygenation after extubation and&#47;or &#40;b&#41; subsequent difficulty in managing the airway using any of the above modalities &#40;95&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Pre-anaesthesia evaluation</span><p id="par0115" class="elsevierStylePara elsevierViewall">All patients should undergo an airway evaluation before an anaesthetic procedure&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;8&#8211;11&#44;20&#44;21</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The evaluation should take into account potential difficulties in all aspects of management&#58; ventilation&#44; intubation&#44; SAD placement&#44; and surgical access&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;10&#44;11&#44;21</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">It is essential to take a directed medical history in order to obtain relevant information on the patient&#39;s airway &#40;previous difficulties&#44; associated pathologies&#44; etc&#46;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;8&#44;9&#44;11</span></a> The existence of a prior difficulty in airway management is an independent criterion if the conditions that caused it persist&#44; so the patient&#39;s records must be checked for a <span class="elsevierStyleItalic">difficult airway alert</span><span class="elsevierStyleItalic">card</span><span class="elsevierStyleItalic">or report</span> detailing previous difficulties in airway management &#40;95&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">22</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The pre-anaesthesia evaluation also includes an exploration to identify the physical characteristics&#44; signs and symptoms known to be risk factors for DA &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; &#40;100&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;8&#44;9&#44;11&#44;23</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">Complementary imaging studies should not be performed routinely&#44; but should be considered when they can provide essential information in the presence of local pathology &#40;100&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">6</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Although evidence and experience supporting the use of ultrasound is still limited and the technique requires prior training&#44; in expert hands it can be used to locate the cricothyroid membrane faster and more accurately than palpation&#44; especially in women and in patients with anatomical difficulties&#46; In patients with anticipated DA&#44; it is recommended to locate the cricothyroid membrane with ultrasound and mark its position in hyperextension before starting airway management &#40;80&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0675"><span class="elsevierStyleSup">24&#44;25</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">The combination of multiple variables increases the predictive capacity with respect to isolated parameters&#46; However&#44; the predictive value of multivariate indices remains low and insufficient&#44;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;8&#44;9&#44;11&#44;26</span></a> and there is evidence that a systematic evaluation using multivariate indices is not superior to routine evaluation by an experienced anaesthesiologist&#44;<a class="elsevierStyleCrossRefs" href="#bib0690"><span class="elsevierStyleSup">27&#8211;29</span></a> and does not improve adherence to airway management algorithms&#46;<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">30</span></a> Much of the evidence for predicting DA is based on conventional laryngoscopy and tracheal intubation&#44; and evidence for predicting SAD difficulty or failure is based primarily on first-generation or unspecified devices&#46; These studies do not reflect current practice in our setting&#44; where VLSs and second generation SADs are widely available and have substantially improved the estimated success rate in these techniques&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The aim of the airway evaluation is to identify patients who are at high risk for failure of the techniques described above&#44; and therefore&#44; severe oxygenation impairment&#46; Once the patient-related factors have been evaluated&#44; the experience of the anaesthesiologist&#44; the availability of material resources and the characteristics of the setting should also be considered &#40;82&#46;8&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">8</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The DA has been classified into 3 categories in order to simplify the parameters evaluated in the different studies and guidelines<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;8&#8211;13&#44;21&#44;31&#8211;33</span></a> &#40;91&#46;4&#37;&#41;&#58;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Obvious or known difficult airway</span><p id="par0160" class="elsevierStylePara elsevierViewall">If one of the following conditions is met&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#40;A&#41;</span><p id="par0165" class="elsevierStylePara elsevierViewall">History of DA&#44; if the criteria or causative factors persist &#40;100&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#40;B&#41;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Presence of obvious difficulty&#44; such as deformities or neck and face trauma &#40;100&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#40;C&#41;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Presence of any of the following difficulty criteria&#44; common to all airway management techniques&#58;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Interdental distance &#60;3<span class="elsevierStyleHsp" style=""></span>cm &#40;100&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8226;</span><p id="par0185" class="elsevierStylePara elsevierViewall">Neck mobility &#60;80&#176; &#40;94&#46;3&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8226;</span><p id="par0190" class="elsevierStylePara elsevierViewall">Radiation changes to face and neck affecting tissue plasticity &#40;94&#46;3&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0195" class="elsevierStylePara elsevierViewall">Obstructive pathology or airway deformation &#40;100&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#40;D&#41;</span><p id="par0200" class="elsevierStylePara elsevierViewall">Presence of more than 3 criteria or pathologies with a high risk of difficulty &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; &#40;100&#37;&#41;&#46;</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Potentially difficult airway</span><p id="par0205" class="elsevierStylePara elsevierViewall">The likelihood of difficulty increases with the number and severity of the risk criteria present&#46; If the patient presents one or more ventilation and intubation difficulty criteria&#44; but these are inconclusive&#44; other factors or safety criteria should be considered individually in order to plan management&#46;<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">8&#44;9&#44;11</span></a>&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">&#8226;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Patient status&#58; risk of aspiration&#44; low tolerance to apnoea&#44; lack of collaboration&#44; emergency situation &#40;100&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">Experience of the anaesthesiologist in routine and rescue techniques &#40;100&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Environment factors&#58; material resources and help available &#40;100&#37;&#41;&#46;</p></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Airway with no anticipated difficulty</span><p id="par0225" class="elsevierStylePara elsevierViewall">Patients who do not present high-risk criteria and less than 3 minor airway-related criteria &#40;88&#46;6&#37;&#41;&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Pre-airway management preparation</span><p id="par0230" class="elsevierStylePara elsevierViewall">Careful planning and preparation can prevent or reduce the severity of complications from airway manipulation&#46; Routine application of the following measures is recommended before starting anaesthesia induction or airway management in spontaneous ventilation&#46;</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Planning</span><p id="par0235" class="elsevierStylePara elsevierViewall">Establish an action strategy based on the difficulties envisaged&#44; the type of intervention&#44; the patient&#39;s preferences&#44; the experience of the anaesthesiologist&#44; the setting and the resources available&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;8&#44;10&#44;11&#44;34</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Communication</span><p id="par0240" class="elsevierStylePara elsevierViewall">All information must be transmitted clearly and promptly to&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">&#8226;</span><p id="par0245" class="elsevierStylePara elsevierViewall">The patient&#44; if any difficulty is foreseen &#40;100&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;8&#44;9</span></a></p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">&#8226;</span><p id="par0250" class="elsevierStylePara elsevierViewall">The assistant&#44; specifying the planned strategy&#44; the fallback options if the primary approach fails&#44; and the material resources needed &#40;plan B&#44; C and D&#41; &#40;94&#46;8&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0605"><span class="elsevierStyleSup">10&#44;35</span></a></p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">&#8226;</span><p id="par0255" class="elsevierStylePara elsevierViewall">Other experts who can provide competent help&#44; if necessary&#44; in patients with anticipated difficult airway &#40;100&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;8</span></a></p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">&#8226;</span><p id="par0260" class="elsevierStylePara elsevierViewall">The surgical team responsible for the patient &#40;culture of patient safety&#41;&#46;</p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Material</span><p