Decision making in airway management

Two important characteristics of the AAA should be apparent from the most casual appraisal: First, each branch-point-question calls on the clinician to apply his or her own experience and judgment, and second, the true role of the AAA is to help guide entrance into the American Society of Anesthesiologist’s Difficult Airway Algorithm (ASA-DAA). This calls attention to the misnomer of the ASA-DAA – it is not an algorithm for only difficult airways. The ASA-DAA applies to all airways. In 2003, a revision of the ASADAA was published. Apart from the evidence-based medicine format of the new practice guidelines, the 2003 publication introduced a significant change to the graphic algorithm. In this revision, the Laryngeal Mask Airway (LMA) was removed from the emergency pathway, to be placed in the “routine” pathway, i.e., success or failure with the LMA or face mask (after failed laryngoscopy) defining the urgency of the situation. This change reflects the worldwide experience with the LMA since 1992. Takenaka took this concept a step further. In 2000, this author asked, if a patient is identified preoperatively as a possible difficult laryngoscopy, are they a “difficult airway” if there is no indication that LMA ventilation will be difficult? As the reader will see, these two developmental lines of thought contributed to the concepts of the AAA. The following discussion will examine the five questions of the AAA, and how, after preoperative assessment, it guides the clinician into the ASA-DAA.