Facing the airway challenge: a review of difficult airway guidelines in modern practice

Airway management guidelines

Abstract

Background and purpose: Airway management remains one of anesthesiology’s most unpredictable challenges. The prediction of a difficult airway extends beyond the scope of standard bedside tests and anthropometric measurements, therefore patients classified as low risk may present with unanticipated challenges in ventilation or tracheal intubation. This review explores the limitations of current predictive tools and provides an overview of the leading national guidelines for unanticipated difficult airway management.

Materials and methods: A detailed guideline analysis was performed covering definitions, incidence, risk factors, and recommendations issued by major national and professional societies in the field of airway management.

Results: Findings confirm that bedside predictive tests lack accuracy, and most difficult airways are unanticipated. The incidence of the difficult airway varies greatly in the literature, by setting and surgical specialties. Guidelines, though varied in structure, consistently emphasize first-pass success, limited attempts, early alternative device use, and the need for backup strategies and documentation.

Conclusions: Airway difficulty is an essential part of pre-operative evaluation but remains largely unpredictable. Although technological innovations improve management, neither history, clinical examination nor widely used bedside tests are consistently reliable predictors. Effective clinical judgment, individualized planning with a ready back-up strategy for a possible failed airway management, together with structured, evidence based guidelines still remain essential. Documentation, teamwork, and adaptable algorithms tailored to environment and clinician preference are key to enhancing patient safety and reducing airway-related adverse events.