id="par0265" class="elsevierStylePara elsevierViewall">Before starting&#44; make sure the following resources are available&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">&#8226;</span><p id="par0270" class="elsevierStylePara elsevierViewall">Material needed for the initial plan&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">&#8226;</span><p id="par0275" class="elsevierStylePara elsevierViewall">Immediate access to ventilation and oxygenation devices in the operating room &#40;FM&#44; cannulas&#44; SAD&#41; &#40;100&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">11</span></a></p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">&#8226;</span><p id="par0280" class="elsevierStylePara elsevierViewall">Rescue materials and advanced airway management devices needed to implement each step of the algorithm &#40;DA cart&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;8&#8211;11</span></a></p></li></ul></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Position</span><p id="par0285" class="elsevierStylePara elsevierViewall">The position of the patient will determine the effectiveness of spontaneous or assisted ventilation and airway management techniques&#46; Proper positioning of the patient&#39;s head&#44; neck&#44; and chest optimises respiratory mechanics&#44; increases airway patency&#44; improves axis alignment&#44;<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">8&#8211;11</span></a> and exposes the neck for palpation and localisation of the cricothyroid membrane&#46; Two positions are recommended&#44; depending on the scenario&#58;<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">1&#46;</span><p id="par0290" class="elsevierStylePara elsevierViewall">Sniffing position&#58; slight cervical flexion and maximum cephalic extension&#44; placing an 8&#8211;10<span class="elsevierStyleHsp" style=""></span>cm cushion under the neck&#46; This position improves laryngoscopic vision&#44; intubation&#44; and SAD placement &#40;92&#46;1&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0735"><span class="elsevierStyleSup">36&#8211;38</span></a></p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">2&#46;</span><p id="par0295" class="elsevierStylePara elsevierViewall">Chest elevation<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>sniffing position &#40;HELP&#58; Head elevated laryngoscopy position<a class="elsevierStyleCrossRef" href="#bib0750"><span class="elsevierStyleSup">39</span></a> or ramped position&#41;&#44; which consists in placing the external auditory canal and the sternum at the same level in the horizontal plane &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>A&#41;&#46; This position is best suited for patients with anticipated ventilation difficulties and&#47;or low tolerance to apnoea &#40;obese patients&#44; with obstructive sleep apnoea &#91;OSA&#93; syndrome&#44; previous hypoxaemia&#44; etc&#46;&#41; &#40;100&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0735"><span class="elsevierStyleSup">36&#44;40&#8211;42</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></li></ul></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Pre-oxygenation</span><p id="par0305" class="elsevierStylePara elsevierViewall">Pre-oxygenation before anaesthesia induction delays arterial oxygen desaturation induced by apnoea during attempts to secure the airway&#46; It is recommended in all patients<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;8&#44;11</span></a> &#40;100&#37;&#41; after ensuring an airtight FM seal&#44; using either the traditional &#40;100&#37; oxygen&#44; tidal volume&#44; for 3&#8211;5<span class="elsevierStyleHsp" style=""></span>min&#41;<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">43</span></a> or fast &#40;100&#37; oxygen&#44; maximum capacity&#44; for 60<span class="elsevierStyleHsp" style=""></span>s&#41; method if pressed for time&#44; and monitoring the efficiency of pre-oxygenation with EtO<span class="elsevierStyleInf">2</span> &#62;90&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0775"><span class="elsevierStyleSup">44</span></a> The use of positive pressure CPAP should be considered in patients with anticipated difficult airway and&#47;or reduced functional residual capacity&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Intraoperative oxygenation</span><p id="par0310" class="elsevierStylePara elsevierViewall">It is important to guarantee patient oxygenation by all available means during airway manipulation&#46; In case of anticipated or unanticipated difficulties&#44; the following are recommended&#58;<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">&#8226;</span><p id="par0315" class="elsevierStylePara elsevierViewall">Administer supplemental oxygen continuously via nasal cannula<a class="elsevierStyleCrossRef" href="#bib0780">45</a> at a rate of 15 l&#47;min &#40;NODESAT&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>B&#41;&#44; or use humidified high-flow nasal oxygen systems at body temperature&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;8&#8211;10&#44;46&#44;47</span></a> These measures must be started during or after pre-oxygenation in order to prolong apnoea tolerance time&#44; and should continue until the airway has been secured &#40;85&#46;7&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">&#8226;</span><p id="par0320" class="elsevierStylePara elsevierViewall">Use ventilation devices if necessary &#40;FM<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>laryngeal cannula or SAD&#41;&#46;</p></li></ul></p><p id="par0325" class="elsevierStylePara elsevierViewall">These rescue devices must be immediately available in all operating rooms&#46; This recommendation extends to extubation and recovery of stable spontaneous ventilation &#40;100&#37;&#41;&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">Alveolar recruitment&#58; There is evidence that pre-oxygenation with O<span class="elsevierStyleInf">2</span> 100&#37; causes reabsorption atelectasis&#46; The risk&#47;benefit of this strategy&#44; therefore&#44; should be evaluated in each case&#44; and recruitment and prevention measures should be applied once the airway has been secured<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">48</span></a> &#40;100&#37;&#41;&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Monitoring</span><p id="par0335" class="elsevierStylePara elsevierViewall">Monitoring ventilation&#44; oxygenation and verifying the effectiveness of tracheal intubation &#40;see below&#41; are essential for good airway management&#46; Pulse oximetry and capnography&#44; in addition to standard monitoring techniques&#44; must be connected and working&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;8&#8211;11</span></a></p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Unanticipated difficult airway</span><p id="par0345" class="elsevierStylePara elsevierViewall">In the apnoeic patient airway management can be difficult from the start&#44; become complicated at any point in the process&#44; or rapidly evolve to a critical situation&#46; It is important to optimise the initial strategy in all patients and adapt alternative techniques to the context at all times&#46;</p><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Plan A</span><p id="par0350" class="elsevierStylePara elsevierViewall">The first attempt at laryngoscopy and intubation should be performed under optimal conditions<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;8&#44;10&#44;11</span></a>&#58;<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">&#8226;</span><p id="par0355" class="elsevierStylePara elsevierViewall">Apply the aforementioned recommendations for positioning and pre-oxygenation&#44; and choose the most appropriate material &#40;right sized blade and laryngoscope&#44; etc&#46;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;8&#8211;11</span></a></p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">&#8226;</span><p id="par0360" class="elsevierStylePara elsevierViewall">Correctly titre drugs and monitor their effect to achieve an optimal anaesthetic depth and neuromuscular blockade that facilitates ventilation&#44; intubation&#44; or SAD insertion &#40;97&#46;1&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">8&#44;10&#44;11</span></a> There is no evidence to justify the confirmation of ventilation before administering the neuromuscular block &#40;64&#46;7&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0800"><span class="elsevierStyleSup">49&#8211;51</span></a></p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">&#8226;</span><p id="par0365" class="elsevierStylePara elsevierViewall">Apply external laryngeal pressure &#40;<span class="elsevierStyleItalic">BURP&#58; back&#44; up&#44; right</span><span class="elsevierStyleItalic">pressure</span>&#41;&#44; as this can improve laryngoscopic vision&#46;<a class="elsevierStyleCrossRefs" href="#bib0590"><span class="elsevierStyleSup">7&#44;9&#44;10</span></a></p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">&#8226;</span><p id="par0370" class="elsevierStylePara elsevierViewall">Use a VLS on the first attempt if it more likely to be successful than conventional laryngoscopy &#40;100&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;7&#44;10&#44;11&#44;52&#8211;54</span></a></p></li></ul></p><p id="par0375" class="elsevierStylePara elsevierViewall">If&#44; despite these measures&#44; intubation is unsuccessful&#44; re-ventilate with an FM and assess the difficulty of maintaining adequate ventilation&#47;oxygenation&#46;</p><p id="par0380" class="elsevierStylePara elsevierViewall">The second attempt should significantly improve the chances of success compared to the first&#58;<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">&#8226;</span><p id="par0385" class="elsevierStylePara elsevierViewall">Improve intubation conditions&#58; optimise positioning&#44; and depth of anaesthesia or neuromuscular block&#44; if necessary &#40;100&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">&#8226;</span><p id="par0390" class="elsevierStylePara elsevierViewall">Change the technique according to the difficulty detected&#46; In patients with Cormack grade 2&#44; bougies