Airway Management : Narrative Review
DOI:
https://doi.org/10.64531/cb1awc47Keywords:
airway management, airway difficulty, intensive care unitAbstract
Effective airway management is a cornerstone of safe anesthetic practice, particularly in critical care and surgical settings. This narrative review explores contemporary strategies for airway assessment, preparation, and instrumentation, integrating evidence-based guidelines and current research. Standard clinical predictors such as the Modified Mallampati Test, thyromental distance, neck mobility, and inter-incisor gapare evaluated alongside adjunctive tools like point-of-care ultrasound (POCUS) and fiberoptic endoscopy for enhanced diagnostic accuracy. The review addresses patient-specific risk factors including obesity, obstructive sleep apnea, and cervical spine pathology. Key preoxygenation techniques and pharmacologic considerations, including the use of propofol, ketamine, and opioids for hemodynamic optimization, are discussed in detail. Various airway devices ranging are compared for effectiveness in routine and difficult scenarios. The review also outlines protocols for rapid sequence induction, awake intubation, and extubation management. By consolidating current evidence and clinical practice guidelines, this article aims to support anesthesiologists in optimizing airway safety and minimizing perioperative complications.
References
1. Li X, Lian Y, Pan F, Zhao H. Global research trends in prediction of difficult airways: A bibliometric and visualization study. Medicine. 2023 May 12;102(19):e33776.
2. Soni VM, Pappu A, Zarabi S, Khalil C, You‐Ten KE, Siddiqui N, et al. Point‐of‐care ultrasound of the upper airway in difficult airway management: a systematic review and meta‐analysis*. Anaesthesia. 2025 Dec 2;80(12):1556–67.
3. De Luis-Cabezón N, Ly-Liu D, Renedo-Corcostegui P, Santaolalla-Montoya F, Zabala-Lopez de Maturana A, Herrero-Herrero JC, et al. A new score for airway assessment using clinical and ultrasound parameters. Front Med (Lausanne). 2024 Feb 14;11.
4. Sotoodehnia M, Khodayar M, Jalali A, Momeni M, Safaie A, Abdollahi A. Prediction of difficult laryngoscopy / difficult intubation cases using upper airway ultrasound measurements in emergency department: a prospective observational study. BMC Emerg Med. 2023 Jul 25;23(1):78.
5. Jackson JS, Rondeau B. Mallampati Score. 2025.
6. Hendrix JM, Patel R, Friede R. 3-3-2 Rule. 2025.
7. Wang Z, Jin Y, Zheng Y, Chen H, Feng J, Sun J. Evaluation of preoperative difficult airway prediction methods for adult patients without obvious airway abnormalities: a systematic review and meta-analysis. BMC Anesthesiol. 2024 Jul 17;24(1):242.
8. Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway *. Anesthesiology. 2022 Jan 11;136(1):31–81.
9. Marchis IF, Negrut MF, Blebea CM, Crihan M, Alexa AL, Breazu CM. Trends in Preoperative Airway Assessment. Diagnostics. 2024 Mar 13;14(6):610.
10. Paxton E, Parotto M. The best visible Mallampati score—too good to be true? Canadian Journal of Anesthesia/Journal canadien d’anesthésie. 2024 Oct 15;71(10):1339–43.
11. Rao S, Paliwal N, Saharan S, Bihani P, Jaju R, Sharma UD, et al. A Comparative Study to Evaluate Difficult Intubation Using Ratio of Patient Height to Thyromental Distance, Ratio of Neck Circumference to Thyromental Distance and Thyromental Height in Adult Patients in Tertiary Care Centre. The Turkish Journal of Anaesthesiology and Reanimation. 2023 May 2;51(2):90–6.
12. Xia M, Ma W, Zuo M, Deng X, Xue F, Battaglini D, et al. Expert consensus on difficult airway assessment. Hepatobiliary Surg Nutr. 2023 Aug;12(4):545–66.
13. Tang X, Dong Z, Xu J, Cheng P, Wang M, Wang B, et al. Observation of the validity of the upper lip bite test in predicting difficult intubation. Sci Rep. 2023 Dec 13;13(1):22160.
