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anesthesia.preop-airway-evaluation.core.v1PRODUCTION
anesthesia.preop-airway-evaluation.core.v1

Preoperative Airway Evaluation and Difficult Airway Management

critical_carechronicadultpediatric
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm preoperative airway evaluation scope — risk-stratify and plan primary + backup + rescue strategies before induction (ASA 2022)

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Actions
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evaluation initiated

Patient inputs (12)

Pediatric and elderly airways have distinct anatomic considerations (ASA 2022, DAS 2015)

BMI >=40 raises mask-ventilation and intubation difficulty risk (ASA 2022)

Documented prior difficult intubation is the single best predictor (ASA 2022)

STOP-BANG / Berlin / known PAP use; OSA increases supraglottic obstruction (ASA 2022)

Tumor, radiation, surgery, rheumatoid arthritis, ankylosing spondylitis (ASA 2022)

Drives RSI vs awake fiberoptic decision (ASA 2022)

Class III-IV (palate/uvula not visible) suggests difficult laryngoscopy (Mallampati 1985)

<6 cm suggests difficult laryngoscopy (LEMON) (ASA 2022)

<3 cm (one finger-breadth) suggests difficult laryngoscopy (LEMON) (ASA 2022)

Limited atlanto-occipital extension (<35 degrees) limits laryngoscopic view (ASA 2022)

Pregnancy alters airway edema + desat speed; influences awake-fiberoptic threshold (ASA 2022)

MH susceptible patients require trigger-free anesthetic + alternative NMB plan (MHAUS 2023, ASA 2022)

* = hard-required. Engine cannot meaningfully run until these are filled.

No severity triggers declared for this engine.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

Difficult Airway — ASA 2022 + DAS 2015 induction / rescue / reversal medications
axis: difficult_airway_drug_pathwaystep 1 - Step 1 — Awake fiberoptic prep (anticipated difficult airway, cooperative patient)
Selected step "Step 1 — Awake fiberoptic prep (anticipated difficult airway, cooperative patient)" — Anticipated difficult laryngoscopy AND patient cooperative AND no contraindication to awake technique
  • lidocaine_topical
    first line
    amide_local_anesthetic
    4% nebulized 4-6 mL + 2-4% spray-as-you-go; maintain total dose under 9 mg/kg LBW • topical/nebulized • preinduction
    triggers: awake_fiberoptic
    Topical airway anesthesia for awake intubation; track cumulative dose to avoid LAST (ASRA 2020, ASA 2022)
    rxcui 6387
  • midazolam
    first line
    benzodiazepine
    0.5-2 mg IV titrated • IV • titrated to anxiolysis with patient cooperation preserved
    triggers: awake_fiberoptic
    Anxiolysis without obtunding cooperation (ASA 2022, DAS 2015)
    rxcui 6960
  • remifentanil
    first line
    opioid_short_acting
    TCI 1-3 ng/mL or 0.05-0.1 mcg/kg/min • IV • continuous
    triggers: awake_fiberoptic
    Antitussive + analgesia; rapid offset preserves spontaneous ventilation (ASA 2022, DAS 2015)
    rxcui 73032

outpatient playbook — drug actions (0)

No drug actions defined for this setting.

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Preoperative anesthesia evaluation visit (any surgery requiring airway management) (ASA 2022); Prior documented difficult intubation / failed intubation / surgical airway (ASA 2022); Severe OSA, BMI >=40, history of failed mask ventilation (ASA 2022).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Preoperative Airway Evaluation and Difficult Airway Management** (anesthesia.preop-airway-evaluation.core.v1).
Phenotype framing: Categorize: anticipated easy airway / anticipated difficult laryngoscopy / anticipated difficult mask ventilation / anticipated difficult SGA / anticipated difficult surgical airway (ASA 2022)
Scope: Confirm preoperative airway evaluation scope — risk-stratify and plan primary + backup + rescue strategies before induction (ASA 2022)

Plan

Regimen axis: **Difficult Airway — ASA 2022 + DAS 2015 induction / rescue / reversal medications** — step "Step 1 — Awake fiberoptic prep (anticipated difficult airway, cooperative patient)".
1. lidocaine_topical 4% nebulized 4-6 mL + 2-4% spray-as-you-go; maintain total dose under 9 mg/kg LBW topical/nebulized preinduction (amide_local_anesthetic, first line) — Topical airway anesthesia for awake intubation; track cumulative dose to avoid LAST (ASRA 2020, ASA 2022)
2. midazolam 0.5-2 mg IV titrated IV titrated to anxiolysis with patient cooperation preserved (benzodiazepine, first line) — Anxiolysis without obtunding cooperation (ASA 2022, DAS 2015)
3. remifentanil TCI 1-3 ng/mL or 0.05-0.1 mcg/kg/min IV continuous (opioid_short_acting, first line) — Antitussive + analgesia; rapid offset preserves spontaneous ventilation (ASA 2022, DAS 2015)

