• Users Online: 573
  • Print this page
  • Email this page

 Table of Contents    
Year : 2015  |  Volume : 59  |  Issue : 12  |  Page : 801-806  

Current practice of difficult airway management: A survey

1 Department of Anaesthesia, BMH, Calicut, Kerala, India
2 Department of Anaesthesia, Government Medical College, Calicut, Kerala, India

Date of Web Publication11-Dec-2015

Correspondence Address:
M C Rajesh
Department of Anaesthesia, BMH, Calicut - 673 017, Kerala
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5049.171571

Rights and Permissions

Background and Aims: Difficult airway (DA) management depends on both training and actual usage of the various approaches in the event of difficulty. The aim of the study was to assess how well the anaesthesiologists are equipped to deal with DA situations. The current practice preference of DA management was also assessed. Methods: A questionnaire was distributed in a continuing medical education (CME) programme dedicated to DA and responses were noted and analysed, using Statistical Package for Social Sciences (SPSS) version 18. Results: The response rate was 73%. Airway assessment was performed by majority. Sixty eight percent consultants and 47% residents were well aware of the American Society of Anesthesiologists' DA algorithm. 67% consultants and 65% residents attended at least one CME on DA in the previous 5 years. There was an overall deficiency of video laryngoscopes, retrograde intubation and cricothyrotomy sets. Most of the respondents were comfortable in using supraglottic airway devices (SGADs). In anticipated DA, the preferred choice of management for junior doctors was attempting conventional method once and awake fibreoptic bronchoscopy (FOB) for the experienced. In unanticipated DA, most of the residents and consultants opted for SGAD. Extubation strategy was similar for both. Thirty four percent of respondents experienced a 'cannot intubate-cannot ventilate' situation at least once. Conclusion: Our survey showed that most respondents performed routine pre-operative airway assessment. A good armamentarium of airway gadgets should be made available in hospitals. Further training in techniques like video laryngoscopy, FOB or cricothyrotomy are essential.

Keywords: Airway management, difficult airway, survey

How to cite this article:
Rajesh M C, Suvarna K, Indu S, Mohammed T, Krishnadas A, Pavithran P. Current practice of difficult airway management: A survey. Indian J Anaesth 2015;59:801-6

How to cite this URL:
Rajesh M C, Suvarna K, Indu S, Mohammed T, Krishnadas A, Pavithran P. Current practice of difficult airway management: A survey. Indian J Anaesth [serial online] 2015 [cited 2021 May 12];59:801-6. Available from: https://www.ijaweb.org/text.asp?2015/59/12/801/171571

   Introduction Top

Maintaining an adequate airway is the first and foremost responsibility of the anaesthesiologists, the importance of which is being emphasized not only in the curriculum but also in different academic forums.

Difficult airway (DA) is a challenge even to the experienced anaesthesiologists and a 'cannot intubate-cannot ventilate' (CICV) situation though rare, is life threatening. Inability to maintain an adequate airway can cause adverse respiratory events leading to hypoxic brain damage or even death. [1],[2] Close adherence to international guidelines like American Society of Anesthesiologists (ASA) DA algorithm Or Difficult Airway Society (DAS) guidelines in a DA scenario will definitely prevent such mishaps. [3],[4] Airway assessment, adequate training and experience, and availability of essential equipment are the pillars of successful airway management.

In this study, we aimed to evaluate the routine pre-operative airway assessment practices, equipment availability and the current practice preferences of DA management.

   Methods Top

After obtaining Institutional Research and Ethics Committee approval, a questionnaire was distributed among anaesthesiologists who attended a continuing medical education (CME) - Workshop on DA.

The questionnaire included 15 questions covering demographic profile, working experience, availability and comfort level with equipment and the current practice preference of DA management. The participation was voluntary and anonymity was maintained.

The first half of the questionnaire was mainly to collect demographic data including age, gender, years of practice, type of hospital and the workload of their hospital. Also, the familiarity with ASA DA algorithm and attendance in DA workshop in the previous 5 years was also probed.

The second half of questionnaire was designed to assess the routine pre-operative airway assessment practices, availability of various equipment, and the level of comfort with airway techniques like video-laryngoscopy (VL), fibreoptic bronchoscopy (FOB), cricothyroidotomy (CT) and retrograde intubation (RGI). The level of comfort of the respondents was asked to be mark on a 4-point scale. The comfort level with airway techniques were grouped as comfortable (scores 3 and 4) and uncomfortable (scores 1 and 2) [Appendix 1 [Additional file 1]].