14. Mahendra Kuttarmare S, Rajesh Sonsale A. European Journal of Cardiovascular Medicine (EJCM) Cross-Sectional Study of Difficult Airway Predictors and Their Association with Cormack-Lehane Grades in Surgical Patients. 2025; Available from: https://www.healthcare-bulletin.co.uk/
15. Wang Z, Jin Y, Zheng Y, Chen H, Feng J, Sun J. Evaluation of preoperative difficult airway prediction methods for adult patients without obvious airway abnormalities: a systematic review and meta-analysis. BMC Anesthesiol. 2024 Jul 17;24(1):242.
16. Dabo-Trubelja A. Point-of-Care Ultrasound: A Review of Ultrasound Parameters for Predicting Difficult Airways. Journal of Visualized Experiments. 2023 Apr 7;(194).
17. Karanth S, Padyana M. Difficult Airway: Is this the Time to Focus on Point-of-care Ultrasonography? Indian Journal of Critical Care Medicine. 2024 Dec 30;29(1):1–2.
18. Sajitha NS, Kachru N, Yadav U, Yadav R. Evaluation of Ultrasound Guided Measurement of Tongue Thickness in Predicting Difficult Tracheal Intubation in Patients Undergoing Elective Surgery: A Cross Sectional Study [Internet]. Vol. 9, Archives of Anesthesiology and Critical Care. 2023. Available from: http://aacc.tums.ac.ir
19. Parameshwar S, Karna ST, Waindeskar V, Kumar H, Singh P, Saigal S. Accuracy of Sonographic Airway Parameters in Difficult Laryngoscopy Prediction: A Prospective Observational Cohort Study from Central India. Turk J Anaesthesiol Reanim. 2023 Oct 1;51(5):434–42.
20. Riveros-Perez E, Avella-Molano B, Rocuts A. Airway Ultrasound: A Narrative Review of Present Use and Future Applications in Anesthesia. Healthcare. 2025 Jun 24;13(13):1502.
21. Abdel Aziz G, A. B, Mohamed H, Hasan A. Prediction of Difficult Airway Using Sonographic Assessment of Pre-Epiglottic Space Versus Mallampati Grading in Correlation to Cormack Lehane Grading. Zagazig University Medical Journal. 2024 Mar 11;0(0):0–0.
22. Saul SA, Ward PA, McNarry AF. Airway Management: The Current Role of Videolaryngoscopy. J Pers Med. 2023 Aug 29;13(9):1327.
23. Ahmad I, El-Boghdadly K, Iliff H, Dua G, Higgs A, Huntington M, et al. Difficult Airway Society 2025 guidelines for management of unanticipated difficult tracheal intubation in adults. Br J Anaesth. 2025 Nov;
24. Köhl V, Wünsch VA, Müller M, Sasu PB, Dohrmann T, Peters T, et al. Hyperangulated vs. Macintosh videolaryngoscopy in adults with anticipated difficult airway management: a randomised controlled trial. Anaesthesia. 2024 Sep 24;79(9):957–66.
25. De Luis-Cabezón N, Ly-Liu D, Renedo-Corcostegui P, Santaolalla-Montoya F, Zabala-Lopez de Maturana A, Herrero-Herrero JC, et al. A new score for airway assessment using clinical and ultrasound parameters. Front Med (Lausanne). 2024 Feb 14;11.
26. Lin J, Bellinger R, Shedd A, Wolfshohl J, Walker J, Healy J, et al. Point-of-Care Ultrasound in Airway Evaluation and Management: A Comprehensive Review. Diagnostics. 2023 Apr 25;13(9):1541.
27. Riveros-Perez E, Avella-Molano B, Rocuts A. Airway Ultrasound: A Narrative Review of Present Use and Future Applications in Anesthesia. Healthcare. 2025 Jun 24;13(13):1502.
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Yosafat Beltsazar Hutabarat, S.Ked, dr. Agustina Br Haloho, Sp. An-TI (K) (Author)
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