and VLS can resolve the problem &#40;97&#37;&#41;&#46; In Cormack grade 4&#44; however&#44; neither bougies nor other blind intubation attempts are recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">10</span></a> VLS can improve vision in these cases &#40;97&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0830"><span class="elsevierStyleSup">55</span></a></p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">&#8226;</span><p id="par0395" class="elsevierStylePara elsevierViewall">Change operator if one with more experience is available &#40;92&#46;1&#37;&#41;&#46;</p></li></ul></p><p id="par0400" class="elsevierStylePara elsevierViewall">Repeated airway manipulation can cause mucosal oedema and hamper or entirely prevent ventilation&#46; Therefore&#44; no more than 2 attempts at laryngoscopy intubation should be made at this stage &#40;77&#46;5&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0835"><span class="elsevierStyleSup">56&#44;57</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Plan B</span><p id="par0405" class="elsevierStylePara elsevierViewall">If intubation has not been successful after 2 attempts in the best possible conditions&#44; a situation of unanticipated difficult airway should be declared&#44; help should be sought and the DA cart brought in&#46;</p><p id="par0410" class="elsevierStylePara elsevierViewall">If FM ventilation is still possible&#44; an alternative intubation technique may be considered&#58;<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">&#8226;</span><p id="par0415" class="elsevierStylePara elsevierViewall">VLS&#44; if this has not already been attempted&#44; if a different VLS is used&#44; or if a more experienced anaesthesiologist can take over&#46;<a class="elsevierStyleCrossRef" href="#bib0845"><span class="elsevierStyleSup">58</span></a> VLSs significantly improve laryngoscopic vision compared to conventional laryngoscopes&#46;<a class="elsevierStyleCrossRefs" href="#bib0820"><span class="elsevierStyleSup">53&#44;55&#44;59</span></a> Despite better vision&#44; intubation may be complicated due to difficulty directing or advancing the tube between the vocal cords<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;7&#44;9&#8211;11</span></a> &#40;100&#37;&#41;&#46; When a VLS without a channel is used&#44; care must be taken to choose the right curvature for the blade&#46; Injury to the oropharyngeal mucosa has been described during blind tube insertion&#44;<a class="elsevierStyleCrossRefs" href="#bib0855"><span class="elsevierStyleSup">60&#44;61</span></a> so the tip of the tube should be introduced under direct vision<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">10</span></a> until it is visible on the screen&#46; A bougie with a flexible tip can facilitate insertion by reducing the risk of mucosal injury&#46;</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">&#8226;</span><p id="par0420" class="elsevierStylePara elsevierViewall">SADs can be used to deliver ventilation and also as a conduit for fibreoptic intubation &#40;FOI&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;7&#44;9&#8211;11&#44;21</span></a> The latest&#44; second generation devices that incorporate a large bore gastric channel give higher sealing pressure and allow direct endotracheal intubation &#40;Ambu AuraGain or LMA Protector&#41; are the most suitable&#44;<a class="elsevierStyleCrossRefs" href="#bib0865"><span class="elsevierStyleSup">62&#8211;64</span></a> although there is still not enough evidence to demonstrate their superiority over other devices &#40;90&#37;&#41;&#46; Second generation devices &#40;i-gel&#44; LMA Proseal and LMA Supreme&#41; are preferable<a class="elsevierStyleCrossRef" href="#bib0880"><span class="elsevierStyleSup">65</span></a> &#40;84&#46;3&#37;&#41; to devices that do not have a gastric canal &#40;such as AML Fastrach&#41; &#40;60&#46;6&#37;&#41;&#46; If ventilation is adequate&#44; the following alternatives should be considered&#44; depending on the context&#58; make an additional attempt at FOI&#44; continue the procedure with these devices&#44;<a class="elsevierStyleCrossRefs" href="#bib0885"><span class="elsevierStyleSup">66&#44;67</span></a> or wake the patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;7&#44;9&#8211;11</span></a> Correct SAD placement must be verified by capnography&#44; by checking for obstruction&#44; leakage and correct insertion of the gastric tube &#40;through the channel&#41;&#44; and by pulmonary auscultation &#40;97&#46;2&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">9&#44;68</span></a> Over-inflation of the cuff may worsen ventilation and increase the risk of oropharyngeal morbidity&#59; therefore&#44; pressure should not exceed 60 cmH<span class="elsevierStyleInf">2</span>O&#46;<a class="elsevierStyleCrossRefs" href="#bib0900"><span class="elsevierStyleSup">69&#44;70</span></a> SAD insertion can be facilitated and malposition avoided by inserting a suction tube through the gastric canal to the distal end of the device&#46;</p></li><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">&#8226;</span><p id="par0425" class="elsevierStylePara elsevierViewall">FOI through an anaesthetic FM that permits non-invasive ventilation&#46;</p></li></ul></p><p id="par0430" class="elsevierStylePara elsevierViewall">No more than 2 attempts at intubation should be made at this stage&#44; and no more than 3 overall &#40;plan A<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>plan B&#41;&#46; A fourth attempt would only be justified if performed by an expert anaesthesiologist &#40;67&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0590"><span class="elsevierStyleSup">7&#44;56&#44;57</span></a></p><p id="par0435" class="elsevierStylePara elsevierViewall">If none of these alternatives are available&#44; or if the level of expertise is inadequate&#44; the patient should be woken up while maintaining FM or SAD ventilation&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;7&#44;9&#8211;11</span></a></p><p id="par0440" class="elsevierStylePara elsevierViewall">If all attempts at intubation with different techniques have failed&#44; but FM or SAD ventilation is still effective&#44; it is time to <span class="elsevierStyleItalic">stop&#44; think and decide</span> the next step by consensus with the team &#40;90&#46;9&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0590"><span class="elsevierStyleSup">7&#44;10</span></a></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Plan C</span><p id="par0445" class="elsevierStylePara elsevierViewall">When FM ventilation&#47;oxygenation is difficult or insufficient&#44; the anaesthesiologist should&#58;<ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">1&#46;</span><p id="par0450" class="elsevierStylePara elsevierViewall">Take all possible measures to optimise FM ventilation<a class="elsevierStyleCrossRef" href="#bib0910"><span class="elsevierStyleSup">71</span></a>&#58;</p></li></ul></p><p id="par0455" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">&#8226;</span><p id="par0460" class="elsevierStylePara elsevierViewall">Raise the base of the tongue and open the upper airway with the following manoeuvres&#58; raise the chest&#44; place patient in the sniffing position&#44; perform jaw thrust &#40;if not contraindicated&#41;&#44; use oral or nasal cannulas&#44; resize the FM if necessary&#44; and perform 4-handed ventilation&#46;<a class="elsevierStyleCrossRefs" href="#bib0590"><span class="elsevierStyleSup">7&#44;9&#8211;11</span></a></p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">&#8226;</span><p id="par0465" class="elsevierStylePara elsevierViewall">When faced with severe ventilation difficulties&#44;<a class="elsevierStyleCrossRef" href="#bib0915"><span class="elsevierStyleSup">72</span></a> ensure complete neuromuscular block using fast-acting drugs<a class="elsevierStyleCrossRefs" href="#bib0590"><span class="elsevierStyleSup">7&#44;9&#8211;11</span></a> &#40;88&#46;3&#37;&#41;&#46; Consider using rocuronium&#44; as this can be reverse with sugammadex if the patient is awakened once effective oxygenation has been restored<a class="elsevierStyleCrossRefs" href="#bib0920"><span class="elsevierStyleSup">73&#8211;75</span></a> &#40;97&#46;1&#37;&#41;&#46;</p></li></ul></p><p id="par0470" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">2&#46;</span><p id="par0475" class="elsevierStylePara elsevierViewall">Insert a SAD if this has not already been attempted&#44; or change device if the first SAD is ineffective&#46; A more experienced anaesthesiologist should make the second attempt&#44; if available &#40;100&#37;&#41;&#46;</p></li></ul></p><p id="par0480" class="elsevierStylePara elsevierViewall">When airway management becomes complicated&#44; a SAD should be inserted without delay &#40;97&#46;1&#37;&#41;&#46; When correctly used&#44; these devices can restore effective ventilation in patients with difficult airway management when other methods have failed&#46; Second-generation SADs should be immediately available in all areas<a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">9&#44;11</span></a> &#40;94&#46;1&#37;&#41;&#46; Restoring oxygenation gives the team time to think and prepare for the next step<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;7&#44;9&#8211;11</span></a>&#58;<ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">&#8226;</span><p id="par0485" class="elsevierStylePara elsevierViewall">Wake up the patient and restore spontaneous ventilation if possible&#44; after reversing muscle relaxants and other drugs using antagonists &#40;97&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">&#8226;</span><p id="par0490" class="elsevierStylePara elsevierViewall">Attempt FOI through the SAD&#44; if not attempted before &#40;90&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">&#8226;</span><p id="par0495" class="elsevierStylePara elsevierViewall">Continue the procedure with the SAD if ventilation is sufficient and the intervention cannot be postponed &#40;87&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">&#8226;</span><p id="par0500" class="elsevierStylePara elsevierViewall">Perform front-of-neck access &#40;95&#37;&#41; if the