The respondents were asked about their preferred choice of management in anticipated and unanticipated DA scenarios and their extubation strategy in a DA case. The last two questions assessed their experience of CICV situation if any and the clinical scenario of the same.

Survey responses were analysed using Statistical Package for Social Sciences (SPSS) version 18. Categorical variables were compared using Chi-squire test and a P < 0.05 was considered significant with a degree of freedom 24. The 4-point scale for comfort level were converted to a binary variable as comfortable (score 3 and 4) and uncomfortable (score 1 and 2).

   Results Top

Out of the 175 questionnaires distributed, 127 were returned completed making a response rate of 73%. Sixty two residents and 65 consultants responded the survey.

The demographic data is summarized in [Table 1]. Fifty one percent of respondents were between 25 and 34 years. Sixty one percent were males and 39% were females. Most of the respondents were from teaching institutes (76%) mainly Government Medical Colleges (50%). Sixty seven percent of consultants and 65% of residents had attended a DA workshop/CME in the previous 5 years. As far as the awareness of ASA DA algorithm is concerned, our survey found out that 68% of consultants and 47% of residents were familiar with it.
Table 1: Demographic data

Click here to view

The incidence of DA of 1/100 cases was reported by 25% of respondents. The primary step in DA management is proper evaluation and recognition of a potentially DA. The majority of our respondents (>95%) routinely performed pre-operative airway assessments like adequacy of mouth opening, Mallampatti classification, neck movements and thyromental distance.

Our survey showed that while supraglottic airway devices (SGADs) were widely available, those of advanced airway equipments like VL, Retrograde wire set (RGWS) were below 50% [Figure 1]. The availability of equipment was almost similar between government and private institutions but when compared to teaching institutions, non-teaching hospitals showed a deficiency of advanced airway equipment such as VL, FOB and RGWS.
Figure 1: Availability of airway equipment in institutes (%)

Click here to view

When the level of comfort with various airway techniques was assessed, the proportion of respondents comfortable with advanced airway devices was related to their experience. Most of the respondents were comfortable with SGADs, but not with FOB, VL or RGI. Although FOB was available for 59% of respondents, only 45% of consultants and 3.2% of residents were comfortable in using it, which shows the need for further training. It was alarming that availability and confidence with CT - a life-saving technique in CICV was very low. Only 18% of consultants and 2% of residents were comfortable with CT technique [Table 2].
Table 2: Number of respondents comfortable with alternate airway devices/technique

Click here to view

Airway management choices of our respondents in anticipated DA cases is summarized in [Figure 2]. Nearly 73% residents and 36% of junior consultants (<5 years) opted for attempting conventional method once, whereas the experienced consultants opted for awake FOB (47-67%). The difference was statistically significant (P = 0.001). However, the second choice of junior consultants and residents in DA was awake FOB. The more experienced anaesthesiologists (more than 20 years experience) when compared with their juniors, were more confident with conventional techniques in DA. Among them, nearly 47% opted for awake FOB as the first choice.
Figure 2: Airway management of choice in anticipated difficult airway

Click here to view

But in an unanticipated difficult intubation scenario [Figure 3], when conventional methods failed, most of the consultants (73%) and residents (66%) opted for SGADs as a rescue measure. Only 2.95% of consultants and 1.6% of residents preferred tracheostomy over the less invasive SGADs as a rescue measure. When questioned about the extubation strategy, (74%) residents and (81.5%) consultants preferred to extubate a DA case when fully awake in Intensive Care Unit. The alternate strategies of extubation in DA like the short-term use of a guide (bougie) or conduit (laryngeal mask airway [LMA]) was less preferred by our respondents.
Figure 3: Airway management choices in unanticipated difficult airway

Click here to view

Only 34% of our respondents had encountered a CICV situation at least once and mostly in head and neck surgical patients followed by trauma patients [Table 3].
Table 3: Incidence of CICV with clinical situations

Click here to view

   Discussion Top

The survey included airway assessment, equipment availability and current DA management practices of anaesthesiologists who attended a CME/workshop on DA. There is a paucity of such surveys reported in Indian scenario, and few of the reported surveys had a low response rate also. [5],[6] The high response rate (73%) of our survey was similar to many Western reports. [7],[8],[9]

Pre-operative airway assessment was routinely performed by more than 95% of respondents which were similar to many previous reports. [7],[10],[11] The high awareness of ASA DA algorithm and recent attendance in DA workshop/CME among our anaesthesiologists reflected their desire to update and improve their airway skills. The positive mindsets of anaesthesiologists to improve their procedural skills by showing a desire to attend workshop/CMEs were reported earlier also. [12]

Availability of equipment varied between teaching and non-teaching hospitals. Availability of airway equipment was comparatively less in non-teaching hospitals, similar to the finding of a previous report. [13] When Jenkins et al. reported a 99% availability of FOB among Canadian anaesthesiologists, [13] our survey revealed only 59% overall availability of FOB and 47% of VL. Various other Western surveys also reported a high availability of FOB. [7],[13],[14],[15] Cost constraints may be the limiting factor in a developing country like ours.

