The Difficult Airway: A Brief Overview of the Airway Disruption Algorithm

The American Society of Anesthesiologists (ASA) in 2005 modified the ASA Difficult Airway Algorithm.⁹ A surgical airway may be the best choice in patients with oromaxillofacial trauma. In this particular case, a tracheostomy could be performed in the operating suite under somewhat controlled circumstances. More recent ASA guidelines suggest awake intubation for airway disruption if there is a major laryngeal, tracheal, or bronchial tear, provided that the patient is awake, cooperative, hemodynamically stable, and able to maintain adequate oxygen saturation.¹⁰ For infralaryngeal and tracheal injury, recommendations include rapid sequence intubation or direct laryngoscopy (perhaps video-assisted) with a flexible intubation scope with an appropriately sized ETT already loaded over it. The ETT is then introduced over the flexible intubation scope with the cuff positioned over the airway. Positive-pressure ventilation and transtracheal jet ventilation should be avoided proximal to an infralaryngeal tear.¹⁰

Dr. Glauser is faculty at the Case Western Reserve University/MetroHealth Medical Center/Cleveland Clinic emergency medicine residency program in Cleveland, Ohio.

Dr. Effron is faculty at the Case Western Reserve University/MetroHealth Medical Center/Cleveland Clinic emergency medicine residency program in Cleveland, Ohio.

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