possibility of rapidly recovering effective spontaneous ventilation has been ruled out&#46;</p></li></ul></p><p id="par0505" class="elsevierStylePara elsevierViewall">Do not make more than 2 ventilation attempts with a SAD at this stage&#46; If the airway has not been secured but oxygenation is maintained &#40;with FM or SAD&#41;&#44; waking the patient must be given priority &#40;80&#37;&#41;&#46; Otherwise&#44; proceed immediately to plan D&#46;</p><p id="par0510" class="elsevierStylePara elsevierViewall">At this stage&#44; any device that incorporates a gastric channel and allows direct endotracheal intubation should be used &#40;91&#46;1&#37;&#41;&#46; Check that the device is correctly placed&#44; as indicated above&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Plan D</span><p id="par0515" class="elsevierStylePara elsevierViewall">An emergency &#40;CICO&#41; must be declared if SAD or FM oxygenation is insufficient and awaking the patient is not an option&#44; or if oxygenation progressively worsens&#46; In this situation&#44; surgical access is required&#46;<a class="elsevierStyleCrossRefs" href="#bib0590"><span class="elsevierStyleSup">7&#44;10&#44;21</span></a></p><p id="par0520" class="elsevierStylePara elsevierViewall">Efforts to restore and maintain oxygenation through the FM&#44; high flow nasal cannulas&#47;SAD must be continued until an effective subglottic airway has been established &#40;97&#37;&#41;&#46; It is recommended to ensure complete neuromuscular block to facilitate ventilation and the performance of the technique &#40;90&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">8&#44;10&#44;21</span></a></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Techniques</span><p id="par0525" class="elsevierStylePara elsevierViewall">There is insufficient evidence or consensus to recommend any particular technique&#46; Therefore&#44; the anaesthesiologist should choose the best technique in each case&#44; or the one he or she is most familiar with &#40;68&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;7&#44;10</span></a> The SEVA expert group has listed these techniques in order of preference&#58;<ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">&#8226;</span><p id="par0530" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Surgical</span> &#40;68&#37;&#41;&#58; a skin incision is made with a scalpel &#40;no&#46; 10&#41;&#44; the cricothyroid membrane is located by palpation and dissected&#44; the incision is enlarged by rotating the scalpel 90&#176; and removing it to insert a narrow bore &#40;5 or 6<span class="elsevierStyleHsp" style=""></span>mm&#41; tracheal tube&#46; Insertion can be made easier by using an introducer &#40;Frova&#44; Eschmann&#41;&#46; All the materials needed are standard issue in all operating rooms&#46;<a class="elsevierStyleCrossRefs" href="#bib0605"><span class="elsevierStyleSup">10&#44;76</span></a></p></li><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">&#8226;</span><p id="par0535" class="elsevierStylePara elsevierViewall">Wide bore cannula-over-needle technique &#40;27&#46;3&#37;&#41;&#58; needle puncture<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>guide wire &#40;Seldinger technique&#41; followed by insertion of a dilator<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>&#62;4<span class="elsevierStyleHsp" style=""></span>mm bore cannula&#44; usually with a cuff&#46;<a class="elsevierStyleCrossRefs" href="#bib0935"><span class="elsevierStyleSup">76&#44;77</span></a></p></li><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">&#8226;</span><p id="par0540" class="elsevierStylePara elsevierViewall">Small-bore cannula &#40;4&#46;5&#37;&#41;&#58; needle puncture<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>dilator<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>cannula in one step&#46; The use of intravenous cannulas for this purpose is not recommended&#44; due to the high risk of collapse and displacement&#46;</p></li></ul></p><p id="par0545" class="elsevierStylePara elsevierViewall">All these techniques have their advantages and risks&#44;<a class="elsevierStyleCrossRefs" href="#bib0945"><span class="elsevierStyleSup">78&#44;79</span></a> and all require practice&#59; therefore&#44; specific and regular training is essential&#46;<a class="elsevierStyleCrossRef" href="#bib0955"><span class="elsevierStyleSup">80</span></a></p><p id="par0550" class="elsevierStylePara elsevierViewall">Surgical access is fast&#44; more reliable&#44; but also more invasive&#44; and could delay the decision to perform cricothyrotomy&#46;<a class="elsevierStyleCrossRef" href="#bib0960"><span class="elsevierStyleSup">81</span></a></p><p id="par0555" class="elsevierStylePara elsevierViewall">The narrow-bore cannula technique &#40;&#60;4<span class="elsevierStyleHsp" style=""></span>mm&#41; is fast and more intuitive for anaesthesiologists&#44; but has the highest complication and failure rate&#44; and is only effective if a high pressure or high flow ventilation system is available&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">7</span></a></p><p id="par0560" class="elsevierStylePara elsevierViewall">If the cricothyroid membrane cannot be located by palpation&#44; a vertical skin incision should be made in the midline to locate the membrane and proceed with the surgical technique &#40;84&#46;9&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">10</span></a></p><p id="par0565" class="elsevierStylePara elsevierViewall">If cricothyrotomy is not an option&#44; an emergency surgical tracheostomy will be needed &#40;82&#46;3&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">11</span></a></p><p id="par0570" class="elsevierStylePara elsevierViewall">The cricothyroid membrane can be located faster and more accurately with ultrasound than with palpation in patients with anatomical difficulties&#44;<a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">24</span></a> but the technique requires training and the scanner must be immediately available and prepared&#46; Therefore&#44; in cases of unanticipated DA&#44; the scanner should be requested together with the DA cart at the first sign of difficulty &#40;84&#46;9&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">24</span></a></p><p id="par0575" class="elsevierStylePara elsevierViewall">These techniques restore oxygenation&#44; but are not appropriate to maintain ventilation during the surgical procedure&#44; except in emergent situations&#46; It is best to postpone surgery and wake the patient if it is not possible to establish intubation or perform a tracheostomy&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Check the position of the tracheal tube or cannula</span><p id="par0580" class="elsevierStylePara elsevierViewall">It is important to check that the tube or cannula is correctly placed in the trachea after insertion&#46; This can be done by chest inspection and auscultation&#44; and also by observing the capnography curve &#40;100&#37;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">82</span></a> which is the gold standard and must be available wherever anaesthesia is administered&#46; If FOI has been performed&#44; the bronchoscope can be used to confirm the position of the tip of the tube tip in the trachea &#40;100&#37;&#41;&#46; Ultrasound can also be used to confirm correct intubation by observing the symmetrical movement of the lungs or the diaphragm when the other options do not give immediate confirmation of intubation &#40;78&#46;9&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0970"><span class="elsevierStyleSup">83</span></a></p></span></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Anticipated difficult airway</span><p id="par0585" class="elsevierStylePara elsevierViewall">When a difficult airway is anticipated&#44; the anaesthesiologist has 2 options&#58; either proceed with anaesthesia induction or maintain spontaneous ventilation&#46; The choice will depend on both the degree of likelihood of intubation difficulty or failure and safety considerations &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0590" class="elsevierStylePara elsevierViewall">In either case&#44; management of the anticipated difficult airway requires special preparation in addition to all the recommendations already set forth above&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;8&#44;9&#44;11</span></a> The patient should be informed of the cause of the potential difficulty&#44; the options available&#44; the details of the chosen procedure&#44; and the need for collaboration&#46; It is important to reassure the patient and gain their trust &#40;100&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">6</span></a> The DA cart&#44; including oxygenation rescue devices and supplies&#44; must be available immediately&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;8</span></a></p><p id="par0595" class="elsevierStylePara elsevierViewall">Preparations for airway management under spontaneous ventilation include correct positioning &#40;94&#46;4&#37;&#41; &#40;chest elevation<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>sniffing position&#44; if not contraindicated&#41;&#44; pre-oxygenation and&#47;or continuous oxygenation&#44; continuous pulse oximetry and capnography monitoring&#44; and individual drug titration&#46; Patients should receive an antisialagogue &#40;atropine&#41;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>topical nasal&#47;oral anaesthesia<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>individually titrated sedation to maintain spontaneous ventilation&#44; protective reflexes&#44; and muscle tone &#40;100&#37;&#41;&#46; The goal is to keep the patient calm and cooperative&#46;<a class="elsevierStyleCrossRef" href="#bib0975"><span class="elsevierStyleSup">84</span></a></p><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Potentially difficult airway</span><p id="par0600" class="elsevierStylePara elsevierViewall">Patients with DA risk criteria who meet the following safety criteria&#58;<ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">&#8226;</span><p id="par0605" class="elsevierStylePara elsevierViewall">Can be ventilated with FM or