These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. They are founded on published evidence. Where evidence is lacking, they have been directed by feedback from members of the Difficult Airway Society and based on expert opinion. These guidelines have been informed by advances in the understanding of crisis management; they emphasize the recognition and declaration of difficulty during airway management. A simplified, single algorithm now covers unanticipated difficulties in both routine intubation and rapid sequence induction. Planning for failed intubation should form part of the pre-induction briefing, particularly for urgent surgery. Emphasis is placed on assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions. It is recommended that the number of airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video- or fibre-optically guided intubation. If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Second-generation devices have advantages and are recommended. When both tracheal intubation and supraglottic airway device insertion have failed, waking the patient is the default option. If at this stage, face-mask oxygenation is impossible in the presence of muscle relaxation, cricothyroidotomy should follow immediately. Scalpel cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. The plans outlined are designed to be simple and easy to follow. They should be regularly rehearsed and made familiar to the whole theatre team.

Summary: Awake tracheal intubation has a high success rate and a favourable safety profile but is underused in cases of anticipated difficult airway management. These guidelines are a comprehensive document to support decision making, preparation and practical performance of awake tracheal intubation. We performed a systematic review of the literature seeking all of the available evidence for each element of awake tracheal intubation in order to make recommendations. In the absence of high‐quality evidence, expert consensus and a Delphi study were used to formulate recommendations. We highlight key areas of awake tracheal intubation in which specific recommendations were made, which included: indications; procedural setup; checklists; oxygenation; airway topicalisation; sedation; verification of tracheal tube position; complications; management of unsuccessful awake tracheal intubation; post‐tracheal intubation management; consent; and training. We recognise that there are a range of techniques and regimens that may be effective and one such example technique is included. Breaking down the key practical elements of awake tracheal intubation into sedation, topicalisation, oxygenation and performance might help practitioners to plan, perform and address complications. These guidelines aim to support clinical practice and help lower the threshold for performing awake tracheal intubation when indicated.

Background. Early warning scores using physiological measurements may help identify ward patients who are, or who may become, critically ill. We studied the value of abnormal physiology scores to identify high‐risk hospital patients. Methods. On a single day we recorded the following data from 433 adult non‐obstetric inpatients: respiratory rate, heart rate, systolic pressure, temperature, oxygen saturation, level of consciousness, urine output for catheterized patients, age and inspired oxygen. We also noted the care required and given. Results. Twenty‐six patients (6%) died within 30 days. They were significantly older than survivors (P<0.001). Their median hospital stay was 26 days (interquartile range 16–39). Mortality increased with the number of physiological abnormalities (P<0.001), being 0.7% with no abnormalities, 4.4% with one, 9.2% with two and 21.3% with three or more. Patients receiving a lower level of care than desirable also had an increased mortality (P<0.01). Logistic regression modelling identified level of consciousness, heart rate, age, systolic pressure and respiratory rate as important variables in predicting outcome. Conclusions. Simple physiological observations identify high‐risk hospital inpatients. Those who die are often inpatients for days or weeks before death, allowing time for clinicians to intervene and potentially change outcome. Access to critical care beds could decrease mortality. Br J Anaesth 2004; 92: 882–4

Summary: We analysed the physiological values and early warning score obtained from 1047 ward patients assessed by an intensive care outreach service. Patients were either referred directly from the wards ( n = 245, 23.4%) or were routine critical care follow‐ups. Decisions were made to admit 135 patients (12.9%) to a critical care area and limit treatment in another 78 (7.4%). An increasing number of physiological abnormalities was associated with higher hospital mortality (p < 0.0001) ranging from 4.0% with no abnormalities to 51.9% with five or more. An increasing early warning score was associated with more intervention (p < 0.0001) and higher hospital mortality (p < 0.0001). For patients with scores above one ( n = 660), decisions to admit to a critical care area or limit treatment were taken in 200 (30.3%). Scores of all physiological variables except temperature contributed to the need for intervention and all variables except temperature and heart rate were associated with hospital mortality.

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.

Summary: Neurological assessment is an essential component of early warning scores used to identify seriously ill ward patients. We investigated how two simple scales (ACDU – Alert, Confused, Drowsy, Unresponsive; and AVPU – Alert, responds to Voice, responds to Pain, Unresponsive) compared to each other and also to the more complicated Glasgow Coma Scale (GCS). Neurosurgical nurses recorded patients' conscious level with each of the three scales. Over 7 months, 1020 analysable measurements were collected. Both simple scales identified distinct GCS ranges, although some overlap occurred (p < 0.001). Median GCS scores associated with AVPU were 15, 13, 8 and 6 and for ACDU were 15, 13, 10 and 6. The median values of ACDU were more evenly distributed than AVPU and may therefore be better at identifying early deteriorations in conscious level when they occur in critically ill ward patients.