The German guidelines for airway management aim to optimize the care of patients undergoing anesthesia or intensive care. The preanesthesia evaluation is an important component for detection of anatomical and physiological indications for difficult mask ventilation and intubation. If predictors for a difficult or impossible mask ventilation and/or endotracheal intubation are present the airway should be secured while maintaining spontaneous breathing. In an unexpectedly difficult intubation, attempts to secure the airway should be limited to two with each method used. A video laryngoscope is recommended after an unsuccessful direct laryngoscopy. Therefore, a video laryngoscope should be available at every anesthesiology workspace throughout the hospital. Securing the airway should primarily be performed with a video laryngoscope in critically ill patients and patients at risk of pulmonary aspiration. Experienced personnel should perform or supervise airway management in the intensive care unit.
UNASSIGNED: Die Leitlinie Atemwegsmanagement soll zur optimalen Versorgung der anästhesiologisch und intensivmedizinisch betreuten Patient:innen beitragen. Die präanästhesiologische Evaluation ist ein wichtiger Baustein zur Detektion anatomischer und physiologischer Hinweise für eine erschwerte Maskenbeatmung und Intubation. Wenn Prädiktoren für eine schwierige oder unmögliche Maskenbeatmung und/oder endotracheale Intubation vorliegen, soll die Atemwegssicherung unter Erhalt der Spontanatmung erfolgen. Besteht ein unerwartet schwieriger Atemweg, wird nach erfolgloser direkter Laryngoskopie die Verwendung eines Videolaryngoskops empfohlen, weshalb ein Videolaryngoskop an jedem anästhesiologischen Arbeitsplatz verfügbar sein soll. Bei aspirationsgefährdeten und kritisch kranken Patient:innen soll primär die Sicherung der Atemwege mit einem Videolaryngoskop erfolgen. Die Durchführung bzw. Supervision von Atemwegssicherungen auf der Intensivstation obliegt im Atemwegsmanagement erfahrenem Personal.

The German airway management guidelines are intended to serve as an orientation and decision-making aid and thus contribute to the optimal care of patients undergoing anesthesiologic- and intensive medical care. As part of the pre-anesthesiologic evaluation, anatomical and physiological indications for difficult mask ventilation and intubation shall be evaluated. This includes the assessment of mouth opening, dental status, mandibular protrusion, cervical spine mobility and existing pathologies. The airway shall be secured while maintaining spontaneous breathing if there are predictors or anamnestic indications of difficult or impossible mask ventilation and/or endotracheal intubation. Various techniques can be used here. If there is an unexpectedly difficult airway, a video laryngoscope is recommended after unsuccessful direct laryngoscopy, consequently a video laryngoscope must be available at every anesthesiology workplace. The airway shall primarily be secured with a video laryngoscope in critically ill- and patients at risk of aspiration. Securing the airway using translaryngeal and transtracheal techniques is the \"ultima ratio\" in airway management. The performance or supervision of airway management in the intensive care unit is the responsibility of experienced physicians and nursing staff. Appropriate education and regular training are essential. Clear communication and interaction between team members are mandatory before every airway management procedure. Once the airway has been secured, the correct position of the endotracheal tube must be verified using capnography.

Despite prior publications of clinical practice guidelines related to ventilator liberation, some questions remain unanswered. Many of these questions relate to the details of bedside implementation. We, therefore, formed a guidelines committee of individuals with experience and knowledge of ventilator liberation as well as a medical librarian. Using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, we make the following recommendations: (1) We suggest that calculation of a rapid shallow breathing index is not needed to determine readiness for a spontaneous breathing trial (SBT) (conditional recommendation; moderate certainty); (2) We suggest that SBTs can be conducted with or without pressure support ventilation (conditional recommendation, moderate certainty); (3) We suggest a standardized approach to assessment and, if appropriate, completion of an SBT before noon each day (conditional recommendation, very low certainty); and (4) We suggest that FIO2 should not be increased during an SBT (conditional recommendation, very low certainty). These recommendations are intended to assist bedside clinicians to liberate adult critically ill patients more rapidly from mechanical ventilation.

High flow nasal cannula (HFNC) is a relatively recent respiratory support technique which delivers high flow, heated and humidified controlled concentration of oxygen via the nasal route. Recently, its use has increased for a variety of clinical indications. To guide clinical practice, we developed evidence-based recommendations regarding use of HFNC in various clinical settings.
We formed a guideline panel composed of clinicians, methodologists and experts in respiratory medicine. Using GRADE, the panel developed recommendations for four actionable questions.
The guideline panel made a strong recommendation for HFNC in hypoxemic respiratory failure compared to conventional oxygen therapy (COT) (moderate certainty), a conditional recommendation for HFNC following extubation (moderate certainty), no recommendation regarding HFNC in the peri-intubation period (moderate certainty), and a conditional recommendation for postoperative HFNC in high risk and/or obese patients following cardiac or thoracic surgery (moderate certainty).
This clinical practice guideline synthesizes current best-evidence into four recommendations for HFNC use in patients with hypoxemic respiratory failure, following extubation, in the peri-intubation period, and postoperatively for bedside clinicians.

Extubation has an important role in optimal patient recovery in the perioperative period. The All India Difficult Airway Association (AIDAA) reiterates that extubation is as important as intubation and requires proper planning. AIDAA has formulated an algorithm based on the current evidence, member survey and expert opinion to incorporate all patients of difficult extubation for a successful extubation. The algorithm is not designed for a routine extubation in a normal airway without any associated comorbidity. Extubation remains an elective procedure, and hence, patient assessment including concerns related to airway needs to be done and an extubation strategy must be planned before extubation. Extubation planning would broadly be dependent on preventing reflex responses (haemodynamic and cardiovascular), presence of difficult airway at initial airway management, delayed recovery after the surgical intervention or airway difficulty due to pre-existing diseases. At times, maintaining a patent airway may become difficult either due to direct handling during initial airway management or due to surgical intervention. This also mandates a careful planning before extubation to avoid extubation failure. Certain long-standing diseases such as goitre or presence of obesity and obstructive sleep apnoea may have increased chances of airway collapse. These patients require planned extubation strategies for extubation. This would avoid airway collapse leading to airway obstruction and its sequelae. AIDAA suggests that the extubation plan would be based on assessment of the airway. Patients requiring suppression of haemodynamic responses would require awake extubation with pharmacological attenuation or extubation under deep anaesthesia using supraglottic devices as bridge. Patients with difficult airway (before surgery or after surgical intervention) or delayed recovery or difficulty due to pre-existing diseases would require step-wise approach. Oxygen supplementation should continue throughout the extubation procedure. A systematic approach as briefed in the algorithm needs to be complemented with good clinical judgement for an uneventful extubation.

Since the publication of the first German guidelines on airway management in 2004 new techniques have been established in the clinical routine and new insights into existing strategies have been published. As a consequence the new guidelines on airway management of the German Society of Anesthesiology and Intensive Care Medicine represent the current state of scientific knowledge and integrate the currently recommended techniques and strategies. The aim of these guidelines is to guarantee an optimal care of patients undergoing anesthesiological procedures and serve as an orientation and decision aid for users.

Since the publication of the first german guidelines on airway management in 2014, new techniques have been established in the clinical routine and new insights into existing strategies have been published. As a consequence the new guidelines on airway management of the German Society of Anesthesiology and Intensive Care Medicine represent the current state of scientific knowledge and integrate the currently recommended techniques and strategies. The aim of these guidelines is to guarantee an optimal care of patients undergoing anesthesiological procedures and serve as an orientation and decision aid for users.