Evidence-based guideline for airway assessment, preoxygenation, RSI medications, difficult airway algorithms, surgical airway, and scenario-specific airway management.
A comprehensive, evidence-based clinical guideline for acute airway management and rapid sequence intubation (RSI) in emergency and critical care settings. This resource synthesizes recommendations from the major airway management societies, national audit findings, emergency medicine and anesthesiology practice guidelines, and critical care consensus statements into a single integrated reference for emergency physicians, anesthesiologists, intensivists, and all clinicians who perform emergent airway management.1 2 3 4 5 6 7
Airway management remains the single most critical procedural skill in acute care medicine. Failure to secure a patent airway results in hypoxemia, brain injury, and death within minutes. Emergency intubation — whether in the emergency department, intensive care unit, operating room, or prehospital environment — carries a complication rate of 10–20%, with first-pass success rates in emergency settings historically ranging from 75% to 85%, compared to greater than 95% in elective operative settings. The adoption of structured airway assessment tools, systematic preparation protocols, pharmacologic optimization through rapid sequence intubation, video laryngoscopy, and algorithmic approaches to the failed airway has progressively improved outcomes. Major national audit data have demonstrated that the majority of airway-related deaths and serious complications are attributable to failures in planning, human factors, and rescue technique rather than to anatomic difficulty alone. This guideline addresses the complete spectrum of emergency airway management — from initial assessment and preoxygenation through induction, intubation, difficult airway rescue, front-of-neck access, scenario-specific modifications, confirmation, and post-intubation care.
Contents:
| Part | Title | Coverage |
|---|---|---|
| Part 1 | Airway Assessment & Preoxygenation | LEMON assessment; Mallampati classification (I–IV); Cormack-Lehane grading (I–IV); MOANS (difficult BVM); RODS (difficult SGA); SHORT (difficult cricothyrotomy); 3-3-2 rule; standard preoxygenation; HFNC apneic oxygenation; NIV preoxygenation; patient positioning (ramped/sniffing, head-elevated laryngoscopy) |
| Part 2 | RSI Protocol & Medications | Preparation and equipment check; pretreatment agents (lidocaine, fentanyl, atropine); induction agents with complete dosing (ketamine, propofol, etomidate, midazolam); neuromuscular blocking agents (succinylcholine, rocuronium) with contraindications and reversal; paralysis verification; post-intubation sedation and analgesia; confirmation of intubation (waveform capnography); drug-assisted intubation without paralysis (DSI); awake intubation techniques |
| Part 3 | Difficult Airway Management & Surgical Airway | Failed first attempt optimization; video laryngoscopy (types, evidence, technique); bougie and adjuncts; supraglottic airways (LMA, i-gel, King LT) with sizing tables; intubating through SGA; front-of-neck access (FONA); surgical cricothyrotomy (scalpel-bougie-tube); needle cricothyrotomy and jet ventilation; emergent tracheostomy; complete difficult airway algorithm |
| Part 4 | Clinical Scenarios & Post-Intubation Management | Trauma airway; elevated ICP; status asthmaticus; morbid obesity; pregnancy; pediatric airway (Broselow, ETT sizing, medication dosing); angioedema/anaphylaxis; burns/inhalation injury; extubation criteria; post-intubation ventilator settings by condition; sedation/analgesia regimens; equipment reference tables (ETT, blade, LMA sizes by age/weight) |
Frerk C, Mitchell VS, McNarry AF, et al. “Difficult Airway Society 2015 Guidelines for Management of Unanticipated Difficult Intubation in Adults.” British Journal of Anaesthesia. 2015;115(6):827-848. DOI: 10.1093/bja/aev371 ↩︎
Apfelbaum JL, Hagberg CA, Connis RT, et al. “2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway.” Anesthesiology. 2022;136(1):31-81. DOI: 10.1097/ALN.0000000000004002 ↩︎
Cook TM, Woodall N, Frerk C, eds. “4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society: Major Complications of Airway Management in the United Kingdom.” British Journal of Anaesthesia. 2011;106(5):617-631. DOI: 10.1093/bja/aer058 ↩︎
Higgs A, McGrath BA, Goddard C, et al. “Guidelines for the Management of Tracheal Intubation in Critically Ill Adults.” British Journal of Anaesthesia. 2018;120(2):323-352. DOI: 10.1016/j.bja.2017.10.021 ↩︎
Mosier JM, Joshi R, Hypes C, et al. “The Physiologically Difficult Airway.” Western Journal of Emergency Medicine. 2015;16(7):1109-1117. DOI: 10.5811/westjem.2015.8.27467 ↩︎
Brown CA III, Sakles JC, Mick NW, eds. The Walls Manual of Emergency Airway Management. 5th ed. Philadelphia: Wolters Kluwer; 2018. ISBN: 978-1496351968. ↩︎
Driver BE, Semler MW, Self WH, et al. “Effect of Use of a Bougie vs Endotracheal Tube With Stylet on First-Attempt Intubation Success in Patients Undergoing Emergency Tracheal Intubation: The BEAM Randomized Clinical Trial.” JAMA. 2018;319(21):2179-2189. DOI: 10.1001/jama.2018.6496 ↩︎
Scenario-specific airway management for trauma, elevated ICP, status asthmaticus, morbid obesity, pregnancy, pediatric patients, angioedema/anaphylaxis, and burns. Complete post-intubation ventilator settings, sedation/analgesia regimens, extubation criteria, and equipment reference tables by age and weight.
Failed first attempt optimization, video laryngoscopy types and evidence, bougie technique, supraglottic airways with sizing tables, intubating through SGA, front-of-neck access (FONA), surgical cricothyrotomy (scalpel-bougie-tube), needle cricothyrotomy, and the complete difficult airway algorithm.
Complete RSI protocol including preparation, pretreatment agents, induction agents with dosing tables, neuromuscular blocking agents with contraindications and reversal, paralysis verification, post-intubation sedation, confirmation of intubation, awake intubation, and drug-assisted intubation without paralysis.
LEMON assessment, Mallampati classification, Cormack-Lehane grading, MOANS/RODS/SHORT mnemonics, 3-3-2 rule, standard preoxygenation, HFNC apneic oxygenation, NIV preoxygenation, and optimal patient positioning.