The Editorial authored by Asai and Hillman1  contains the statement “If difficult airway management is predicted, general anesthesia should not be induced before securing the airway.” We believe their statement may be inconsistent with the American Society of Anesthesiologists (Schaumburg, Illinois; ASA) Practice Guidelines for Management of the Difficult Airway.2  The ASA Practice Guidelines defines a difficult airway as “the clinical situation in which a conventionally trained anesthesiologist experiences difficulty with facemask ventilation of the upper airway, difficulty with tracheal intubation, or both.” In addition, Asai and Hillman do not define their use of the word “predicted.”

Contained within the ASA Practice Guidelines is a difficult airway algorithm, which recommends that the anesthesiologist consider the relative merits and feasibility of basic management choices:

  • Awake intubation versus intubation after induction of general anesthesia

  • Noninvasive technique versus invasive techniques for the initial approach to intubation

  • Video-assisted laryngoscopy as an initial approach to intubation

  • Preservation versus ablation of spontaneous ventilation

The ASA Practice Guidelines provide multiple options to deal with a difficult airway and outline a strategy for intubation of the difficult airway that does not mandate intubation before general anesthesia is induced.

We believe that with the availability and appropriate use of supraglottic airways, video-assisted laryngoscopes, and flexible fiberoptic scopes, there is a reduced need to secure the airway before inducing general anesthesia. If a previous anesthesia record reveals that mask ventilation is not difficult and conventional rigid laryngoscopy is difficult, then after general anesthesia induction, a video-assisted laryngoscope intubation attempt or an asleep flexible fiberoptic intubation attempt are acceptable options. We believe our opinion is consistent with the ASA Practice Guidelines. The fact that certain practitioners may not follow the ASA Practice Guidelines is not a problem with the guidelines themselves.

Dr. Marymont has stock options in ImaCor (Jericho, New York). Dr. Vender reports no competing interests.

1.
Asai
T
,
Hillman
D
: .
Current difficult airway management: Not good enough!
Anesthesiology
.
2019
;
131
:
774
6
2.
Apfelbaum
JL
,
Hagberg
CA
,
Caplan
RA
,
Blitt
CD
,
Connis
RT
,
Nickinovich
DG
,
Hagberg
CA
,
Caplan
RA
,
Benumof
JL
,
Berry
FA
,
Blitt
CD
,
Bode
RH
,
Cheney
FW
,
Connis
RT
,
Guidry
OF
,
Nickinovich
DG
,
Ovassapian
A
;
American Society of Anesthesiologists Task Force on Management of the Difficult Airway
: .
Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway.
Anesthesiology
.
2013
;
118
:
251
70