Let’s Ditch the ASA Difficult Airway Algorithm for Once and All!

Do you ever feel the same way as the picture shown above with ASA algorithm? I definitely do. Every time I look at it when I am not under stress, I feel overwhelmed. I ask myself how I can use this as a tool when I am having a difficult airway situation. Dr. Larson who was an professor at Stanford University once said that “there is no scientific evidence that anesthesia is safer because of the ASA Difficult Airway Algorithm. While an interesting educational document, I question the daily clinical value of this algorithm, even in its most recent form (Anesthesiology 2013; 118:251-70). The ASA Difficult Airway Algorithm was developed by committee and has all the problems that result when done that way.  It is complex, diffuse, multi-dimensional, and all-encompassing such that it is not an instrument that one can easily adopt and practice in the clinical setting.

Human factors issues were considered to have contributed to adverse outcomes in 40% of the instances reported; however, a more in-depth analysis of a subset of patients identified human factor influences in every instance. During a crisis, it is common to be presented with more information than can be processed. This overload information delay the decision-making and can cause clinicians to lose sight of the big picture. If anyone has watched the well-known airway disaster case of Elaine Bromley, you can clearly see the the clinicians lost sight of the big picture and became fixated on a particular task. The other pitfall the practitioner may run into is over-analysing the difficult airway options with the view to finding the ideal management strategy. As a consequence, rather than selecting an option and dealing with subsequent issues arising from it, no action is taken. The practitioner fails to respond in the time frame because of the fear of making a wrong choice, leading to errors of omission rather of commission. Hence, the difficult airway algorithm should be easy to follow and understand so it can be used as a crisis checklist. There are a few different airway algorithms out there, I particularly like the DAS airway algorithm.


In addition, cognitive aid is extremely helpful in crisis situation. The vortex approach is simple and straightforward. VortexCognitiveAid.png

Key points:

  • Preparation and planning are key to good outcomes.
  • Lack of oxygenation kills rather than failure of intubation.
  • Waking the patient is always an option
  • During critical events
  • Avoid fixation error.
  • Attempt alternatives
  • Not lose sense of time.
  • Use cognitive aids to support decision-making during difficult airway situation.
  • When faced with cannot intubate, cannot ventilate scenario, decision to secure surgical airway is life-saving and hesitation can be costly

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