Skip to main navigation menu Skip to main content Skip to site footer

Review article: Medical guidelines

Vol. 152 No. 3738 (2022)

Swiss Latin Airway Guidelines: a holistic approach for improving airway management

  • Gabriele Casso 
  • Georges L. Savoldelli 
  • Christian Balmer 
  • Patrick Ravussin 
  • Patrick Schoettker
Cite this as:
Swiss Med Wkly. 2022;152:w30225


Airway management is a core competency for many different medical specialties. Despite continuous improvements in equipment, clinical understanding, education and training, airway management complications remain a significant cause of morbidity and mortality worldwide. Several international airway management guidelines already exist, but there has never been a national consensus document for Switzerland. The Fondation Latine des Voies Aériennes (FLAVA) has developed a new set of airway management guidelines based on the latest scientific evidence and the authors’ extensive clinical experience. These recommendations are intended to guide and assist clinicians in managing a wide array of airway situations. They are applicable to the daily routine management of anticipated and unanticipated airway difficulties. The new 2022 FLAVA Airway Guidelines (FLAGs) combine cognitive aids for using the latest technical skills and non-technical skills. Specially-designed key mnemonics and ergonomic tools complement these guidelines, including a colour-coded airway cart.


  1. Joffe AM, Aziz MF, Posner KL, Duggan LV, Mincer SL, Domino KB. Management of Difficult Tracheal Intubation: A Closed Claims Analysis. Anesthesiology. 2019 Oct;131(4):818–29.
  2. Fornebo I, Simonsen KA, Bukholm IR, Kongsgaard UE. Claims for compensation after injuries related to airway management: a nationwide study covering 15 years. Acta Anaesthesiol Scand. 2017 Aug;61(7):781–9.
  3. Cook TM, Scott S, Mihai R. Litigation related to airway and respiratory complications of anaesthesia: an analysis of claims against the NHS in England 1995-2007. Anaesthesia. 2010 Jun;65(6):556–63.
  4. Crosby ET, Duggan LV, Finestone PJ, Liu R, De Gorter R, Calder LA. Anesthesiology airway-related medicolegal cases from the Canadian Medical Protection Association. Can J Anaesth. 2021 Feb;68(2):183–95.
  5. Cook TM, Woodall N, Frerk C ; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth. 2011 May;106(5):617–31.
  6. Cook TM, Woodall N, Harper J, Benger J ; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth. 2011 May;106(5):632–42.
  7. Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al.; Difficult Airway Society intubation guidelines working group. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827–48.
  8. Law JA, Duggan LV, Asselin M, Baker P, Crosby E, Downey A, et al.; Canadian Airway Focus Group. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient. Can J Anaesth. 2021 Sep;68(9):1373–404.
  9. Law JA, Duggan LV, Asselin M, Baker P, Crosby E, Downey A, et al.; Canadian Airway Focus Group. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway. Can J Anaesth. 2021 Sep;68(9):1405–36.
  10. Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2022 Jan;136(1):31–81.
  11. Langeron O, Bourgain JL, Francon D, Amour J, Baillard C, Bouroche G, et al. Difficult intubation and extubation in adult anaesthesia. Anaesth Crit Care Pain Med. 2018 Dec;37(6):639–51.
  12. Piepho T, Cavus E, Noppens R, Byhahn C, Dörges V, Zwissler B, et al.; German Society of Anesthesiology and Intensive Care Medicine. [S1 guidelines on airway management]. Anaesthesist. 2015 Nov;64(11):859–73.
