A Cogntive Upgrade a Decade in the Making

The 2025 Difficult Airway Society (DAS) guidelines for the management of unanticipated difficult tracheal intubation in adults have been a decade in the making, and they were worth the wait. This new iteration corrects many of the limitations of the 2015 version, shifting the focus from recovery after failure to optimization for success.

The update brings sharper attention to human factors, the physiologically complex airway, and the sobering truth that not every patient can simply be “woken up” when things go wrong. It feels more grounded in the realities of modern airway management and more inclusive of the diverse specialties and clinical environments that exist beyond anesthesiology or the operating theater.

It’s not perfect, but it is a major improvement.

There’s a lot to unpack, and we won’t cover every detail here. Instead, this first glance offers a high-level overview of the most significant updates. In the weeks ahead, we’ll take deeper dives into specific recommendations within each section, exploring how these guidelines play out across different disciplines and contexts.

At a Glance – The 2025 DAS Airway Guidelines

From Managing Failure to Optimizing Success

The 2015 guidelines gave us a clear four-step structure (Plans A, B, C, and D) and emphasized oxygenation over repeated attempts at intubation. But they were written for a world before routine video laryngoscopy, before high-flow nasal oxygen (HFNO) was common, and before we fully appreciated how physiology and human performance determine outcomes as much as anatomy does.

The 2025 guidelines retain the same A–B–C–D structure but redefine its purpose.

The framework hasn’t changed — the philosophy has.
The focus is no longer on “what to do when things fail,” but on how to set up for success from the first attempt, maintaining oxygenation and situational awareness throughout.

The Core Algorithm: A–B–C–D

Plan A: Intubation — Get It Right the First Time

Plan A is no longer about a series of “tries.” It’s about deliberate success: optimizing physiology, positioning, and teamwork before the blade ever enters the mouth.

Video laryngoscopy is now the default, not the backup. Continuous oxygen delivery via a nasal cannula or HFNO is expected throughout all phases, not just during preoxygenation. Point-of-care ultrasound (POCUS) is endorsed for airway and gastric assessment, reflecting how technology has become an extension of judgment.

And yet, the old “3 + 1” rule persists.

Don’t be fooled by the “3 + 1.”
It’s not an invitation to take three failed attempts before moving through the algorithm, it’s simply a hard upper limit determined by likelihood of success.

The new DAS document makes clear: this is an upper limit, not a quota. The intent is to prevent provide a hard stop before you must move on. It is not an invitation to justify repeated failure in the face of worsening hypoxia.

Personally, I’d like to see the official infographic go further. The subtle vertical “Oxygenate” bar that runs down the algorithm should be impossible to miss — bold red letters stating “Prioritize Oxygenation.” (over any additional attempts at intubation). Not everyone reads the full text, but everyone sees the picture.

Plan B: Supraglottic Oxygenation — Not Just Rescue

In 2015, Plan B was to pause, oxygenate, and think about waking the patient. The 2025 update recognizes reality: some patients can’t be woken up.

Plan B also now reframes the supraglottic airway as a tool for ongoing oxygenation and strategic pause, not a symbol of failure. Whether it’s used for fiber-optic intubation, to maintain oxygenation while regrouping, or to support continued ventilation in critical illness, the emphasis is the same — oxygen first, decisions second.

Plan C: Face-Mask Ventilation — Buying Time

The jump from Plan C (final facemask attempt) to Plan D (eFONA) is still the soft spot in the 2025 update. The “stop, think, communicate” pause is fine only if oxygenation is clearly stable. In the patient who has already failed intubation and supraglottic rescue, sustained BVM is unlikely. Treat Plan C as a trigger for Plan D unless there’s an obvious, compelling reason not to.

The authors write that “Clinicians should be aware that rapid progression to Plan D might be necessary at this point.” Personally, I would like to see this be a little clearer.

“Wake the patient” is rarely real in hypoxemic, acidotic, or unstable patients — it’s a mirage. Framing Plan C as another reflection point invites delay when seconds matter. The diagram’s “OXYGENATE” sidebar implies time you no longer have. This should always be a deliberately coordinated, parallel process.

• If you’re in Plan C, prepare for eFONA now.
• Make the pause an active one.
• Unless there is a clear reason not to (and there usually isn’t), perform eFONA.

Plan D: eFONA — Simpler, Earlier, and Less Dogmatic

The scalpel–bougie–tube remains the recommended technique, but the debate about incision type is gone. A vertical incision is the way to go. The priority now is decisiveness and practice. Train in one technique. Know it. Use it early.

The new guidance also strips away the comforting fiction that “wake up” is always an option. In many physiologically difficult cases, it isn’t. The recommendation now is to act earlier and avoid delay — a significant cultural shift from the 2015 text.

The Broader Shifts In 2025

1. Human Factors Front and Center

Human factors are no longer an appendix, they run through the entire document. Shared mental models, leadership, and “stop-and-think” prompts are explicitly built into every plan. The guidelines now read more like a practical guide to cognitive performance under pressure.

2. The Physiologically Difficult Airway

For the first time, DAS formally addresses the airway of the critically ill — hypoxemic, acidotic, or hypotensive patients. Preparation and optimization now extend beyond airway geometry to include circulation, oxygen reserve, and post-intubation stability.

3. Continuous Oxygenation Becomes Standard

The guidelines establish ongoing oxygenation as the central organizing principle. The text makes clear that oxygen flow should never stop — not between attempts, not during pauses, not during transitions.

4. Teamwork and Institutional Accountability

The 2025 update places responsibility not only on individuals but on institutions. Simulation, debriefing, and airway governance are now defined as organizational duties — embedding airway safety into culture, not just competence.

Final Thoughts

The 2025 DAS guidelines preserve the framework that has served us for the last ten years, but redefine its philosophy. It’s no longer about rescue from failure; it’s about engineering success from the start.

By including more emphasis on human factors, physiology, and continuous oxygenation, DAS has transformed a procedural algorithm into a cognitive one — a model not just for what we do, but how we think. In my opinion this transformation is a work in progress and could go further.

If there’s a single lesson that rises above the rest, it’s this:

Oxygenation is the mission. Everything else is a tactic.

Guidelines will always lag behind innovation. But when they finally catch up, as these have, they give us something better than novelty — they give us clarity.

References:
Ahmad I, El-Boghdadly K, Iliff H, et al. Difficult Airway Society 2025 Guidelines for Management of Unanticipated Difficult Tracheal Intubation in Adults. Br J Anaesth. 2025.
Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 Guidelines. Br J Anaesth. 2015; 115: 827–848.