Beyond difficult: matching airway risk to intervention · Journal Watch

The article

Chahal R. Beyond difficult: matching airway risk to intervention. Anaesthesia 2026 (editorial).¹ doi:10.1111/anae.70455

Read the editorial

What the editorial says

Airway assessment has spent decades trying to answer one binary question: is this airway easy or difficult? Chahal argues that this question is fundamentally flawed.¹ "Easy" encourages routine management. "Difficult" often produces little more than anxiety, a videolaryngoscope in the anaesthetic room and vaguely ordered backup plans. Neither label says what might fail, how quickly failure will harm the patient, or what should be done.

Bedside tests have limited sensitivity, and structured multivariable assessment has not reduced unanticipated difficulty in large trials. That led to an orthodoxy that difficulty is unpredictable. Chahal rejects the nihilism that followed. Fixed trismus or an obstructing laryngeal cancer is not unpredictable. The error was not assessment; it was asking assessment to predict one ill-defined endpoint.

He proposes five interacting risk domains:

anatomy: baseline physical relationships affecting oxygenation
pathology: tumour, infection, oedema, bleeding or trauma that may obstruct, distort or progress
function: what the lesion is doing now, such as stridor, orthopnoea, voice change, secretion handling and airway protection
physiology: tolerance of induction, apnoea, positive-pressure ventilation and cardiovascular stress
context: operator, team, equipment, urgency, location, organisation and patient co-operation

These are "lenses, not boxes". One critical obstruction may outweigh several minor abnormalities.

The framework has three stages:

Assess and stratify: identify the dominant risks by mechanism and severity.
Match risk to mitigation: link each material risk to one or more proportionate, non-routine measures. These include continuous oxygen delivery, awake intubation or tracheostomy, hyperangulated videolaryngoscopy, preserving spontaneous ventilation, rapid neuromuscular blockade, skilled assistance and haemodynamic support.
Plan and execute: choose an awake or post-induction strategy, a technique matched to the mechanism and an access route. Then check readiness with the PEP TALKS mnemonic: positioning, equipment, personnel, timing, advocacy, location, knowledge and safe strategy.

Chahal also argues for a change in language. "Difficult airway" is a performance label that asks "can I do it?" "At risk of hypoxaemia" is a vulnerability label that asks "can the patient tolerate this?" Strategy must precede technique, because a videolaryngoscope is a device, not a plan. In his words, prediction without a change in plan "is theatre, not strategy".

He is careful to describe the framework as an author-proposed reasoning scaffold, not a validated score, guideline or cognitive aid. It now needs testing for usability, inter-rater reliability and its effect on decisions and outcomes.

What is valuable

It moves the question from "will it be difficult?" to "what may fail, why, with what consequence, and is rescue credible?" That is the question clinicians actually need answered.
It separates pathology, function and physiology. A friable tumour is pathology; when it causes stridor it is function; when it comes with cachexia it reduces physiological reserve. That distinction explains why one intervention is often not enough.
It insists that every departure from routine is linked to a specific threat. That makes plans explicit, teachable and auditable.
The language shift from "difficult" to "at risk of hypoxaemia" puts the patient, not the operator, at the centre.
It is portable. Head and neck disease makes the domains visible, but the same structure works in obesity, obstetrics, critical illness and the haemodynamically unstable patient with an apparently normal airway.
It is honest about its status. It does not claim to be a validated tool, and it says what testing is needed.

What to bear in mind

It is a synthesis, not an evidence-based tool. The eight interventions are illustrative associations, not prescriptions, and weighting the domains remains a matter of judgement.
The supporting evidence for risk-aligned decisions comes largely from selected head and neck populations, notably the Expect-It tool.⁹
Frameworks and mnemonics accumulate. PEP TALKS joins a crowded field, and its value will depend on whether it simplifies rather than adds to cognitive load at the bedside.
Rescue readiness and extubation are implied but not explicit. Both deserve a clearer place (see below).

My commentary

I should declare an interest. Rani Chahal kindly acknowledges my early input into this editorial, and we are co-authors on an unrelated review. I am, however, in a position to say that it resolves a debate that has run in the pages of Anaesthesia for almost a decade.

In 2017, Keith Greenland, André van Zundert, Michael Irwin and I responded to Pandit and Heidegger's case for a binary approach to airway prediction.² Our letter drew on the ANZCA Airway Assessment resource.³ We argued that binary assessment tends to produce binary management, and that bedside tests should serve as screening: the first step in a process that may include imaging, nasendoscopy and ultrasound. We also observed that difficulty was being defined by management outcomes rather than by underlying morphology and pathology.

In reply, Pandit and Heidegger made a fair pragmatic point.⁴ Detailed assessment of every patient is neither feasible nor necessary, and adding categories to scoring systems has not improved prediction. Importantly, they agreed that patients judged plausibly difficult need a plan tailored to their specific problem.

