2025 Difficult Airway Guidelines vs. Older Guidelines

Comparative Summary:  2025 Airway Guidelines 

Key Highlights from DAS 2025 Difficult Airway Guidelines

🔹 Guideline Evolution

• Focus shifts from managing failure (2015) to maximizing first-attempt success and maintaining oxygenation throughout.

• Incorporates evidence from >1200 new studies since 2012.

• Greater emphasis on human factors, teamwork, and peroxygenation.
  
  
  

🔹 Airway Assessment

• Airway assessment must include history, exam, and relevant investigations.

• Should identify both anatomical and physiological difficulties.

• Early identification of cricothyroid membrane (preferably with ultrasound).

• Recommendation: Perform assessment early and act upon findings.
  
  
  

🔹 Planning & Strategy

• Structured plans (A–D) should be preformulated.

• Awake tracheal intubation (ATI) considered if difficulty anticipated in A, B, C, or D.

• Communication with assistant and team briefing mandatory.

• Out-of-hours airway management identified as higher risk.
  
  
  

🔹 Monitoring

• Continuous waveform capnography is mandatory throughout.

• Audible SpO₂ tones must be on before induction.

• Quantitative neuromuscular monitoring to confirm block.

• Use a timer to prevent task fixation.
  
  
  

🔹 Drugs & Neuromuscular Block

• Routine use of neuromuscular blockers recommended.

• Rocuronium increasingly preferred (reversal with sugammadex available).

• Sugammadex not reliable in “cannot intubate, cannot oxygenate (CICO)” scenarios.

🔹 Peroxygenation

• Introduces concept of peroxygenation (pre-, apnoeic, and ongoing oxygenation).

• Head-up position + positive pressure improves safe apnoea time.

• HFNO (High-Flow Nasal Oxygen) preferred for apnoeic oxygenation.

• Example: Continue nasal oxygen during laryngoscopy.
  
  
  

🔹 Plan A: Tracheal Intubation

• Videolaryngoscopy now first-line.

• 3+1 attempt rule retained; maximum of 3 + final by senior.

• Two-point confirmation (visual + waveform capnography).

• Example: Use bougie or stylet with hyperangulated blade.
  
  
  

🔹 Plan B: Supraglottic Airway Device (SAD)

• Second-generation SADs recommended for rescue ventilation.

• Maximum three insertion attempts.

• After success: “Stop, Think, Communicate.”

• Default action: wake patient up unless surgery is essential.

• Example: Avoid blind intubation through SAD.
  
  
  

🔹 Plan C: Final Facemask Ventilation

• One final attempt before eFONA.

• Use full neuromuscular block, two-person technique, adjuncts.

• If ventilation fails → declare CICO → move to Plan D.
  
  
  

🔹 Plan D: Emergency Front-of-Neck Airway (eFONA)

• eFONA must be performed if CICO confirmed.

• Default approach: Vertical incision for all (palpable or not).

• Full paralysis mandatory before performing eFONA.

• Emphasis on psychological debrief and support post-event.

🔹 Rapid Sequence Induction (RSI)

• Re-evaluates cricoid pressure: use if high aspiration risk, remove if view poor.

• Head-up position ≥30° and HFNO recommended.

• Cricoid pressure must only be applied by trained assistant.
  
  
  

🔹 Physiologically Difficult Airway

• New domain in 2025 version.

• Identifies risk of hemodynamic collapse or hypoxaemia during induction.

• Team member assigned specifically for hemodynamic monitoring.
  
  
  

🔹 Obesity

• Use head-up ≥30°, consider awake intubation, and HFNO.

• Early help and SAD insertion emphasized.
  
  
  

🔹 Human Factors & Team Dynamics

• Introduces “priming” (prepare for eFONA early).

• “Transitioning” (move promptly between A–D to avoid fixation).

• Designates assistant role: monitors CO₂, triggers transitions, calls for help.
  
  
  

🔹 Point-of-Care Ultrasound

• Encouraged for airway assessment, cricothyroid localization, and aspiration risk (gastric scan).

• Still considered aspirational pending training standardization.
  
  
  

🔹 Documentation & Education

• Mandates clear, structured airway documentation.

• Difficult airway cases must be logged, communicated, and coded.

• Shared institutional and individual responsibility for ongoing training.