This chapter is written for practitioners working within the perioperative environment that require an understanding of how to assess and manage a patient’s airway. An introduction to airway anatomy highlights relevant anatomical landmarks, and a number of techniques that can be employed for both basic and advanced airway management are described. Airway equipment used by the anaesthetic practitioner will vary depending on requirements of the patient and procedure. Therefore, an overview of both standard and specialist airway equipment available, and how this is used to establish and maintain a patent airway, is provided.

Tracheal tube introducers or bougies and airway exchange catheters (AECs) are widely used airway adjuncts for facilitating airway management in difficult circumstances. They are easy to use, relatively inexpensive and have success rates of ≥ 90% in most settings. Both are included in many modern airway management algorithms. The use of bougies has expanded over the years, and they are now used to aid insertion of supraglottic airways (SGAs), videolaryngoscope-guided intubation and as adjuncts to emergency front of neck airway procedures. Stylets are rigid or semi-rigid airway adjuncts that are inserted into the tracheal tube before intubation. They maintain the tracheal tube in a particular shape and may therefore assist during intubation. AECs are semi-rigid hollow tubes designed to aid airway device (SGA, and single- or double-lumen tracheal tube) exchange or to manage ‘at-risk’ extubation. The risk of serious airway trauma associated with the use of bougies and airway exchange catheters, and the risk of barotrauma with the latter, invites cautious and educated use of these devices.

Pre-hospital airway management is an essential skill for every pre-hospital clinician and should be performed to the same standards as would be expected in the emergency department. This chapter recommends tailored pre-hospital airway management in terms of clinical care delivered to the patient, skills of the clinician and the infrastructure of emergency medical system to achieve this. The importance of having a standardised, well-rehearsed approach, using aids to reduce cognitive load, articulating a clear airway management plan and having a structured way of handling airway management difficulties is highlighted. The concept of the physiologically difficult airway is discussed and the significance of excellent pre-oxygenation, peroxygenation, first-pass success and post-intubation care is discussed. Backup equipment in the form of second generation supraglottic airway devices, a videolaryngoscope with both standard and hyperangulated blades and equipment for an emergency front of neck airway should be available when advanced pre-hospital airway management is provided. When delivering airway management to trauma patients, an awareness of potential anatomical difficulties combined with careful management of physiological derangement is necessary to deliver safe, high quality care.

As opposed to the simplistic promotion of one given technique or device, the multimodal airway management relies on the recognition that each individual approach may fail, that the maintenance of oxygenation during the procedure is a key point, that the prerequisites to the practical step of placing a tube in the trachea involve the knowledge of intelligent and intelligible algorithms and the previous acquisition of skills, with understanding of their foundations. An example of the ‘combination techniques’ using the specific advantages of one medical device to mitigate the limitations of another is the use of a videolaryngoscope to facilitate intubation with a flexible optical bronchoscope, which increases the ease and the success of the process during the clinical as well as the training phases. Other multimodal approaches such as the combination of bronchoscopy with the use of a supraglottic airway or with high flow nasal oxygen optimise the safety of the procedure by maintaining the delivery of oxygen. The multimodal approach is particularly useful for the anaesthesiologist and intensivist only occasionally exposed to the management of difficult airway situations. It improves high quality care of patients, education and training.

Videolaryngoscopes have been in existence for several decades but in the last decade have taken a central role in both difficult and routine airway management. During that time videolaryngoscopy has not only become embedded in most difficult airway algorithms but the technique has become part of core airway management skills and the use of awake videolaryngoscopy has increased. This chapter describes the various types of videolaryngoscopes, their roles, strengths and limitations. Strategies to optimise use of Macintosh and hyperangulated devices are described as well as which adjuncts are best suited to their use. The issue of ‘can see, cannot intubate’ is discussed along with techniques to overcome it. The role of videolaryngoscopy outside the operating theatre, in critical care, in the emergency department and in pre-hospital care is discussed in this and other chapters.