• J Adam Law, Laura V Duggan, Mathieu Asselin, Paul Baker, Edward Crosby, Andrew Downey, Orlando R Hung, George Kovacs, François Lemay, Rudiger Noppens, Matteo Parotto, Roanne Preston, Nick Sowers, Kathryn Sparrow, Timothy P Turkstra, David T Wong, Philip M Jones, and Canadian Airway Focus Group.
• Department of Anesthesia, Pain Management and Perioperative Medicine, QEII Health Sciences Centre, Dalhousie University, Halifax Infirmary Site, 1796 Summer Street, Room 5452, Halifax, NS, B3H 3A7, Canada. jlaw@dal.ca.
• Can J Anaesth. 2021 Sep 1; 68 (9): 140514361405-1436.

PurposeSince the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the published airway management literature has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This second of two articles addresses airway evaluation, decision-making, and safe implementation of an airway management strategy when difficulty is anticipated.SourceCanadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence is lacking, statements are based on group consensus.Findings And Key RecommendationsPrior to airway management, a documented strategy should be formulated for every patient, based on airway evaluation. Bedside examination should seek predictors of difficulty with face-mask ventilation (FMV), tracheal intubation using video- or direct laryngoscopy (VL or DL), supraglottic airway use, as well as emergency front of neck airway access. Patient physiology and contextual issues should also be assessed. Predicted difficulty should prompt careful decision-making on how most safely to proceed with airway management. Awake tracheal intubation may provide an extra margin of safety when impossible VL or DL is predicted, when difficulty is predicted with more than one mode of airway management (e.g., tracheal intubation and FMV), or when predicted difficulty coincides with significant physiologic or contextual issues. If managing the patient after the induction of general anesthesia despite predicted difficulty, team briefing should include triggers for moving from one technique to the next, expert assistance should be sourced, and required equipment should be present. Unanticipated difficulty with airway management can always occur, so the airway manager should have a strategy for difficulty occurring in every patient, and the institution must make difficult airway equipment readily available. Tracheal extubation of the at-risk patient must also be carefully planned, including assessment of the patient's tolerance for withdrawal of airway support and whether re-intubation might be difficult.© 2021. The Author(s).

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