SAD&#46;</p></li><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">&#8226;</span><p id="par0610" class="elsevierStylePara elsevierViewall">Low risk of aspiration&#46;</p></li><li class="elsevierStyleListItem" id="lsti0275"><span class="elsevierStyleLabel">&#8226;</span><p id="par0615" class="elsevierStylePara elsevierViewall">Low risk of rapid desaturation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0280"><span class="elsevierStyleLabel">&#8226;</span><p id="par0620" class="elsevierStylePara elsevierViewall">High probability of successful VLS intubation &#40;if available&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0285"><span class="elsevierStyleLabel">&#8226;</span><p id="par0625" class="elsevierStylePara elsevierViewall">Expert help and sufficient material for rescue techniques available&#46;</p></li></ul></p><p id="par0630" class="elsevierStylePara elsevierViewall">In these cases&#44; anaesthesia induction would be justified if the expert anaesthesiologist believes that the probability of first-attempt success is high&#44; the risk of oxygenation failure is low&#44; and an alternative plan can be implemented quickly and efficiently &#40;95&#46;5&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">8&#44;11</span></a></p><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Plan A</span><p id="par0635" class="elsevierStylePara elsevierViewall">A VLS should be used if tracheal intubation is anticipated &#40;maximum 2 attempts&#41; &#40;94&#46;4&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0980"><span class="elsevierStyleSup">85&#44;86</span></a></p><p id="par0640" class="elsevierStylePara elsevierViewall">If tracheal intubation is not required and SAD is planned&#44;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">8</span></a> a second generation SAD should be used&#46;</p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Plan B</span><p id="par0645" class="elsevierStylePara elsevierViewall">If the first attempt fails&#44; the previously planned alternative strategy should be implemented according to the recommendations described for unanticipated difficult airway &#40;FOI under assisted ventilation&#44; intubation with SAD&#44; awakening&#41;&#46;</p><p id="par0650" class="elsevierStylePara elsevierViewall">If the above criteria are not met&#44; or when in doubt&#44; the recommendations for obvious or known DA should be followed &#40;97&#46;2&#37;&#41;&#46;</p></span></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Obvious&#44; known&#44; or anticipated difficult airway</span><p id="par0655" class="elsevierStylePara elsevierViewall">In these cases&#44; intubation should be performed under spontaneous ventilation&#44; regardless of the technique chosen &#40;100&#37;&#41;&#46;</p><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Plan A</span><p id="par0660" class="elsevierStylePara elsevierViewall">The following options are recommended&#58;<ul class="elsevierStyleList" id="lis0085"><li class="elsevierStyleListItem" id="lsti0290"><span class="elsevierStyleLabel">&#8226;</span><p id="par0665" class="elsevierStylePara elsevierViewall">Nasal or oral FOI&#58; this is the technique of choice&#44; particularly when the difficulty is due to serious anatomical alterations&#44; limited mouth opening or cervical mobility&#44; obstruction&#44; or airway stenosis&#46; It is associated with a success rate of 88&#8211;100&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0990"><span class="elsevierStyleSup">87</span></a> and can be used in combination with VLS and SAD &#40;100&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">8</span></a></p></li><li class="elsevierStyleListItem" id="lsti0295"><span class="elsevierStyleLabel">&#8226;</span><p id="par0670" class="elsevierStylePara elsevierViewall">VLS&#58; can be as effective as FOI under spontaneous ventilation when mouth opening and cervical mobility is not severely limited and the oropharynx is not obstructed &#40;89&#46;5&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0995"><span class="elsevierStyleSup">88&#44;89</span></a></p></li><li class="elsevierStyleListItem" id="lsti0300"><span class="elsevierStyleLabel">&#8226;</span><p id="par0675" class="elsevierStylePara elsevierViewall">SAD with intubation capability&#58; can be effective in difficult intubation<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ventilation&#46; Awake SAD insertion is tolerated as well or even better than laryngoscopy&#46; FOI is recommended when intubating through these devices &#40;86&#46;1&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib1005"><span class="elsevierStyleSup">90&#44;91</span></a></p></li></ul></p><p id="par0680" class="elsevierStylePara elsevierViewall">In cases of airway obstruction&#47;stenosis&#44; the indication for intubation should be evaluated individually&#46; If the obstruction is severe and is accompanied by symptoms of dyspnoea&#44; dysphonia&#44; and hypoxaemia that can worsen with topical anaesthesia or endoscope insertion&#44; surgical techniques &#40;plan B&#41; should be considered as the first option &#40;88&#46;6&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">8&#44;11&#44;92&#44;93</span></a></p><p id="par0685" class="elsevierStylePara elsevierViewall">If the patient is not cooperative&#44; inhalation induction under spontaneous ventilation and fibreoptic&#44; VLS or SAD intubation can be considered&#46; All the material required for cricothyrotomy should be immediately available &#40;94&#46;4&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">8</span></a></p><p id="par0690" class="elsevierStylePara elsevierViewall">If the procedure does not require tracheal intubation&#44; consider inserting a SAD under spontaneous ventilation<a class="elsevierStyleCrossRefs" href="#bib1025"><span class="elsevierStyleSup">94&#44;95</span></a> following the same pre-operative preparation and verification steps described above &#40;88&#46;5&#37;&#41;&#46; Preferably use a second generation SAD that provide high sealing pressure and allow direct endoscopic intubation in case the technique needs to be converted &#40;94&#46;6&#37;&#41;&#46;</p></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Plan B</span><p id="par0695" class="elsevierStylePara elsevierViewall">When plan A is not feasible or fails&#58;<ul class="elsevierStyleList" id="lis0090"><li class="elsevierStyleListItem" id="lsti0305"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">&#8226;</span></span><p id="par0700" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Establish a surgical airway</span> &#40;cricothyrotomy and percutaneous or surgical tracheotomy&#41; under spontaneous ventilation&#46; This is the first option in the following cases&#58; if difficult FOI is anticipated due to obstruction&#44; severe stenosis or serious tracheal lesions &#40;93&#46;6&#37;&#41;&#44; or if tracheostomy is expected in the postoperative period &#40;97&#46;2&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0310"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">&#8226;</span></span><p id="par0705" class="elsevierStylePara elsevierViewall">Consider other options&#44; such as locoregional anaesthesia or cancel surgery&#44; depending on the procedure &#40;91&#46;6&#37;&#41;&#46;</p></li></ul></p></span></span></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Risk of bronchoaspiration</span><p id="par0710" class="elsevierStylePara elsevierViewall">Special precautions must be taken with patients with risk criteria for regurgitation&#46;</p><p id="par0715" class="elsevierStylePara elsevierViewall">If DA &#40;difficult ventilation or intubation&#41; and&#47;or low tolerance to apnoea are suspected in addition to the risk of bronchoaspiration&#44; tracheal intubation should be performed under spontaneous ventilation &#40;90&#37;&#41;&#46;</p><p id="par0720" class="elsevierStylePara elsevierViewall">If DA is not anticipated&#44; the degree of aspiration risk should be assessed on the basis of the cause and the patient&#39;s clinical status&#46; Consider using gastric ultrasound&#44; if available&#44; to assess the type of content &#40;liquid&#44; solid&#44; or mixed&#41; and estimate the approximate volume<a class="elsevierStyleCrossRef" href="#bib1035"><span class="elsevierStyleSup">96</span></a> &#40;taking into account the limitations inherent to the technique and formulas used to determine intragastric volume&#41; &#40;86&#46;4&#37;&#41;&#46; The approach taken will depend on whether the risk of aspiration is high or moderate&#58;<ul class="elsevierStyleList" id="lis0095"><li class="elsevierStyleListItem" id="lsti0315"><span class="elsevierStyleLabel">&#40;a&#41;</span><p id="par0725" class="elsevierStylePara elsevierViewall">High risk of bronchoaspiration &#40;gastric bloating&#44; ileus&#44; intestinal obstruction&#44; solid content or estimated volume &#62;1&#46;5<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#41;&#58;</p></li></ul></p><p id="par0730" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0100"><li class="elsevierStyleListItem" id="lsti0320"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">&#8226;</span></span><p id="par0735" class="elsevierStylePara elsevierViewall">Place a gastric tube prior to rapid sequence induction&#46; Connect to suction and maintain continuous aspiration &#40;90&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0605"><span class="elsevierStyleSup">10&#44;97&#44;98</span></a> The same procedure is followed in patients with an existing gastric tube&#46;</p></li><li class="elsevierStyleListItem" id="lsti0325"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">&#8226;</span></span><p id="par0740" class="elsevierStylePara elsevierViewall">If the gastric tube cannot be inserted&#44; consider performing intubation under spontaneous ventilation or proceed to rapid sequence induction&#44; depending on which has the greatest likelihood of first-attempt success &#40;87&#46;2&#37;&#41;&#46;</p></li></ul></p><p id="par0745" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0105"><li class="elsevierStyleListItem" id="lsti0330"><span class="elsevierStyleLabel">&#40;b&#41;</span><p id="par0750" class="elsevierStylePara elsevierViewall">Moderate