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DAS Guidelines 2022 PDF Free Download, Download DAS Guidelines | Difficult Airway Society, 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway*.
The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care; Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway.
Practice guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. In addition, practice guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data.
This document is a revision of the “Practice guidelines for management of the difficult airway: A report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway,” adopted by the ASA in 2012 and published in 2013.1
For these practice guidelines, a difficult airway includes the clinical situation in which anticipated or unanticipated difficulty or failure is experienced by a physician trained in anesthesia care, including but not limited to one or more of the following: facemask ventilation, laryngoscopy, ventilation using a supraglottic airway, tracheal intubation, extubation, or invasive airway. These clinical situations are further defined as follows.
It is not possible to provide adequate ventilation (e.g., confirmed by end-tidal carbon dioxide detection), because of one or more of the following problems: inadequate mask seal, excessive gas leak, or excessive resistance to the ingress or egress of gas.
It is not possible to visualize any portion of the vocal cords after multiple attempts at laryngoscopy.
It is not possible to provide adequate ventilation because of one or more of the following problems: difficult supraglottic airway placement, supraglottic airway placement requiring multiple attempts, inadequate supraglottic airway seal, excessive gas leak, or excessive resistance to the ingress or egress of gas.
Tracheal intubation requires multiple attempts or tracheal intubation fails after multiple attempts.
The loss of airway patency and adequate ventilation after removal of a tracheal tube or supraglottic airway from a patient with a known or suspected difficult airway (i.e., an “at risk” extubation).
Anatomic features or abnormalities reducing or preventing the likelihood of successfully placing an airway into the trachea through the front of the neck.
Indicators of inadequate ventilation include absent or inadequate exhaled carbon dioxide, absent or inadequate chest movement, absent or inadequate breath sounds, auscultatory signs of severe obstruction, cyanosis, gastric air entry or dilatation, decreasing or inadequate oxygen saturation, absent or inadequate exhaled gas flow as measured by spirometry, anatomic lung abnormalities as detected by lung ultrasound, and hemodynamic changes associated with hypoxemia or hypercarbia (e.g., hypertension, tachycardia, bradycardia, arrhythmia). Additional clinical symptoms may include changed mental status or somnolence.
The purposes of these guidelines are to guide the management of patients with difficult airways, optimize first attempt success of airway management, improve patient safety during airway management, and minimize/avoid adverse events. The principal adverse outcomes associated with the difficult airway include (but are not limited to) death, brain injury, cardiopulmonary arrest, airway trauma, and damage to the teeth. The appropriate choice of medications and techniques for anesthesia care and airway management is dependent upon the experience, training, and preference of the individual practitioner, requirements or constraints imposed by associated medical issues of the patient, type of procedure, and environment in which airway management takes place. The choice of agents, techniques, and devices may be limited by federal, state, or municipal regulations or statutes.
These guidelines focus specifically on the management of the difficult airway encountered with mask ventilation, tracheal intubation, or supraglottic airway placement during procedures requiring general anesthesia, deep sedation, moderate sedation, or regional anesthesia or elective airway management without a procedure. Procedures include diagnostic, elective, and emergency procedures and invasive airway access. Airway management during cardiopulmonary resuscitation is not addressed by these guidelines. The guidelines are intended for adult and pediatric patients with either anticipated or unanticipated difficult airways, obstetric patients, intensive care (ICU) patients, and critically ill patients. The guidelines do not address patients at risk of aspiration without anatomically difficult airways, patients where difficult airways are not encountered, or physiologically difficult airways that are not anatomically difficult.‡
These guidelines do not address education, training, or certification requirements for practitioners who provide anesthesia and airway management. Some aspects of the guidelines may be relevant in other clinical contexts. The guidelines do not represent an exhaustive consideration of all manifestations of the difficult airway or all possible approaches to airway management.
These guidelines are intended for use by anesthesiologists and all other individuals who perform anesthesia care or airway management. The guidelines are intended to apply to all airway management and anesthetic care delivered in inpatient (e.g., perioperative, nonoperating room, emergency department, and critical care settings) and ambulatory settings (e.g., ambulatory surgery centers and office-based surgery and procedure centers performing invasive airway procedures). Excluded are prehospital settings and individuals who do not deliver anesthetic care or perform airway management. These guidelines are also intended to serve as a resource for other physicians and patient care personnel who are involved in the care of difficult airway patients, including those involved in local policy development.
In 2019, the ASA Committee on Standards and Practice Parameters requested that these guidelines be updated. This update is a revision developed by an ASA-appointed task force of 15 members, including physician anesthesiologists in both private and academic practices from the United States, India, Ireland, Italy, and Switzerland; an independent consulting methodologist; and an ASA staff methodologist. Conflict-of-interest documentation regarding current or potential financial and other interests pertinent to the practice guideline were disclosed by all task force members and managed.§
These updated guidelines were developed by means of a six-step process. First, consensus was reached on the criteria for evidence. Second, a comprehensive literature search was conducted by an independent librarian to identify citations relevant to the evidence criteria. Third, original published articles from peer-reviewed journals relevant to difficult airway management were evaluated and added to literature included in the previous update. Fourth, consultants who had expertise or interest in difficult airway management and who practiced or worked in various settings (e.g., private and academic practice) were asked to participate in opinion surveys addressing the appropriateness, completeness, and feasibility of implementation of the draft recommendations and to review and comment on a draft of the guidelines. Fifth, additional opinions were solicited from random samples of active members of the ASA and participating organizations. Sixth, all available information was used to build consensus to finalize the Guidelines. A summary of recommendations is provided in appendix 1. Preparation of these updated guidelines followed a rigorous methodologic process, described in more detail in appendix 2 and other related publications.2–5
Criteria for literature acceptance included randomized controlled trials, prospective nonrandomized comparative studies (e.g., quasiexperimental, cohort), retrospective comparative studies (e.g., case control), observational studies (e.g., correlational or descriptive statistics), and case reports or case series from peer-reviewed journals. Literature exclusion criteria included: (1) patients or practitioners described in the study who were specifically excluded or not identified by evidence criteria in the evidence model; (2) interventions not identified or specifically excluded in the evidence model; (3) studies with insufficient or no outcome data or reported outcomes not relevant to the evidence model; (4) articles with no original data, including review articles, descriptive letters, or editorials; (5) systematic reviews, secondary data, meta-analysis,‖ or other articles with no original data; (6) abstracts, letters, or articles not published in a peer-reviewed journal; (7) studies outside of designated search dates; (8) duplicate data presented in a different reviewed article; or (9) retracted publications.
Within the text of these guidelines, literature classifications are reported for each intervention as follows: Category A, level 1, meta-analysis of randomized controlled trials; Category A, level 2, multiple randomized controlled trials; Category A, level 3, a single randomized controlled trial; Category B, level 1, nonrandomized studies with group comparisons; Category B, level 2, nonrandomized studies with associative findings; Category B, level 3, nonrandomized studies with descriptive findings; and Category B, level 4, case series or case reports. Statistically significant outcomes (P < 0.01) are designated as either beneficial (B) or harmful (H) to the patient; statistically nonsignificant findings are designated as equivocal (E).# When available, Category A evidence is given precedence over Category B evidence for any particular outcome. The lack of sufficient scientific evidence in the literature is reported in the text of the guidelines as “insufficient evidence.”** Opinions regarding the scientific quality of the studies or opinion ratings of the strength of recommendations are not reported in this document.
Survey findings from task force–appointed expert consultants and samples of the memberships of ASA and participating organizations†† are reported in appendix 2. Survey responses for each recommendation are reported using a five-point scale based on median values from strongly agree to strongly disagree.
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