Evolving challenges and opportunities for difficult airway management guidelines.

Airway management is a key competency for every anesthesiologist. In 1990, Caplan et al. reported that 34% of anesthesia-related claims were related to airway management. Since that time, several national airway management guidelines have been published with the aim to establish and promote safer airway management practice. Since the publication of those guidelines, studies have shown a decrease in anesthesia complications related to airway management. Of course, it is not possible to determine causality, and there have been other significant changes in practice over this time, e.g., supraglottic airways are now used in more than half the patients in the United Kingdom (UK). Unfortunately, despite these advances in both protocols and technology, airway complications in anesthesia still occur, and they are often associated with severe complications, i.e., brain damage or death. Herein, we consider the contents of future airway management guidelines that might create a further impact on patient safety, while bearing in mind the known problematic adherence to airway management guidelines, the role of medical education, and the rapid evolution of new airway management technology and skills. When we consider the history of major developments in airway management, we observe a recent acceleration of the development of technology and skills in this area. The Macintosh and Miller blades, designed in the 1940s when curare was introduced into anesthesia, are still in common use. Major incremental steps in airway management occurred with the development of fibreoptic intubation in the early 1970s, and again in the 1980s, with the invention of the laryngeal mask airway (LMA) and the rigid fibreoptic laryngoscopes (e.g., Bullard). Other major advances were made in the 1990s with the intubating laryngeal mask airway (ILMA), devices for transillumination (e.g., Trachlight), and videolaryngoscopy. During the last decade, anesthesiologists have used combinations of these new techniques to produce even further airway management possibilities, e.g., the combination of the LMA or the ILMA with fibreoptic bronchoscopy. The recent availability of sugammadex may change airway management practice and should be considered in new airway management guidelines. In addition to these ‘‘quantum leaps’’, there has also been a rapid increase in the number of new versions of very similar airway management devices, in part because of the ‘‘me too device’’ phenomenon. This increase in technology provides both advantages and disadvantages to anesthesiologists. Although we have more options for managing difficult intubation, it can be difficult to know the appropriate airway tool to use for a given purpose, especially considering the logistic challenges of conducting controlled trials on patients with difficult airways. A key tension for future guidelines is to reconcile the increasing number of new airway management options with Attributable to: Department of Anesthesiology, St. Michael’s Hospital, University of Toronto, 30 Bond St., Toronto, ON M5B 1W8, Canada.