risk of bronchoaspiration&#58; proceed to rapid sequence tracheal intubation using the Sellick manoeuvre &#40;apply pressure to the cricoid cartilage to occlude the proximal oesophagus&#41; &#40;96&#46;6&#37;&#41;&#46;</p></li></ul></p><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Preparation</span><p id="par0755" class="elsevierStylePara elsevierViewall">The general preparations described above should be made for airway management under spontaneous ventilation and for rapid sequence induction&#58;<ul class="elsevierStyleList" id="lis0110"><li class="elsevierStyleListItem" id="lsti0335"><span class="elsevierStyleLabel">&#8226;</span><p id="par0760" class="elsevierStylePara elsevierViewall">Consider administering drugs to reduce gastric pH and accelerate emptying&#46;</p></li><li class="elsevierStyleListItem" id="lsti0340"><span class="elsevierStyleLabel">&#8226;</span><p id="par0765" class="elsevierStylePara elsevierViewall">Maintain chest elevation<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>sniffing position to facilitate spontaneous and&#47;or assisted ventilation and improve glottic vision &#40;96&#46;6&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0345"><span class="elsevierStyleLabel">&#8226;</span><p id="par0770" class="elsevierStylePara elsevierViewall">It is essential to maximise pre-oxygenation in patients at risk of aspiration in order to avoid the need for assisted ventilation&#46; Apnoeic oxygenation with high-flow nasal cannula should be used to prolong apnoea time &#40;93&#46;3&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib1050"><span class="elsevierStyleSup">99</span></a></p></li><li class="elsevierStyleListItem" id="lsti0350"><span class="elsevierStyleLabel">&#8226;</span><p id="par0775" class="elsevierStylePara elsevierViewall">If rapid sequence induction is performed in patients with limited apnoea tolerance&#44; administer low pressure FM ventilation &#40;&#60;20<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>0&#41; and apply cricoid pressure of 30<span class="elsevierStyleHsp" style=""></span>N before intubation to delay oxygen desaturation &#40;80&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">10</span></a></p></li></ul></p><p id="par0780" class="elsevierStylePara elsevierViewall">Despite the controversy over the efficacy of the Sellick manoeuvre&#44; it is recommended during rapid sequence induction &#40;92&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">8&#44;10&#44;11&#44;46</span></a> This manoeuvre can impede FM ventilation&#44; SAD placement&#44; and laryngoscopic vision&#46; Obstructed glottic vision can delay tracheal tube insertion&#44; and thus increase the risk of bronchoaspiration&#46; If the manoeuvre obstructs the glottis&#44; the pressure should be partially released while maintaining direct vision and aspiration&#46;<a class="elsevierStyleCrossRef" href="#bib1055"><span class="elsevierStyleSup">100</span></a> If regurgitation occurs&#44; re-apply pressure immediately and aspirate &#40;92&#46;4&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">10</span></a></p><p id="par0785" class="elsevierStylePara elsevierViewall">If intubation fails during rapid sequence induction&#44; low pressure &#40;&#60;20<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&#41; FM ventilation should be started immediately while maintaining appropriate cricoid pressure &#40;30<span class="elsevierStyleHsp" style=""></span>N&#41; &#40;100&#37;&#41;&#46; If ventilation is insufficient&#44; the pressure should be gradually released &#40;83&#46;7&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">8&#44;11</span></a> If FM ventilation is not effective&#44; a second generation SAD should be inserted immediately<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">10</span></a> together with a tube to aspirate the gastric contents&#46; The Sellick manoeuvre should be partially released if it prevents SAD placement &#40;96&#46;7&#37;&#41;&#46;</p></span></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Extubation in the difficult airway patient</span><p id="par0790" class="elsevierStylePara elsevierViewall">The incidence of morbidity and mortality associated with complications arising both during and after extubation has remained constant in recent years&#46; The tracheal tube is removed at the discretion of the anaesthesiologist&#44; and can therefore be postponed until the conditions are appropriate &#40;96&#46;7&#37;&#41;&#46; It is always necessary to establish an extubation strategy&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;8&#8211;10&#44;20&#44;101</span></a></p><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Evaluation</span><p id="par0795" class="elsevierStylePara elsevierViewall">The first step is to identify patients with DA criteria who are also at risk of poor oxygenation after extubation<a class="elsevierStyleCrossRefs" href="#bib0670"><span class="elsevierStyleSup">23&#44;102</span></a>&#58;<ul class="elsevierStyleList" id="lis0115"><li class="elsevierStyleListItem" id="lsti0355"><span class="elsevierStyleLabel">&#8226;</span><p id="par0800" class="elsevierStylePara elsevierViewall">Patients with a history of anticipated or unanticipated difficult airway management &#40;who might also present airway lesions&#44; oedema&#44; etc&#46;&#41; &#40;100&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0360"><span class="elsevierStyleLabel">&#8226;</span><p id="par0805" class="elsevierStylePara elsevierViewall">Surgical procedures that carry a risk of anatomical or functional airway alteration &#40;extensive or complex surgery involving the head and neck surgery&#44; thyroid&#44; maxilla&#44; etc&#46;&#41; &#40;96&#46;6&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0365"><span class="elsevierStyleLabel">&#8226;</span><p id="par0810" class="elsevierStylePara elsevierViewall">Patients with DA criteria and risk of post-intubation hypoventilation &#40;limited tolerance of apnoea&#44; airway hyperresponsiveness&#44; vocal cord oedema&#44; vocal cord dysfunction&#44; etc&#46;&#41; &#40;96&#46;6&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib1065"><span class="elsevierStyleSup">102</span></a></p></li></ul></p><p id="par0815" class="elsevierStylePara elsevierViewall">In these patients&#44; the extent and severity of the changes &#40;trauma&#44; bleeding&#44; oedema&#41; should be assessed&#46;<ul class="elsevierStyleList" id="lis0120"><li class="elsevierStyleListItem" id="lsti0370"><span class="elsevierStyleLabel">&#8226;</span><p id="par0820" class="elsevierStylePara elsevierViewall">Upper airway examination &#40;96&#46;7&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0375"><span class="elsevierStyleLabel">&#8226;</span><p id="par0825" class="elsevierStylePara elsevierViewall">Cuff leak test&#58; check for audible leakage &#40;or by spirometry&#41; around the tube during ventilation after the sealing balloon cuff has been deflated&#46; No leakage &#40;&#60;10&#37; of tidal volume&#41; indicates risk of obstruction due to airway oedema after extubation &#40;93&#46;4&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib1070"><span class="elsevierStyleSup">103&#44;104</span></a></p></li><li class="elsevierStyleListItem" id="lsti0380"><span class="elsevierStyleLabel">&#8226;</span><p id="par0830" class="elsevierStylePara elsevierViewall">Respiratory function and general status &#40;100&#37;&#41;&#46;</p></li></ul></p><p id="par0835" class="elsevierStylePara elsevierViewall">It is essential to evaluate the results of these examinations together with other clinical parameters before deciding on extubation&#46;</p></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Preparing for extubation in the difficult airway patient</span><p id="par0840" class="elsevierStylePara elsevierViewall">In addition to optimising the overall status of the patient &#40;haemodynamic&#44; respiratory&#44; pharmacological&#41;&#44; the pre-intubation preparations described above should also be made before extubation &#40;100&#37;&#41;&#58;<ul class="elsevierStyleList" id="lis0125"><li class="elsevierStyleListItem" id="lsti0385"><span class="elsevierStyleLabel">&#8226;</span><p id="par0845" class="elsevierStylePara elsevierViewall">Plan the strategy according to the difficulty anticipated&#46;</p></li><li class="elsevierStyleListItem" id="lsti0390"><span class="elsevierStyleLabel">&#8226;</span><p id="par0850" class="elsevierStylePara elsevierViewall">Check the availability of airway management resources &#40;personnel and material&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0395"><span class="elsevierStyleLabel">&#8226;</span><p id="par0855" class="elsevierStylePara elsevierViewall">Pre-oxygenate&#46;</p></li><li class="elsevierStyleListItem" id="lsti0400"><span class="elsevierStyleLabel">&#8226;</span><p id="par0860" class="elsevierStylePara elsevierViewall">Optimise the patient&#39;s position to promote ventilation &#40;raise chest<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>sniffing position&#41;&#46;</p></li></ul></p></span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Extubation techniques in high-risk patients</span><p id="par0865" class="elsevierStylePara elsevierViewall">Depending on the patient&#39;s status&#44; the following alternatives can be applied&#58;<ul class="elsevierStyleList" id="lis0130"><li class="elsevierStyleListItem" id="lsti0405"><span class="elsevierStyleLabel">&#8226;</span><p id="par0870" class="elsevierStylePara elsevierViewall">Extubation with a tube exchanger or with specific extubation sets that allow rapid guided reintubation if necessary &#40;96&#46;5&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;8&#8211;10&#44;101&#44;105</span></a></p></li><li class="elsevierStyleListItem" id="lsti0410"><span class="elsevierStyleLabel">&#8226;</span><p id="par0875" class="elsevierStylePara elsevierViewall">Extubation with a SAD that replaces the tracheal tube &#40;89&#46;7&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;9&#44;10&#44;102</span></a></p></li><li class="elsevierStyleListItem" id="lsti0415"><span class="elsevierStyleLabel">&#8226;</span><p id="par0880" class="elsevierStylePara elsevierViewall">Tracheostomy &#40;77&#37;&#41;&#46;</p></li></ul></p></span><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0205">Post-extubation follow-up</span><p id="par0885" class="elsevierStylePara elsevierViewall">Oxygen delivery and monitoring must continue in the post-extubation period&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;8&#44;9</span></a></p><p id="par0890" class="elsevierStylePara elsevierViewall">The professionals involved in post-procedural care must be informed of the cause of the extubation difficulty and the risk of complications &#40;100&#37;&#41;&#46; The patient must be continuously monitored for early signs and symptoms of deterioration&#44; and the corresponding treatment strategies must be established in consensus with the treating teams &#40;96&#46;6&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">9&#44;106</span></a></p></span></span><span id="sec0190" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0210">Documentation</span><p id="par0895" class="elsevierStylePara elsevierViewall">The details of the airway management procedure must be documented and given to the patient in the form of a letter or airway management card&#46; Although there is no evidence to support the effectiveness of these measures&#44; they are recommended in the consensus guidelines consulted<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">6&#44;7&#44;9&#8211;11&#44;21</span></a>&#58;<ul class="elsevierStyleList" id="lis0135"><li class="elsevierStyleListItem" id="lsti0420"><span class="elsevierStyleLabel">1&#46;</span><p id="par0900" class="elsevierStylePara elsevierViewall">The causes of the DA &#40;history&#44; anatomical characteristics&#41; and the specific difficulty encountered during management &#40;FM ventilation&#44; SAD insertion&#44; laryngoscopy or intubation&#59; number of attempts and operators&#59; types of devices used&#59; possible future management options&#44; etc&#46;&#41; should be noted in the patient&#39;s medical history &#40;100&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0425"><span class="elsevierStyleLabel">2&#46;</span><p id="par0905" class="elsevierStylePara elsevierViewall">Fill in the SCARTD DA card &#40;which describes the factors involved in the DA&#41; and give it to the patient&#44; their legal guardian and primary care doctor &#40;100&#37;&#41;&#46; If the DA card is not available&#44; provide a DA report containing the same information&#46;</p></li><li class="elsevierStyleListItem" id="lsti0430"><span class="elsevierStyleLabel">3&#46;</span><p id="par0910" class="elsevierStylePara elsevierViewall">Assess and monitor the patient if complications have occurred during airway manipulation &#40;oedema&#44; bleeding&#44; oesophageal or tracheal perforation&#44; pneumothorax&#44; or bronchial aspiration&#41;&#46; The patient&#44; their relatives and the primary care physician should be warned of the signs and symptoms of late complications &#40;pharyngeal inflammation&#44; pain or oedema of the face and neck&#44; fever&#44; chest pain&#44; subcutaneous emphysema and difficulty swallowing&#41;&#44; and the need to consult the medical team again if these occur &#40;100&#37;&#41;&#46;</p></li></ul></p><p id="par0915" class="elsevierStylePara elsevierViewall">The DA documentation should ideally include the diagnosis and treatment of possible complications and a guideline for airway management planning in any future interventions&#46;</p><p id="par0920" class="elsevierStylePara elsevierViewall">DA cases reported in the corresponding registries must be periodically analysed by experts from the Service in order to determine and correct the causative factors&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">10</span></a></p><p id="par0925" class="elsevierStylePara elsevierViewall">The DA diagnosis should be included in the hospital discharge report or added as a risk factor for the patient &#40;in the same way as allergies&#44; etc&#46;&#41; &#40;100&#37;&#41;&#46;</p><p id="par0930" class="elsevierStylePara elsevierViewall">The introduction of new technologies and inter-hospital databases&#44; such as the Catalonia Shared Patient History &#40;HCCC&#44; in its Spanish acronym&#41;&#44; allows this documentation to be accessed by any authorised healthcare professional in order to improve patient safety and the quality of care&#46; Information related to the DA should be included in the HCCC &#40;100&#37;&#41;&#46;</p></span><span id="sec0195" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0215">Education</span><p id="par0935" class="elsevierStylePara elsevierViewall">DA management requires clinicians to acquire and maintain specific knowledge and skills&#46; The structure of both general and DA skills-specific continuous professional development courses needs to be clearly defined&#46;<a class="elsevierStyleCrossRefs" href="#bib1090"><span class="elsevierStyleSup">107&#44;108</span></a></p><p id="par0940" class="elsevierStylePara elsevierViewall">The cornerstones of the successful implementation of a DA management algorithm are&#58;<ul class="elsevierStyleList" id="lis0140"><li class="elsevierStyleListItem" id="lsti0435"><span class="elsevierStyleLabel">&#40;a&#41;</span><p id="par0945" class="elsevierStylePara elsevierViewall">An institutional training programme that facilitates the acquisition and maintenance of DA management skills &#40;100&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0440"><span class="elsevierStyleLabel">&#40;b&#41;</span><p id="par0950" class="elsevierStylePara elsevierViewall">Commitment on the part of each anaesthesiologist to develop&#44; maintain and self-evaluate their own competences throughout their professional life &#40;100&#37;&#41;&#46;</p></li></ul></p><p id="par0955" class="elsevierStylePara elsevierViewall">The programme should include the recommendations listed in the algorithm&#44; and should facilitate&#58;<ul class="elsevierStyleList" id="lis0145"><li class="elsevierStyleListItem" id="lsti0445"><span class="elsevierStyleLabel">1&#46;</span><p id="par0960" class="elsevierStylePara elsevierViewall">Acquisition of theoretical and practical knowledge &#40;100&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0450"><span class="elsevierStyleLabel">2&#46;</span><p id="par0965" class="elsevierStylePara elsevierViewall">Development of the technical skills needed to perform all DA management techniques&#58; FM ventilation&#44; use of SADs&#44; tracheal intubation &#40;laryngoscopy&#44; VLS and FOI&#41; and surgical airway &#40;96&#46;6&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib1100"><span class="elsevierStyleSup">109</span></a> These techniques should be taught in stages using mannequins or simulators before they are used in clinical practice&#46;</p></li><li class="elsevierStyleListItem" id="lsti0455"><span class="elsevierStyleLabel">3&#46;</span><p id="par0970" class="elsevierStylePara elsevierViewall">Development of non-technical skills &#40;decision making&#44; leadership&#44; etc&#46;&#41; in the management of critical airway situations &#40;100&#37;&#41;&#46;</p></li></ul></p><p id="par0975" class="elsevierStylePara elsevierViewall">Practical workshops should be organised that allow all team members to acquire technical skills using mannequins and non-technical skills in group simulation exercises &#40;96&#46;6&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib1105"><span class="elsevierStyleSup">110&#44;111</span></a></p><p id="par0980" class="elsevierStylePara elsevierViewall">A schedule of training activities in airway management should be drawn up &#40;100&#37;&#41;&#46;</p></span><span id="sec0200" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0220">Conflicts of interest</span><p id="par0985" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The Airway Division of the Catalan Society of Anaesthesiology&#44; Intensive Care and Pain Management &#40;SCARTD&#41; presents its latest guidelines for the evaluation and management of the difficult airway&#46; This update includes the technical advances and changes observed in clinical practice since publication of the first edition of the guidelines in 2008&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The recommendations were defined by a consensus of experts from the 19 participating hospitals&#44; and were adapted from 5 recently published international guidelines following an in-depth analysis and systematic comparison of their recommendations&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The final document was sent to the members of SCARTD for evaluation&#44; and was reviewed by 11 independent experts&#46; The recommendations&#44; therefore&#44; are supported by the latest scientific evidence and endorsed by professionals in the field&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">This edition develops the definition of the difficult airway&#44; including all airway management techniques&#44; and places emphasis on evaluating and classifying the airway into 3 categories according to the anticipated degree of difficulty and additional safety considerations in order to plan the management strategy&#46; Pre-management planning&#44; in terms of preparing patients and resources and optimising communication and interaction between all professionals involved&#44; plays a pivotal role in all the scenarios addressed&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The guidelines reflect the increased presence of video laryngoscopes and second-generation devices in our setting&#44; and promotes their routine use in intubation and their prompt use in cases of unanticipated difficult airway&#46; They also address the increased use of ultrasound imaging as an aid to evaluation and decision-making&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">New scenarios have also been included&#44; such as the risk of bronchoaspiration and difficult extubation Finally&#44; the document outlines the training and continuing professional development programmes required to guarantee effective and safe implementation of the guidelines&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La Secci&#243;n de V&#237;a A&#233;rea de la Sociedad Catalana de Anestesiolog&#237;a&#44; Reanimaci&#243;n y