What are the expected updates in the Difficult Airway Society guidelines for 2025 regarding airway management?

Changes in Difficult Airway Society Guidelines 2025

I cannot identify specific 2025 Difficult Airway Society (DAS) guideline updates in the provided evidence, as the most recent DAS guidelines available are from 2015 and 2020 (COVID-19 specific). The most current comprehensive difficult airway guidelines in the evidence are the 2022 American Society of Anesthesiologists (ASA) Practice Guidelines, which represent the highest quality and most recent guidance available for difficult airway management. 1

Key Framework from Most Recent Guidelines (2022 ASA)

Pre-Intubation Airway Risk Assessment

The 2022 ASA guidelines emphasize comprehensive airway evaluation before any airway intervention: 1

• Evaluate demographic information, clinical conditions, diagnostic test findings, patient/family interviews, and questionnaire responses from medical records 1
• Assess facial features including mouth opening, ability to prognath, head and neck mobility, prominent upper incisors, presence of beard, and upper lip bite test 1
• Measure anatomical landmarks: Mallampati score, thyromental distance, sternomental distance, interincisor distance, neck circumference, hyomental distance, and their ratios 1
• Consider advanced evaluation with bedside endoscopy, virtual laryngoscopy/bronchoscopy, or three-dimensional printing when available 1
• Assess multiple airway features in combination rather than relying on single predictors 1

Anticipated Difficult Airway Strategy

Before initiating anesthetic care, formulate a documented preformulated strategy that addresses four specific scenarios: 1

1. Awake intubation approach 1
2. Patient who can be adequately ventilated but is difficult to intubate 1
3. Patient who cannot be ventilated or intubated 1
4. Difficulties with emergency invasive airway rescue 1

Equipment Preparation Requirements

• Ensure airway management equipment is immediately available in the room 1
• Have a portable storage unit containing specialized difficult airway equipment immediately accessible 1
• Ensure a skilled individual is present or immediately available to assist when difficult airway is known or suspected 1

Decision Algorithm for Awake vs. Anesthetized Intubation

Perform awake intubation when one or more of the following apply: 1

• Difficult ventilation anticipated (face mask or supraglottic airway) 1
• Increased risk of aspiration 1
• Patient likely incapable of tolerating brief apneic episode 1
• Expected difficulty with emergency invasive airway rescue 1

Proceed with airway management after induction of general anesthesia only when benefits outweigh risks (particularly relevant for uncooperative or pediatric patients where awake intubation may not be feasible) 1

Technique Selection and Combination Approaches

The 2022 ASA guidelines emphasize flexibility with airway devices: 1

• Identify a preferred sequence of noninvasive devices if noninvasive approach selected 1
• Consider combination techniques when difficulty encountered with individual techniques, including: 1
  • Direct laryngoscopy with supraglottic airway, bougie, optical stylet, flexible intubation scope, or airway exchange catheter 1
  • Videolaryngoscopes with supraglottic airway, bougie, optical stylet, flexible scope, or airway exchange catheter 1
  • Flexible intubation scope with supraglottic airway, airway exchange catheter, or retrograde intubation 1

Critical Safety Parameters During Attempts

During airway management attempts, maintain awareness of: 1

• Passage of time 1
• Number of attempts 1
• Oxygen saturation 1
• Provide and test mask ventilation after each attempt when feasible 1
• Limit the number of attempts at tracheal intubation or supraglottic airway placement to avoid injury and complications 1

Emergency Pathway and Invasive Access

When emergency pathway triggered (cannot oxygenate or ventilate): 1

• Call for help immediately 1
• Call for invasive access 1
• Attempt alternative intubation approaches while preparing for emergency invasive airway 1
• Perform emergency invasive airway if alternative approaches fail or ventilation deteriorates 1

Surgical cricothyrotomy is the preferred rescue technique and should be practiced by all practitioners managing airways 1, 2

COVID-19 Specific Modifications (2020 DAS)

The 2020 DAS COVID-19 guidelines introduced specific modifications: 1

• Use second-generation supraglottic airway devices between attempts to reduce aerosol generation due to improved airway seal 1
• Scalpel-bougie-tube technique specifically preferred for emergency front-of-neck access in COVID-19 patients due to reduced aerosolization risk 1
• Inflate tracheal tube cuff immediately after intubation to measured pressure of 20-30 cmH₂O 1
• Confirm tracheal intubation with continuous waveform capnography rather than auscultation (which risks PPE contamination) 1

Documentation and Communication

After managing difficult airway: 1

• Document (1) nature of airway difficulty encountered and (2) description of various airway management techniques used, indicating beneficial or detrimental role of each technique 1
• Record difficult airway plan prominently and display visibly on patient's room 1
• Communicate plan to staff at shift changeovers 1

Common Pitfalls to Avoid

• Do not rely on single airway assessment tool—multiple features must be assessed in combination for better prediction 1, 3
• Do not delay transition through algorithm—minimize number of attempts at each technique 1
• Do not proceed with repeated unsuccessful attempts—this leads to laryngeal edema or hemorrhage that critically compromises airway maintenance 4
• Do not defer mask ventilation initially—consider second-generation supraglottic airway as alternative between attempts 1

The 2022 ASA guidelines represent the most comprehensive and current evidence-based approach to difficult airway management, superseding older DAS recommendations with more detailed algorithmic structure and emphasis on combination techniques, time awareness, and limiting attempts to prevent complications. 1