To the Editor:

The introduction of modern optical airway devices permits a number of new options for safer management of the difficult airway. As the American Society of Anesthesiology Task Force endeavors to update the standardized Difficult Airway Algorithm of 2003 (1), we would like to offer a modular addition to the existing algorithm (Fig. 1). This module can prompt further discussion and provide an initiative for further review and update of the algorithm. In addition, there is opportunity to build on current concepts in the management of the difficult airway (2-5).

Traditionally the ASA Task Force defined ‘difficult airway’ to be when a conventionally trained anesthesiologist has difficulty with either mask ventilation, tracheal intubation, or both. The 2003 standardized algorithm encompasses a wide range of management techniques compiled from literature, expert opinion, commentary and feasibility data. An updated version could include a decision tree for both anticipated and unanticipated airway difficulties. In this way the use of techniques available for difficult intubation as stated in Table 3 (1), now inclusive of optical devices, can be integrated into the rescue sequence on an individualized level.

With the updated module, the modern devices can be utilized after the demonstration of successful ventilation, keeping in mind that practitioners should only attempt intubating techniques that are within their skill set and comfort level. For example, if nasal fiberoptic is attempted, the practitioner would need to be comfortable with management of bleeding complications that may arise. If the patient has a small mouth opening, i.e. less than two finger breadths, the fiberoptic devices would be a recommended next step. If the patient has an adequate mouth opening, video fiberoptic and/or the fiberoptic video stylet devices, or other techniques such as rigid bronchoscopy and intubating LMA may be attempted.

Figure 1

Proposed modular addition to the 2003 Difficult Airway Management Algorithm.