Difficult Airway Society 2025 guidelines for management of unanticipated difficult tracheal intubation in adults

Abstract

Advances in our understanding and practice of airway management necessitate contemporary guidelines for tracheal intubation. The Difficult Airway Society (DAS) therefore produced recommendations to improve the efficacy and safety of tracheal intubation. We conducted a systematic review and a three-round Delphi process to formulate multidisciplinary, evidence-based, expert consensus recommendations. We invited 20 external experts to guide recommendations on emergency front-of-neck airway and engaged DAS members and 16 international airway experts to provide feedback. Twelve members of the guidelines group participated in 65 meetings over 3 years, and 1241 papers were included after a systematic review. Sixty-five recommendations were made in relation to tracheal intubation. These included airway assessment and planning; peroxygenation; postintubation care; rapid sequence induction and intubation; the physiologically difficult airway; obesity; human factors; point-of-care ultrasound; documentation; and education and training. We maintain the concept of a linear algorithm encompassing tracheal intubation (Plan A); supraglottic airway device ventilation (Plan B); facemask ventilation (Plan C); and emergency front-of-neck airway (Plan D). The recommendations prioritise continuous oxygen delivery throughout airway management; maximising the likelihood of successful tracheal intubation at the first attempt; confirmation of ventilation with waveform capnography; progressing through the algorithm in the event of failure; multidisciplinary teamwork; and ongoing education and training. These guidelines are designed to support clinicians in delivering airway management that prioritises efficacy and safety. Overall, we emphasise the importance of maximising the chances of success, rather than the avoidance and management of failure, to improve outcomes for patients undergoing airway management.