The ASA Difficult Airway Algorithm: Is It Time to Include Video Laryngoscopy and Discourage Blind and Multiple Intubation Attempts in the Nonemergency Pathway? : Anesthesia & Analgesia

Secondary Logo

Journal Logo

Letters to the Editor: Letters & Announcements

The ASA Difficult Airway Algorithm: Is It Time to Include Video Laryngoscopy and Discourage Blind and Multiple Intubation Attempts in the Nonemergency Pathway?

Saxena, Shashank MD

Editor(s): Saidman, Lawrence

Author Information
Anesthesia & Analgesia 108(3):p 1052, March 2009. | DOI: 10.1213/ane.0b013e31819341e4
  • Free

To the Editor:

The ASA difficult airway algorithm was revised in 2003 adopting the laryngeal mask airway when ventilation via a face mask fails after the initial attempt to intubate the trachea.1

It is generally accepted that multiple attempts at laryngoscopy can convert a “cannot intubate but able to ventilate” situation to an “unable to intubate and ventilate” situation due to airway trauma and subsequent airway swelling.2–5 Multiple attempts can cause airway bleeding which may make even the video guided systems difficult to use.

With the current ASA difficult airway algorithm, it is difficult to explain alternative approaches to tracheal intubation in the nonemergency pathway that include the light wand, blind oral/nasal intubation, and use of different laryngoscope blades.1

Most anesthesiologists can identify a difficult intubation situation on the first laryngoscopy. In our operating room practice if the first conventional laryngoscopy attempt reveals an unanticipated difficult intubation and we are able to maintain good ventilation via a face mask, we use a Glidescope or a Storz Video laryngoscope as it gives us a better view of the vocal cords.6,7 This avoids the use of multiple blades, multiple attempts or a blind intubation which can all cause airway trauma.

With adequate training in use of the Video Laryngoscopes, they have proven to be fast, atraumatic modalities for anticipated difficult intubation in our operating room practice settings and are our choices in the nonemergency pathway for an unanticipated difficult intubation.

Shashank Saxena, MD

Veterans Affairs Pittsburgh Health Care System

Pittsburgh, Pennsylvania

[email protected]


1.American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of difficult airway. Anesthesiology 2003;98:1269–77
2.Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg 2004;99:607–13
3.Domino KB, Posner KL, Caplan RA, Cheney FW. Airway injury during anesthesia: a closed claims analysis. Anesthesiology 1999;91:1703–11
4.Thierbach AR, Lipp M. Airway management in trauma patients. Anesthesiol Clin North America 1999;71:63–81
5.Peterson GN. Management of the difficult airway: a closed claims analysis. Anesthesiology 2005;103:33–9
6.Cooper RM, Pacey JA, Bishop MJ, McCluskey SA. Early clinical experience with a new video laryngoscope (Glidescope) in 728 patients. Can J Anaesth 2005;52:191–8
7.Kaplan MB, Hagberg CA, Ward DS, Brambrink A, Chhibber AK, Heidegger T, Lozada L, Ovassapian A, Parsons D, Ramsay J, Wilhelm W, Zwissler B, Gerig HJ, Hofstetter C, Karan S, Kreisler N, Pousman RM, Thierbach A, Wrobel M, Berci G. Comparison of direct and video assisted views of larynx during routine intubation. J Clin Anesth 2006;18:357–62
© 2009 International Anesthesia Research Society