Insight

There is no standard definition for a difficult airway. The American Society of Anesthesiologists defines a difficult airway as existing when “a conventionally trained anesthesiologist experiences difficulty with facemask ventilation of the upper airway, difficulty with tracheal intubation, or both.”[1]

This definition is clear and descriptive but lacks utility for the “conventionally trained” clinician in question. It can also also be divisive. An airway that may be difficult for one clinician might be routine for another. This doesn’t make one clinician better than another, it simply underscores the diverse factors that play a role in making a particular airway difficult at that moment for the clinician involved.

It also promotes the misperception that the antecedent cause of a difficult airway should be thought of in purely anatomic terms (think of a swollen tongue or a laryngeal mass) where expected or unexpected anatomic challenges lead to difficulty.

Anatomic difficulty and developing your ability to predict or manage such problems is only one aspect of what can contribute to a difficult airway. Abnormal or critically ill physiology can add another layer of difficulty. Specific clinical situations, unfamiliar environments, lack of resources, and inexperienced teams, can also make an airway difficult.

Some have argued that we should eliminate the term difficult airway altogether and think instead of all the factors (anatomic, physiologic, situational) that might make airway management in a particular case more or less complex. Either way, when thinking about your concept of a difficult airway, the goal should be to expand your understanding of what “difficult” is.

The bottom line: the term “difficult airway” should be useful beyond describing a situation where you can’t do something. Instead, it should help you build a conceptual framework and effective strategies to help you address and overcome any difficulty.

– Jonathan St George MD

Dive Deeper

Now that you understand this term, check out the link below to see them in a clinical context with one of our PAC learning spaces. Start with the Anatomically Difficult Airway learning space.

References

• 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway – https://doi.org/10.1097/ALN.0000000000004002
• The myth of the difficult airway: airway management revisited – https://doi.org/10.1111/anae.12989