Terap&#233;utica del Dolor &#40;SCARTD&#41; presenta la actualizaci&#243;n de las recomendaciones para la evaluaci&#243;n y manejo de la v&#237;a a&#233;rea dif&#237;cil con el fin de incorporar los avances t&#233;cnicos y los cambios observados en la pr&#225;ctica cl&#237;nica desde la publicaci&#243;n de la primera edici&#243;n en 2008&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La metodolog&#237;a elegida fue la adaptaci&#243;n de 5 gu&#237;as internacionales recientemente publicadas&#44; cuyo contenido fue previamente analizado y comparado de forma estructurada&#44; y el consenso de expertos de los 19 centros participantes&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">El documento final fue sometido a la valoraci&#243;n de los miembros de la SCARTD y a la revisi&#243;n por parte de 11 expertos independientes&#46; Estas recomendaciones est&#225;n pues sustentadas en la evidencia cient&#237;fica actualmente disponible y en un amplio acuerdo de los profesionales de su &#225;mbito de aplicaci&#243;n&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">En esta edici&#243;n se ampl&#237;a la definici&#243;n de v&#237;a a&#233;rea dif&#237;cil&#44; abarcando todas las t&#233;cnicas de manejo&#44; y se hace mayor hincapi&#233; en la valoraci&#243;n de la v&#237;a a&#233;rea y en la clasificaci&#243;n en 3 categor&#237;as seg&#250;n el potencial grado de dificultad y las consideraciones de seguridad adicionales&#44; que guiar&#225;n la planificaci&#243;n de la estrategia a seguir&#46; La preparaci&#243;n previa al manejo de la v&#237;a a&#233;rea&#44; no solo relativa al paciente y al material&#44; sino tambi&#233;n a la comunicaci&#243;n e interacci&#243;n entre todos los agentes implicados&#44; ocupa un lugar destacado en todos los escenarios incluidos en el presente documento&#46; El texto refleja el aumento progresivo del uso de los videolaringoscopios y de los dispositivos de segunda generaci&#243;n en nuestro entorno y promueve tanto su uso electivo como el uso precoz en la v&#237;a a&#233;rea no prevista&#46; Tambi&#233;n recoge la creciente utilizaci&#243;n de la ecograf&#237;a como herramienta de apoyo en la exploraci&#243;n y toma de decisiones&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Se han abordado nuevos escenarios como el riesgo de broncoaspiraci&#243;n y la extubaci&#243;n considerada dif&#237;cil&#46; Finalmente&#44; se trazan las l&#237;neas maestras de los programas de entrenamiento y formaci&#243;n continuada en v&#237;a a&#233;rea necesarios para garantizar la implementaci&#243;n efectiva y segura de las recomendaciones&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">The list of authors and members of the SCARTD Section of Via a&#232;ria &#40;SEVA&#41; is available in <a class="elsevierStyleCrossRef" href="#sec0210">Annex 1</a>&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; L&#243;pez AM&#44; Belda I&#44; Bermejo S&#44; Parra L&#44; &#193;&#241;ez C&#44; Borr&#224;s R&#44; et al&#46; Recomendaciones para la evaluaci&#243;n y manejo de la v&#237;a a&#233;rea dif&#237;cil prevista y no prevista de la <span class="elsevierStyleItalic">Societat Catalana d&#8217;Anestesiologia&#44; Reanimaci&#243; i Terap&#232;utica del Dolor</span>&#44; basadas en la adaptaci&#243;n de gu&#237;as de pr&#225;ctica cl&#237;nica y consenso de expertos&#46; Rev Esp Anestesiol Reanim&#46; 2020&#59;67&#58;325&#8211;342&#46;</p>"
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            "apendice" => "<p id="par1000" class="elsevierStylePara elsevierViewall">Pere Esquius&#44; Jos&#233; Huesca Ranea&#44; Jordi Llorca&#44; Francesca Reguant &#40;Althaia&#46; Xarxa Assitencial Universitaria de Manresa&#41;&#59; Silvia Bermejo&#44; Jes&#250;s Carazo&#44; Saida Sanchez &#40;Consorci Mar Parc de Salut de Barcelona&#41;&#59; Carmen Martin &#40;Consorci Sanitari de Terrassa&#41;&#59; Montse Bayo&#44; Olaia G&#252;enaga&#44; Lourdes Parra&#44; Pilar Santos&#44; Meritxell Serra&#44; Vanesa Tejedor&#44; Ana Tejedor &#40;Consorci Sanitari Integral&#41;&#59; M&#170; Lluisa Mart&#237;nez Villar &#40;Fundaci&#243; Hospital-Asil de Granollers&#41;&#59; Daniel Hernando&#44; Sergi Sabat&#233; &#40;Fundaci&#243; Puigvert &#40;IUNA&#41;&#41;&#59; Isabel Belda&#44; Raquel Berg&#233;&#44; M&#170; Jos&#233; Carretero&#44; Paola Hurtado&#44; Ana L&#243;pez&#44; Marta Magaldi&#44; Julia Mart&#237;nez&#44; Ana Plaza&#44; Eva Rivas&#44; Ana Ruiz&#44; Beatriz Tena&#44; Ricard Valero &#40;Hospital Cl&#237;nic de Barcelona&#41;&#59; Teresa Aberasturi &#40;Hospital Comarcal de l&#8217;Alt Pened&#232;s&#41;&#59; Josep M&#170; Soto &#40;Hospital d&#8217; Igualada&#59; SEM&#41;&#59; Josep M&#170; Gil&#44; M&#170;Angels Gil de Bernab&#233;&#44; Ignacio Hinojal &#40;Hospital de la Santa Creu i Sant Pau&#41;&#59; Josep Genis &#40;Hospital d&#8217;Igualada&#41;&#59; Mar&#237;a Escobar &#40;Hospital de Sta&#46; Caterina&#59; Girona&#41;&#59; Lluis Martinez &#40;Hospital Municipal de Badalona&#41;&#59; Silvia Serrano &#40;Hospital Sant Joan de D&#233;u Barcelona&#41;&#59; Maria Farr&#233; &#40;Hospital Universitari Arnau de Vilanova&#41;&#59; Enric Boza&#44; M Jesus Castro Serrano&#44; Maylin Koo Gomez&#44; M Carmen Martin Castro&#44; Victor Mayoral&#44; Isabel Ornaque&#44; Albert Pi&#44; Rosa Villalonga &#40;Hospital Universitari de Bellvitge&#41;&#59; Alfred Mu&#241;oz &#40;Hospital Universitari de Girona Doctor Josep Trueta&#41;&#59; Crist&#242;bal &#193;&#241;ez&#44; Natalia Aragones&#44; Luis Hernando Carrillo&#44; Roc&#237;o Peri&#241;&#225;n &#40;Hospital Universitari de Tarragona Joan XXIII&#41;&#59; Teresa Planella&#44; Julio Roza &#40;Hospital Universitari de Vic&#41;&#59; Rosa Borr&#224;s&#44; Nuria Carbonell&#44; Enric Moncl&#250;s&#44; Elena Sanchez &#40;Hospital Universitari Dexeus&#41;&#59; Carla Costa&#44; Teresa Franco&#44; Eva Mass&#243;&#44; Pere Vila &#40;Hospital Universitari Germans Trias i Pujol&#41;&#59;Carme Colilles&#44; Esteban Garc&#237;a&#44; Alberto Izquierdo&#44; Silvia L&#243;pez&#44; Jordi P&#233;rez&#44; Laura Ricol &#40;Hospital Universitari Parc Taul&#237;&#41;&#59; Dolors del Pozo&#44; Reis Drudis&#44; Gregorio Marco &#40;Hospital Universitari Santa Maria de Lleida&#41;&#59; Erika Schmucker&#44; Ivan Villaverde&#44; Eva Andreu &#40;Hospital Universitari Vall d&#8217;Hebr&#243;&#41;&#59; Anna Casanovas &#40;Parc Sanitari San Joan de Deu de Sant Boi&#41;&#59; Josep Maria Serra &#40;Pius Hospital de Valls&#41;&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Poster of SCARTD recommendations for airway management&#46;</p>"
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Flyer summarising the SCARTD recommendations&#46;</p>"
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Recommended position for airway management&#44; combining chest elevation&#44; slight neck flexion and head extension&#46; &#40;B&#41; Pre-oxygenation is recommended in patients who require optimised airway management&#44; combining the previous position and oxygen delivery through nasal cannula and a properly sealed face mask&#46;</p>"
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Airway management flowchart according to the anticipated degree of difficulty&#46;</p>"
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">BMI&#58; body mass index&#59; DA&#58; difficult airway&#59; OSAS&#58; obstructive sleep apnoea syndrome&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Mallampati III&#8211;IV &#40;94&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Protruding teeth &#40;97&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Limited mandibular thrust &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Edentation &#40;80&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Mandibular pathology &#40;retrognathia&#44; etc&#46;&#41; &#40;97&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Symptoms&#58; dyspnoea&#44; dysphagia &#40;90&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Interdental distance 3&#8211;4<span class="elsevierStyleHsp" style=""></span>cm&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Beard &#40;90&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Thyromental distance &#60;6<span class="elsevierStyleHsp" style=""></span>cm &#40;97&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">BMI &#62;40&nbsp;\t\t\t\t\t\t\n
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evaluaci&#243;n y manejo de la v&#237;a a&#233;rea dif&#237;cil prevista y no prevista&#58; Adopci&#243;n de gu&#237;as de pr&#225;ctica"
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                    0 => array:2 [
                      "doi" => "10.1016/s0034-9356(08)70653-4"
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              "etiqueta" => "3"
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                0 => array:1 [
                  "referenciaCompleta" => "Appraisal of guidelines for research &#38; evaluation II&#46; Available from&#58; <a target="_blank" href="https://www.agreetrust.org/wp-content/uploads/2013/10/AGREE-II-Users-Manual-and-23-item-Instrument_2009_UPDATE_2013.pdf">https&#58;&#47;&#47;www&#46;agreetrust&#46;org&#47;wp-content&#47;uploads&#47;2013&#47;10&#47;AGREE-II-Users-Manual-and-23-item-Instrument&#95;2009&#95;UPDATE&#95;2013&#46;pdf</a> &#91;accessed October 2019&#93;&#46;"
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                  "referenciaCompleta" => "Guideline International Network&#46; Working Groups&#47;Adaptation&#46; Available from&#58; <a target="_blank" href="http://g-i-n.net/working-groups/adaptation">http&#58;&#47;&#47;g-i-n&#46;net&#47;working-groups&#47;adaptation</a> &#91;accessed October 2019&#93;&#46;"
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                      "titulo" => "Consensus development methods&#58; a review of best practice in creating clinical guidelines"
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                      "doi" => "10.1177/135581969900400410"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The difficult airway with recommendations for management &#8211; Part 1 &#8211; Difficult tracheal intubation encountered in an unconscious&#47;induced patient"
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