Difficult Airway Assessment
Gestalt over/previously using (LEMON)
Look, Eval. 3-3-2, Mallampati, Obstruction or Obesity (should also be obstructive for sleep apnea), Neck mobility
Obstructive Sleep Apnea/Snoring
Obesity?
Prior Difficult Airway
System for your Hospital
Nasoendoscopy
MACOCHA Score [10.1164/rccm.201210-1851OC]
0-12
Definition of abbreviation: MACOCHA =
Mallampati score III or IV (5)
Apnea syndrome (obstructive) (2)
Cervical spine limitation (1)
Opening mouth <3 cm (1)
Coma (1)
Hypoxia (1) (should be hypoxemia)
Anesthesiologist=nontrained (1), which should be experienced vs. not
Will This Patient Be Difficult to Intubate?: The Rational Clinical Examination Systematic Review. JAMA. 2019 Feb 5;321(5):493-503. [doi: 10.1001/jama.2018.21413.]
Are you Resus-Ready??
Physiologically Difficult Airway
HOP(PER)
Hypotension
Oxygenation
pH
Don’t Paralyze–Hemodynamically Neutral
PE
Pinhole Valve
Pericardial Tamponade
Right Heart Failure
Always check an echo on sick patients (look for collapsing IVC as well)
Always have push-dose pressors drawn up for sick patients
Prevention of Hypotension
Plan
DAS has 3+1; I disagree with this, it should be 3 and done
See STC Failed Airway Algo-EMCrit Remix
Positioning
EMCrit 226 – Airway Update – Bougie and Positioning
Preoxygenation and Oxygenation Optimization (POO)
In addition to PREOXI, 2 other RCTs demonstrated benefit of NIPPV [10.1056/NEJMoa2313680 & 10.1016/j.bja.2017.11.067] in the 2nd one, benefit was only seen in patients requiring NIPPV before intubation
High-Flow?
Low-Tech
Analog vs. Digital
PEEP 10 [10.1186/s12871-025-03352-z]
Low-Tech Set-up [10.15441/ceem.25.107]
Bag During Apnea
PreVENT and PREOXI
Apneic Oxygenation
Induction Meds
RSI Trial
RSI vs. DSI
Meta Analysis before RSI Trial showed trend towards hypotension [https://doi.org/10.15441/ceem.24.363]
Paralytics
What Layryngoscope?
Standard Geometry Video with a bougie
BEAM vs. BOUGIE
USB Bougie by Levitan
Hyperangulated Geometry Video
See: EMCrit 390 – Hyperangulated Video Laryngoscopy (HAVL)
Cricoid Pressure
For some reason, Anesthesiologists are renewing this debate???
From DAS (there first sentence is belied by the rest of the paragraph???)
These concerns are not founded in robust contemporary evidence, with unreliable data on the safety and efficacy of cricoid force.183 There is increasing evidence that localisation of the cricoid cartilage and nearby anatomical structures is likely inaccurate unless performed with ultrasound.50,51,184, 185, 186 Furthermore, the correct application of force is variable unless the operator undergoes regular training.187,188 First-attempt and overall intubation success with videolaryngoscopy is not hampered by the use of cricoid force,189 though it could reduce the ease of tracheal tube advancement.190 Finally, despite high-quality data, there is no evidence that cricoid force either increases the risk of failed tracheal intubation or reduces the risk of pulmonary aspiration.189,191 Therefore, given the dearth of definitive evidence, pragmatic recommendations are required. In patients at particularly high risk of pulmonary aspiration, cricoid force should be used. If inserting a SAD in Plan B, or difficulty with laryngoscopy or tracheal intubation is encountered, or active vomiting occurs, cricoid force should be removed.
Fantastic Review Paper [Anesthesiology 2025;143:1090]
ETT Size?
Tube Confirmation
2 Point Check
Visual Confirmation: Tube visualized on video passing through cords
ETCO2 > for at least 7 breaths with consistent levels
eFONA
DAS still using bad technique
PUMA has best description of Good Technique
Papers Used in Brainstorming this Post
-
DeMasi, Stephanie C., Jonathan D. Casey, and Matthew W. Semler. “Evidence-Based Emergency Tracheal Intubation.” American Journal of Respiratory and Critical Care Medicine 211, no. 7 (n.d.): 1156–64. https://doi.org/10.1164/rccm.202411-2165CI.
- “Difficult Airway Society 2025 Guidelines for Management of Unanticipated Difficult Tracheal Intubation in Adults.” British Journal of Anaesthesia 136, no. 1 (2026): 283–307. https://doi.org/10.1016/j.bja.2025.10.006.
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Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