Non-pharmacologic actions:
- Document difficult airway category in chart + MedicAlert recommendation (ASA 2022)
- Pre-op nasendoscopy / fiberoptic review if head-neck pathology (ASA 2022)
- ENT or maxillofacial consult for high-risk anatomy (ASA 2022)
- CT/MRI airway if mass or radiation-altered anatomy (ASA 2022)
- Patient counseling on awake fiberoptic vs RSI; informed consent for surgical airway possibility (ASA 2022)
- Plan video-laryngoscope availability (GlideScope, McGRATH, C-MAC) (ASA 2022)
- Plan supraglottic device availability (i-gel, LMA ProSeal) (DAS 2015, ASA 2022)
- Plan emergency front-of-neck kit + ENT/surgery backup (DAS 2015, ASA 2022)

AVOID / contraindication checks:
- Benzocaine_concentrations_above_20_percent_risk_methemoglobinemia (ASA 2022)
- Succinylcholine_contraindicated_in_MH_hyperkalemia_burns_denervation (MHAUS 2023, ASA 2022)
- Awake_fiberoptic_preferred_over_RSI_when_anticipated_CICO (DAS 2015, ASA 2022)
- Capnography_mandatory_NAP4_undetected_oesophageal_intubation_is_never_event (NAP4 Cook 2011, ASA 2022)
- Max_three_intubation_attempts_then_declare_difficult_airway (DAS 2015, ASA 2022)
- Sugammadex_dose_16_mg_per_kg_for_immediate_reversal_RSI_rocuronium (DAS 2015, ASA 2022)

Monitoring

Regimen monitoring:
- continuous etco2 capnography mandatory (ASA 2022, NAP4 Cook 2011)
- continuous spo2 (ASA 2022)
- continuous ecg (ASA 2022)
- cumulative topical lidocaine dose under 9 mg per kg LBW (ASRA 2020, ASA 2022)
- tof train of four neuromuscular monitoring (ASA 2022, DAS 2015)
- recovery post extubation observation minimum 30 min difficult airway (ASA 2022)

Setting (outpatient) monitoring:
- Review prior airway records each subsequent visit (ASA 2022)
- Confirm patient has MedicAlert / chart flag (ASA 2022)

Follow-up plan: Document difficult intubation on chart + MedicAlert; postop airway debrief (especially after CICO or front-of-neck access); patient counseling + future anesthetic-plan letter; Difficult Airway Society registry case report (ASA 2022, DAS 2015)
- Close-out criterion: documentation + counseling + future-plan letter complete

Monitoring phase: Continuous SpO2, EtCO2 (capnography is mandatory — NAP4 most common contributor to harm), arterial line if anticipated difficult / prolonged; assess for awake-fiberoptic plan if intubation fails twice (ASA 2022, NAP4 Cook 2011)

Disposition

Current setting: outpatient — Preoperative anesthesia clinic — risk-stratify airway, document four-plan strategy, set up appropriate location/team, counsel patient (ASA 2022)

Disposition criteria:
- Cleared for surgery with documented four-plan strategy (ASA 2022)
- High-risk -> route to academic / surgical-airway-capable center (ASA 2022)

Escalation triggers (move to higher acuity):
- New symptom (stridor, voice change, dysphagia, OSA worsening) -> repeat airway eval before next anesthetic (ASA 2022)
- Recent radiation / surgery / tumor progression -> mandatory ENT + imaging update (ASA 2022)

Earlier-Return Triggers

- No severity triggers declared for this engine.

Citations

- 2022 ASA Practice Guidelines for Management of the Difficult Airway (Apfelbaum et al, Anesthesiology 2022) + DAS 2015 (Frerk, BJA 2015) + NAP4 (Cook et al, BJA 2011) + Mallampati 1985 [PMID:34762729](https://pubmed.ncbi.nlm.nih.gov/34762729/)
- Cited evidence (PMID 26556848) [PMID:26556848](https://pubmed.ncbi.nlm.nih.gov/26556848/)
- Cited evidence (PMID 21447489) [PMID:21447489](https://pubmed.ncbi.nlm.nih.gov/21447489/)
- Cited evidence (PMID 4027773) [PMID:4027773](https://pubmed.ncbi.nlm.nih.gov/4027773/)

Last reconciled with current guidelines: 2026-05-26.
References
  • 2022 ASA Practice Guidelines for Management of the Difficult Airway (Apfelbaum et al, Anesthesiology 2022) + DAS 2015 (Frerk, BJA 2015) + NAP4 (Cook et al, BJA 2011) + Mallampati 1985 — PMID:34762729
  • Cited evidence (PMID 26556848) — PMID:26556848
  • Cited evidence (PMID 21447489) — PMID:21447489
  • Cited evidence (PMID 4027773) — PMID:4027773