Management of the Difficult Airway in Anesthesia: Prediction, Oxygenation, and Rescue Strategies

Abstract

Difficult airway management remains one of the most critical areas in anesthetic practice because failure to oxygenate or intubate can rapidly lead to hypoxic brain injury, cardiac arrest, or death. A difficult airway includes situations in which a trained clinician encounters difficulty with facemask ventilation, supraglottic airway placement, laryngoscopy, tracheal intubation, or emergency surgical access. Preoperative assessment can identify high-risk patients but has limited ability to reliably exclude difficulty, making universal preparation essential. Risk factors include high Mallampati score, reduced mouth opening, short thyromental distance, limited neck extension, obesity, obstructive sleep apnea, craniofacial abnormalities, airway masses, trismus, and subglottic stenosis. Contemporary management emphasizes preoxygenation, continuous oxygen delivery, early use of videolaryngoscopy or flexible bronchoscopy when indicated, limitation of repeated attempts, rapid transition between airway devices, mandatory waveform capnography, and timely front-of-neck access when ventilation fails. Awake tracheal intubation remains the preferred strategy for anticipated difficult airway when aspiration risk, rapid desaturation, or impossible rescue ventilation is expected. Successful management depends less on a single device and more on structured decision-making, team communication, oxygenation preservation, and early rescue escalation.