All India Difficult Airway Association 2025 Guidelines for the management of unanticipated difficult airway in adults under general anaesthesia

The All India Difficult Airway Association 2025 Adult guideline provides guidance for the management of an unanticipated difficult airway under general anaesthesia. The American Heart Association (AHA) Class of Recommendation and Level of Evidence was used. In addition, for interventions where the evidence was absent or weak, a Delphi process among airway experts was convened to generate expert consensus statements. The most significant difference from the 2016 guidelines is providing guidance for a failed supraglottic airway (SGA) insertion, tracheal intubation, face mask ventilation, or other strategies commonly used as part of the primary airway plan under general anaesthesia, not restricting to a failed intubation. Airway assessment should be routinely performed to identify an anatomical as well as the physiologically difficult airway. Peri-intubation oxygenation with pre-oxygenation and apnoeic oxygen with nasal oxygen (10-15 L/min) or high-flow nasal oxygen increases the safe apnoea time. Videolaryngoscopy and adjuncts such as stylets and bougies improve first pass intubation success. Tracheal tube position should be confirmed by waveform capnography. If the primary airway plan fails, activate 'Code D' as the hospital emergency code to call for help. Airway rescue should then be attempted with any of the three devices (tracheal tube, SGA, or face mask), and switching promptly between them as needed, with no hierarchy, until effective ventilation and adequate oxygen saturation (SpO₂) are achieved. Optimise patient position, ensure neuromuscular blockade, and consider changing the tools, technique, or operator. Allow up to three failed attempts with these devices provided the SpO₂ remains ≥95%. <i>Complete ventilation failure</i> (ventilation using a tracheal tube, SGA, and face mask have all failed, even if oxygenation may be maintained) is the trigger to perform an <i>emergency cricothyroidotomy</i>, preferably by a surgical approach. Team debriefing, team support, patient and family counselling, and documentation are paramount after encountering an unanticipated difficult airway.