Experience Summary

Intubating and oxygenating a patient is an essential skill in Anaesthetic, Intensive Care, and Emergency Medicine. In this video, watch the anaesthetic team follow the difficult airway society’s 2015 stepwise guidance on the management of an unanticipated difficult intubation in adults.

Clinical Context

Full monitoring should be attached prior to attempting to intubate the patient. This includes:

• Oxygen saturations
• ECG
• Blood pressure
• End tidal CO2

Before performing this procedure, the following steps should be taken:

• The patient should be placed in the ‘sniff the morning air’ position.
• 100% oxygen should be applied to the upper airway.
• Neuromuscular blockade should be ensured throughout the procedure.

The difficult airway society 2015 guidelines provide a structured, stepwise algorithm for unanticipated difficult intubation in adults. The approach emphasises safety, clarity, and timely progression through a sequence of plans (A–D), promoting oxygenation over intubation success alone.

Plan A focuses on initial tracheal intubation attempts using direct or video laryngoscopy with up to three attempts (a maximum of four by a more experienced colleague), optimising patient position, preoxygenation, and using adjuncts like a bougie.

If intubation fails, Plan B is to attempt placement supraglottic airway device to re-establish oxygenation. If ventilation is successful, surgery may proceed or alternative airway strategies can be considered.

Plan C involves waking the patient if ventilation is unsuccessful or not feasible. Reversal of anesthesia and safe recovery is prioritized over further invasive attempts.

Plan D addresses a "Can't Intubate, Can't Oxygenate" scenario, prompting an immediate front-of-neck access – typically by scalpel cricothyroidotomy – to secure the airway and restore oxygenation.

Throughout all steps, continuous oxygenation, clear team communication, and early recognition of failure points are emphasised.

Learning Outcomes

1. Understand the steps in the difficult airway management ladder.
2. Understand the equipment required for the management of a difficult airway.

External Resources

Difficult Airway Society Guidelines - Difficult Intubation 

Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults