To the Editor:
We read with great anticipation and interest the latest “Practice Guidelines for Management of the Difficult Airway: An Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway” by Apfelbaum et al.1 Although we would like to congratulate them on a comprehensive review and distillation of evidence and opinion, in general, we must admit that we were incredibly disappointed that determining a patient’s risk of aspiration, which is a critical and essential assessment when considering whether to perform airway management before or after the induction of anesthesia, failed to be considered and added to the new guidelines.
This oversight represents a significant missed opportunity to further enhance the airway management recommendations from our specialty and could possibly compromise the safety of patients given the magnitude of this omission. Certainly, one could argue that aspiration risk assessment is so basic as to mitigate its need to be introduced into the current guidelines. However, the task force’s recommendation that everyone should have a preoperative airway evaluation and that everyone should receive preoxygenation seems as obvious and important so as to not be considered self-evident.
As a simple example, take the patient with advanced scleroderma. In these patients, fascial calcinosis alone or with concurrent temperomandibular joint disease is common and can severely limit mouth opening, necessitating fiberoptic bronchoscope-assisted intubation, generally through the nares. Although a patient with limited mouth opening can often be easily intubated with a fiberscope after induction, esophageal involvement makes aspiration a real risk in these patients (their incidence of gastroesophageal reflux disease is 90%),2 and an awake intubation would be the only prudent means of securing the airway. And although this is but one example, the reader can imagine several others where nonreassuring airway findings and an aspiration risk mean that performance of a rapid sequence induction and intubation could be devastating if not immediately successful. In these cases, the choice of an awake technique is clear and indeed the safest route with a long track record.3 The current algorithm, as written, would not assist a practitioner in this sort of situation simply because ventilation would not necessarily be predicted to be difficult.
When such guidelines are generated, our society must recognize that other societies look to the American Society of Anesthesiologists for guidance and expertise. For example Emergency Medicine physicians and Critical Care physicians use our Difficult Airway Algorithm to guide and support their decision making and patient care. Omitting a critical component such as the aspiration risk assessment from this latest version may subject patients to undue risk, especially as skills with awake techniques like flexible bronchoscopy seem to be continually deemphasized in the literature for various reasons.4,5 Perhaps the task force might recognize the potential gravity of the omission of assessment of a patient’s risk to aspirate and amend the current guidelines so that 10 more years do not need to lapse before it is included.