Our survey revealed that most of the anaesthesiologists are comfortable using SGADs, but not with techniques like VL, FOB, RGI or CT. Their level of comfort was related to their experience, as observed in a previous survey. [16]

Interestingly, the airway management technique of choice in anticipated DA varied with experience. While the experienced consultants (more than 5 years) opted for awake FOB, the less experienced junior consultants and residents still tried conventional method at least once. This showed their lack of experience and confidence with FOB. In a previous report by Bokhari et al. [8] trainees were less likely to choose awake FOB in difficult intubation due to lack of experience/training. In our survey more experienced anaesthesiologists (more than 20 years) were confident with conventional technique as only 47% selected awake FOB in DA. This may be due to their lack of adequate exposure to this newer advanced airway technique or confidence with familiar practices. Similar observations were made by Jenkin et al. also, [13] who in 2002 reported FOB as the preferred choice of management in DA. Even though 59% of our respondents had the availability of FOB in their workplace, only 52% consultants and 22.6% of residents preferred it in a DA case as the first choice. This definitely showed the lack of confidence and need for further training in FOB.

As with FOB, the availability and level of comfort with the novel airway gadget - videolaryngoscope was very low with the respondents (47% and 28.3%). Similar observations were noted in a recent Indian survey also. [12] Although VL has been included in the DA algorithm only very recently, [17] it is gaining rapid popularity and has got a promising role in DA management due to its short learning curve and ease of use. In a recent report by Wong et al., 96% respondents choose VL as the first choice rescue technique in unanticipated difficult laryngoscopy. [18] The majority of their respondents were comfortable with FOB and VL.

When faced with an unanticipated DA, where conventional methods failed, the majority of our respondents chose SGADs as a rescue measure which shows their awareness of ASA DA algorithm. [3] Similar observations were made by Dimitriou et al. in 2008 [10] and Ezri et al. in 2003. [15] The high availability and ease of use may be the reason for this choice. The extubation strategy in a DA case was also same for most of our respondents. 78% of our respondents opted for awake extubation rather than going for alternate extubation strategies like the short-term use of intubating bougie or LMA.

Only 34% of our respondents ever experienced a CICV situation, at one or other time of their professional career, of which majority (51%) were in head and neck surgical patients. Benumof estimates an incidence of CICV as 0.01-2 in 10,000 elective anaesthetic practice. [19] The importance of CT comes in a life threatening CICV situation. Many of our anaesthesiologists lack the confidence to perform a CT comfortably. Only 18% of consultants and 2% of residents were comfortable in performing a CT. Wong et al. in 2003 concluded that training in manikins leads to improvement in the success rate of this life saving technique. [20] Bainten also reported that practice on cricothyrotomy simulators significantly reduced the actual performance time. [21]

Various published reports have confirmed that training on mannequins and simulators are the most effective teaching tools for learning and improving the procedural skills in anaesthesia. [22],[23] In the era of information technology, we should make use of these simulators and computer assisted teaching more effectively to improve our airway skills. Training in life saving technique like CT should be emphasized during airway workshops.

The survey had some limitations. The high response rate of our survey could be because the target population was interested in learning about DA as it was an exclusive DA CME where the questionnaire was distributed. Questionnaire lacked details about the availability of CT set. Participation from non-teaching institutions was limited. Small sample size and 48% of participants being residents could add bias to the results.

