DAS 2015 guidelines and the sacred cows of routine airway management

[Admin]

Marshall and Pandit’s extensive editorial on the DAS 2015 guidelines for difficult intubation explores where new evidence and new guidelines might logically lead in both difficult and routine airway practice. Their conclusions are a challenge to the status quo. Is there an argument to go further still in the pursuit of patient centred safe airway management?

The DAS guidelines put videolaryngoscopy and the 2nd generation supraglottic airway device (SAD) at the centre of management of difficult intubation and prevention of a spiral of physiological decline towards front of neck airway (FONA). While the guidelines are explicitly intended for management of unanticipated difficult intubation, it is a well-documented, but often unappreciated, finding that when one aspect of airway management is difficult, others are also more likely to be – so that when intubation is difficult the likelihood of difficult mask ventilation, SAD placement and FONA are all individually also more likely to be difficult, or fail. The same is true if the starting point of difficulty is mask ventilation or SAD insertion. This leads to the risk of ‘composite failure’ of airway management, and it is for this reason that the DAS ‘difficult intubation’ guidelines have an importance well beyond difficult laryngoscopy and intubation.

[url=Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults Br. J. Anaesth. first published online November 10, 2015 doi.1093/bja/aev371]here[/url]