Chahal's framework works in exactly that space. It does not ask for more categories or a better score. It organises findings by mechanism and matches each material risk to a proportionate mitigation. It therefore reconciles both positions: pragmatic screening for the many, and mechanism-based planning for the few. Heidegger and Pandit have since reached a similar position, recommending that once difficulty is predicted, its cause should be defined and management tailored to maintain oxygenation.⁵ The ANZCA Airway Assessment resource applied the same logic at the level of technique. It matched device selection to the mechanism of difficulty through the two-curve and three-column models. Chahal extends that logic to strategy, physiology and context.

From an Australian perspective, the framework has particular resonance. Our airway practice has long placed oxygenation, rather than intubation, at the centre of airway safety. That principle is the first axiom of the ANZCA Airway Assessment resource. It informs ANZCA's PS61 guideline, with its emphasis on early recognition of deterioration and predefined transition points.⁶ It also underpins the Vortex, which frames airway management around maintaining alveolar oxygenation.⁷ By placing hypoxaemia, rather than failed intubation, at the centre of every domain, Chahal's framework sits firmly within that tradition.

Two additions, both core considerations in the ANZCA Airway Assessment resource, would strengthen it.

The first is readiness for front-of-neck access. Credible rescue is central to Chahal's argument, so identifying the cricothyroid membrane, by palpation or ultrasound, and preparing for neck rescue when it may be needed, deserves an explicit place among the mitigations. A rescue plan is only credible if the patient's anatomy, the equipment and the team will allow it.

The second is extubation. For many head and neck and cervical spine patients, risk does not end when the trachea is secured. Problems after extubation are common, and the recent PUMA extubation guidelines make the same point about reassessing risk at the end of surgery.⁸ Applying the five domains a second time, before the tube comes out, would close the loop. Bleeding, swelling, fixation and residual drug effect change all five.

There is a third point, which connects to two recent commentaries of mine on how we classify videolaryngoscopy and facemask ventilation. Risk-aligned planning depends on what we know, and much of what we know about a patient's airway comes from the last anaesthetic. A record that says "grade 1, easy", without the blade, the adjuncts or the attempts, gives the next anaesthetist nothing to match a mitigation to. If assessment is to identify mechanisms rather than labels, our documentation must record mechanisms too. That means what was used, what was seen, what was done, whether oxygenation was maintained, and, when it was difficult, why. Good assessment and good documentation are two halves of the same safety system.

As Chahal notes, the framework now needs testing for inter-rater reliability and for its effect on decisions and outcomes. Australia's state airway lead networks and incident-reporting systems such as webAIRS may be well placed to support that work. It would be fitting for an Australian framework to be tested in Australian practice.

Perfect prediction was always the wrong ambition. Matching risk to mitigation is a far more useful one.

References

Chahal R. Beyond difficult: matching airway risk to intervention. Anaesthesia 2026. doi:10.1111/anae.70455
Greenland KB, Bradley WPL, van Zundert A, Irwin MG. Airway assessment/management paradigm – does a spectral or a binary approach fit better? Anaesthesia 2017; 72: 1035–7. doi:10.1111/anae.13994
Bradley P, Chapman G, Crooke B, Greenland K. Airway Assessment. Melbourne: Australian and New Zealand College of Anaesthetists, 2016. ANZCA (PDF)
Pandit JJ, Heidegger T. Airway assessment/management paradigm – does a spectral or a binary approach fit better? A reply. Anaesthesia 2017; 72: 1037–8. doi:10.1111/anae.13992
Heidegger T, Pandit JJ. Difficult airway management: from the power of prediction to the art of management. Anesth Analg 2025; 140: 290–4. doi:10.1213/ANE.0000000000007202
Australian and New Zealand College of Anaesthetists. PS61 Guideline for the management of evolving airway obstruction: transition to the Can't Intubate Can't Oxygenate airway emergency. Melbourne: ANZCA, 2016.
Chrimes N. The Vortex: a universal 'high-acuity implementation tool' for emergency airway management. Br J Anaesth 2016; 117 (Suppl 1): i20–7. doi:10.1093/bja/aew175
Ellard L, Higgs A, Cooper RM, et al. Project for Universal Management of Airways: guidelines for tracheal extubation. Anaesthesia 2026. doi:10.1111/anae.70365
Popal Z, Sieg HH, Müller-Wiegand L, et al. Decision-making tool for planning camera-assisted and awake intubation in head and neck surgery. JAMA Otolaryngol Head Neck Surg 2025; 151: 585–94. doi:10.1001/jamaoto.2025.0538

This commentary is my own professional opinion, written for anaesthetists and other professional readers. It does not represent Alfred Health, ANZCA or any other organisation with which I am associated, and it is not individual medical advice. The original article is the work of its author and is linked above.