   Conclusion Top

Our survey clearly showed that majority of consultants are well aware of ASA DA algorithm and follows the same. Also, they are equipped to deal with DA situations, as is evident from their ability to use airway gadgets in DA situations. With respect to residents in anaesthesia, awareness and application of technique shows definite lacunae. A cause of concern is about the relative non-availability of DA gadgets in non-teaching hospitals and the overall lack of comfort in handling life saving techniques like cricothyrotomy.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse respiratory events in anesthesia: A closed claims analysis. Anesthesiology 1990;72:828-33.  Back to cited text no. 1
Cheney FW, Posner KL, Caplan RA. Adverse respiratory events infrequently leading to malpractice suits. A closed claims analysis. Anesthesiology 1991;75:932-9.  Back to cited text no. 2
American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003;98:1269-77.  Back to cited text no. 3
Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004;59:675-94.  Back to cited text no. 4
Sahey BM, Dhande PS, Chhabra MK, Tidke S, Jain S, Fulzele M. National survey of difficult airway equipmwnts in medical colleges in India. Indian J Anaesth 2006;50:104-7.  Back to cited text no. 5
Sahey BM, Jain S, Tidke S, Dhande PS, Premendran B, Dahake S. Difficult airway management methods: A survey in medical colleges in India. Indian J Anaesth 2008;52:51-7.  Back to cited text no. 6
Mellado PF, Thunedborg LP, Swiatek F, Kristensen MS. Anaesthesiological airway management in Denmark: Assessment, equipment and documentation. Acta Anaesthesiol Scand 2004;48:350-4.  Back to cited text no. 7
Bokhari A, Benham SW, Popat MT. Management of unanticipated difficult intubation: A survey of current practice in the Oxford region. Eur J Anaesthesiol 2004;21:123-7.  Back to cited text no. 8
Rassam S, Sandbythomas M, Vaughan RS, Hall JE. Airway management before, during and after extubation: A survey of practice in the United Kingdom and Ireland. Anaesthesia 2005;60:995-1001.  Back to cited text no. 9
Dimitriou V, Iatrou C, Douma A, Athanassiou L, Voyagis GS. Airway management in Greece: A nationwide postal survey. Minerva Anestesiol 2008;74:453-8.  Back to cited text no. 10
Kristensen MS, Moller J. Airway management behavior, experience and knowledge among Danish anesthesiologists-room for improvement. Acta Anaesthesiol Scand 2001;45:1181-5.  Back to cited text no. 11
Ramkumar V. Airway management: How current are we? Indian J Anaesth 2011;55:5-9.  Back to cited text no. 12
[PUBMED]  Medknow Journal  
Jenkins K, Wong DT, Correa R. Management choices for the difficult airway by anesthesiologists in Canada. Can J Anaesth 2002;49:850-6.  Back to cited text no. 13
Rosenblatt WH, Wagner PJ, Ovassapian A, Kain ZN. Practice patterns in managing the difficult airway by anesthesiologists in the United States. Anesth Analg 1998;87:153-7.  Back to cited text no. 14
Ezri T, Konichezky S, Geva D, Warters RD, Szmuk P, Hagberg C. Difficult airway management patterns among attending anaesthetists practising in Israel. Eur J Anaesthesiol 2003;20:619-23.  Back to cited text no. 15
Wong DT, Lai K, Chung FF, Ho RY. Cannot intubate-cannot ventilate and difficult intubation strategies: Results of a Canadian national survey. Anesth Analg 2005;100:1439-46.  Back to cited text no. 16
Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013;118:251-70.  Back to cited text no. 17
Wong DT, Mehta A, Tam AD, Yau B, Wong J. A survey of Canadian anesthesiologists' preferences in difficult intubation and "cannot intubate, cannot ventilate" situations. Can J Anaesth 2014;61:717-26.  Back to cited text no. 18
Benumof JL. Management of the difficult adult airway. With special emphasis on awake tracheal intubation. Anesthesiology 1991;75:1087-110.  Back to cited text no. 19
Wong DT, Prabhu AJ, Coloma M, Imasogie N, Chung FF. What is the minimum training required for successful cricothyroidotomy?: A study in mannequins. Anesthesiology 2003;98:349-53.  Back to cited text no. 20
Bainton CR. Cricothyrotomy. Int Anesthesiol Clin 1994;32:95-108.  Back to cited text no. 21
Ti LK, Chen FG, Tan GM, Tan WT, Tan JM, Shen L, et al.Experimental learning improves the learning and retention of endotracheal intubation. Med Edu 2009;43:654-60.  Back to cited text no. 22
Schwid HA, Rooke GA, Carline J, Steadman RH, Murray WB, Olympio M, et al. Evaluation of anesthesia residents using mannequin-based simulation: A multiinstitutional study. Anesthesiology 2002;97:1434-44.  Back to cited text no. 23


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
    Article Figures
    Article Tables

 Article Access Statistics
    PDF Downloaded841    
    Comments [Add]    

Recommend this journal