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What’s Your Plan?

part of the anatomically difficult airway learning space
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What will you do if your initial plan to intubate fails? First, you must flip that mental switch from intubation to prioritizing oxygenation. Then, you need to have a plan.

Key Features of the DAS Difficult Airway Algorithm

Core Principles

The Difficult Airway Society (DAS) 2015 Guidelines provide a structured approach to managing the unanticipated difficult airway in adults undergoing general anesthesia. These guidelines emphasize a stepwise approach, awareness of human factors, and the importance of a structured, team-based response to difficult airways.

  • Emphasis on optimizing first-attempt success
  • Recognition of failed attempts early to prevent airway trauma
  • A structured four-step approach
  • Prioritization of oxygenation over intubation
  • Use of a “Can’t Intubate, Can’t Oxygenate” (CICO) rescue strategy

We recommend visiting the DAS website and adding them to your learning network.

A Four-Step Approach

Step 1: Plan A – Optimized Laryngoscopy & Intubation Attempts

  • Maximum three intubation attempts (preferably by the most experienced operator early)
  • Use of bougie, video laryngoscopy (VL), or alternative laryngoscope blades if initial attempt fails
  • Maintenance of oxygenation throughout attempts
  • Declare failure early (after three attempts) and proceed to Plan B

Step 2: Plan B – Use of a Supraglottic Airway Device (SAD) for Rescue Oxygenation

  • If intubation fails, the focus shifts to oxygenation over securing the airway
  • Insertion of a 2nd generation SAD (e.g., i-gel, LMA Supreme)
  • If ventilation is successful with a SAD, options include:
  • Wake the patient up if feasible
  • Continue anesthesia and surgery with SAD
  • Attempt intubation via fiberoptic or video laryngoscopy through the SAD
  • If SAD ventilation fails, → Proceed to Plan C

Step 3: Plan C – Face Mask Ventilation & Awakening the Patient

  • If an SAD fails, attempt facemask ventilation
  • If ventilation is possible, the patient should be woken up if feasible
  • Consideration of reversal agents (e.g., sugammadex if a neuromuscular blockade was used)
  • If face mask ventilation fails, → Proceed to Plan D

Step 4: Plan D – Can’t Intubate, Can’t Oxygenate (CICO) Emergency Front-of-Neck Access (FONA)

  • Recognition of CICO early is crucial
  • Immediate transition to a surgical airway technique
  • Scalpel-bougie-tube technique (preferred over needle cricothyroidotomy due to reliability)
  • The stepwise approach:
  • Scalpel → Incise cricothyroid membrane
  • Bougie → Insert into the trachea
  • Tube → Railroading a tracheal tube over the bougie
  • This is a time-critical step and should not be delayed

Additional Key Features

Human Factors & Non-Technical Skills

  • Communication: Declaring failure early and team coordination
  • Crisis resource management (CRM): Assigning clear roles within the team
  • Cognitive Aids: Use of airway checklists and pre-determined difficult airway plans

Airway Equipment Recommendations

  • Use of video laryngoscopy (VL) early
  • 2nd generation supraglottic airway devices
  • Standardized front-of-neck access (FONA) technique using a scalpel-bougie-tube approach

Situational Awareness & Decision-Making

  • Recognizing the importance of early failure declaration
  • Prioritizing oxygenation over securing the airway
  • Considering waking up the patient if feasible

Summary of Key Changes from Prior DAS Guidelines

  • Emphasis is on oxygenation rather than intubation
  • Video laryngoscopy is recommended early
  • CICO rescue mandates a scalpel-bougie approach (instead of needle cricothyroidotomy)
  • Introduction of second-generation SADs for improved ventilation
  • Three failed attempts limit before moving to the next step

Bottom Line

The DAS 2015 Difficult Airway Algorithm provides a structured, stepwise approach to managing unexpected difficult intubation. It emphasizes early recognition of failure, oxygenation prioritization, and human factor management while advocating modern airway devices and a standardized front-of-neck access (FONA) technique. The focus on patient safety and team dynamics makes it an essential guideline for all airway management providers.

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Curated Apps

app resource

The Airway Management Academy recently created a great app full of clinical and educational tools for airway assessment. We invite you to check it out. We have no financial stake in this (we just thought you should know about it).

Airway Triage App

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