The difficult airway

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  • ASA Difficult Airway Algorithm does not necessary apply to the ED since the patient can always be awakened and case cancelled



Difficult Intubation

Advanced Airway Adjuncts Chart

Airway Adjunct Examples Pros Cons
Endotracheal tube introducer Gum elastic bougie
  • Higher first pass success when used with direct laryngscope vs. styletted ET tube regardless of whether difficult airway was expected or not[1]
  • Can pass blind and confirm tracheal placement with tracheal clicks and hold-up sign
  • Success rates likely depend on operator familiarity with device
Lighted optical stylets
  • High success rate - especially good for trauma, c-spine precautions
  • Use for both reg and nasotrach
  • Lower complication rate
  • Limited by fogging, secretion, recognition of anatomy, cost, and rare provider experience
Supraglottic airway LMA
  • Easy to place
  • Can be placed quickly
  • Does not protect against aspiration
Esophogeal obturator Combitube
  • Good for nurses and paramedics with limited intubation skill
  • Indicated if difficult airway predicted: cannot see glottis with laryngoscope
  • Reduced risk for aspiration compared to face mask or LMA *Can maintain spinal immobilization
  • Large size predisposes to esophogeal dilatation and laceration as a complication
Percutaneous transtracheal ventilation
  • Prefered over cricothyrotomy in children up to age 10-12
  • Oxygenates well
  • Can use for 30-45 min
  • Can retain CO2
  • May cause pneumothorax or barotrauma

Intubation Options

Intubation Type Pros Cons
Awake intubation
Nasal intubation
  • Lower success rate
  • Higher complication rate (e.g. bleeding, emesis, and airway trauma)
  • Do not attempt in patients with posterior pharyngeal swelling such as in angioedema
Retrograde intubation
  • Need time to set up
  • Risk hematoma, pneumothorax
Fiberoptic bronchoscopic intubation
  • Takes time to set up
  • Limited by secretions, bleeding, poor suction,
Digital intubation

Surgical Airways

A surgical airway should always be the last step in patients with failure to oxygen and ventilate with BVM and inability to intubate

See Also

Airway Pages


  1. Driver, B. E., Prekker, M. E., Klein, L. R., Reardon, R. F., Miner, J. R., Fagerstrom, E. T., … Cole, J. B. (2018). Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA: The Journal of the American Medical Association, 319(21), 2179–2189.