All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults

Sheila Nainan Myatra; Amit Shah; Pankaj Kundra; Apeksh Patwa; Venkateswaran Ramkumar; Jigeeshu Vasishtha Divatia; Ubaradka S Raveendra; Sumalatha Radhakrishna Shetty; Syed Moied Ahmed; Jeson Rajan Doctor; Dilip K Pawar; Singaravelu Ramesh; Sabyasachi Das; Rakesh Garg

doi:10.4103/0019-5049.195481

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GUIDELINES 1 (AIDAA)

Year : 2016 | Volume : 60 | Issue : 12 | Page : 885-898

All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults

Sheila Nainan Myatra¹, Amit Shah², Pankaj Kundra³, Apeksh Patwa², Venkateswaran Ramkumar⁴, Jigeeshu Vasishtha Divatia¹, Ubaradka S Raveendra⁵, Sumalatha Radhakrishna Shetty⁵, Syed Moied Ahmed⁶, Jeson Rajan Doctor¹, Dilip K Pawar⁷, Singaravelu Ramesh⁸, Sabyasachi Das⁹, Rakesh Garg¹⁰
¹ Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India
² Kailash Cancer Hospital and Research Centre, Vadodara Institute of Neurological Sciences, Vadodara, Gujarat, India
³ Department of Anaesthesiology and Critical Care, JIPMER, Puducherry, India
⁴ Department of Anaesthesiology, Kasturba Medical College, Manipal, Karnataka, India
⁵ Department of Anaesthesiology and Critical Care, K S Hegde Medical Academy, Nitte University, Mangalore, Karnataka, India
⁶ Department of Anaesthesiology and Critical Care, J N Medical College and Hospital, AMU, Aligarh, Uttar Pradesh, India
⁷ Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
⁸ Department of Anaesthesiology, Kanchi Kamakoti Childs Trust Hospital, Chennai, Tamil Nadu, India
⁹ Department of Anaesthesiology, North Bengal Medical College, Darjeeling, West Bengal, India
¹⁰ Department of Onco Anaesthesiology and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Sheila Nainan Myatra
Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Dr. Ernest Borges Road, Mumbai - 400 012, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0019-5049.195481

The All India Difficult Airway Association (AIDAA) guidelines for management of the unanticipated difficult airway in adults provide a structured, stepwise approach to manage unanticipated difficulty during tracheal intubation in adults. They have been developed based on the available evidence; wherever robust evidence was lacking, or to suit the needs and situation in India, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the AIDAA and the Indian Society of Anaesthesiologists. We recommend optimum pre-oxygenation and nasal insufflation of 15 L/min oxygen during apnoea in all patients, and calling for help if the initial attempt at intubation is unsuccessful. Transnasal humidified rapid insufflations of oxygen at 70 L/min (transnasal humidified rapid insufflation ventilatory exchange) should be used when available. We recommend no more than three attempts at tracheal intubation and two attempts at supraglottic airway device (SAD) insertion if intubation fails, provided oxygen saturation remains ≥ 95%. Intubation should be confirmed by capnography. Blind tracheal intubation through the SAD is not recommended. If SAD insertion fails, one final attempt at mask ventilation should be tried after ensuring neuromuscular blockade using the optimal technique for mask ventilation. Failure to intubate the trachea as well as an inability to ventilate the lungs by face mask and SAD constitutes 'complete ventilation failure', and emergency cricothyroidotomy should be performed. Patient counselling, documentation and standard reporting of the airway difficulty using a 'difficult airway alert form' must be done. In addition, the AIDAA provides suggestions for the contents of a difficult airway cart.

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