  13. Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, et al.; Difficult Airway Society; Intensive Care Society; Faculty of Intensive Care Medicine; Royal College of Anaesthetists. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth. 2018 Feb;120(2):323–52.
  14. Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia. 2020 Jun;75(6):785–99.
  15. Quintard H, l’Her E, Pottecher J, Adnet F, Constantin JM, De Jong A, et al. Experts’ guidelines of intubation and extubation of the ICU patient of French Society of Anaesthesia and Intensive Care Medicine (SFAR) and French-speaking Intensive Care Society (SRLF) : In collaboration with the pediatric Association of French-speaking Anaesthetists and Intensivists (ADARPEF), French-speaking Group of Intensive Care and Paediatric emergencies (GFRUP) and Intensive Care physiotherapy society (SKR). Ann Intensive Care. 2019 Jan;9(1):13.
  16. Chrimes N, Higgs A, Law JA, Baker PA, Cooper RM, Greif R, et al. Project for Universal Management of Airways - part 1: concept and methods. Anaesthesia. 2020 Dec;75(12):1671–82.
  17. Frova G, Sorbello M. Algorithms for difficult airway management: a review. Minerva Anestesiol. 2009 Apr;75(4):201–9.
  18. Hofer CK, Wendel Garcia PD, Heim C, Ganter MT. Analysis of anaesthesia services to calculate national need and supply of anaesthetics in Switzerland during the COVID-19 pandemic. PLoS One. 2021 Mar;16(3):e0248997.
  19. Henderson JJ, Popat MT, Latto IP, Pearce AC, Difficult Airway S ; Difficult Airway Society. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia. 2004 Jul;59(7):675–94.
  20. Sorbello M, Afshari A, De Hert S. Device or target? A paradigm shift in airway management: implications for guidelines, clinical practice and teaching. Eur J Anaesthesiol. 2018 Nov;35(11):811–4.
  21. Chrimes N. The Vortex: a universal ‘high-acuity implementation tool’ for emergency airway management. Br J Anaesth. 2016 Sep;117 Suppl 1:i20–7.
  22. Cook TM. Strategies for the prevention of airway complications - a narrative review. Anaesthesia. 2018 Jan;73(1):93–111.
  23. Jackson C. The technique of insertion of intratracheal insufflation tubes. Surg Gynecol Obstet. 1913;17:507–9.
  24. Janeway H. Intra-tracheal anaesthesia from the standpoint of the nose, throat and oral surgeon with a description of a new instrument for catheterizing the trachea. Laryngoscope. 1913;23(11):1082–90.
  25. Miller Robert A. A NEW LARYNGOSCOPE. Anesthesiology. 1941;2(3):317–20.
  26. Macintosh RR. A NEW LARYNGOSCOPE. Lancet. 1943;241(6233):205.
  27. Levitan RM, Heitz JW, Sweeney M, Cooper RM. The complexities of tracheal intubation with direct laryngoscopy and alternative intubation devices. Ann Emerg Med. 2011 Mar;57(3):240–7.
  28. Greenland KB, Eley V, Edwards MJ, Allen P, Irwin MG. The origins of the sniffing position and the Three Axes Alignment Theory for direct laryngoscopy. Anaesth Intensive Care. 2008 Jul;36(1_suppl Suppl 1):23–7.
  29. Knill RL. Difficult laryngoscopy made easy with a “BURP”. Can J Anaesth. 1993 Mar;40(3):279–82.
  30. Kim YS, Song J, Lim BG, Lee IO, Won YJ. Different classes of videoscopes and direct laryngoscopes for double-lumen tube intubation in thoracic surgery: A systematic review and network meta-analysis. PLoS One. 2020 Aug;15(8):e0238060.
  31. Kristensen MS, McGuire B. Managing and securing the bleeding upper airway: a narrative review. Can J Anaesth. 2020 Jan;67(1):128–40.
  32. Cooper RM. Use of a new videolaryngoscope (GlideScope) in the management of a difficult airway. Canadian journal of anaesthesia = Journal canadien d'anesthesie. 2003;50(6):611-3.
  33. Lewis SR, Butler AR, Parker J, Cook TM, Schofield-Robinson OJ, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review. Br J Anaesth. 2017 Sep;119(3):369–83.
  34. Zhu H, Liu J, Suo L, Zhou C, Sun Y, Jiang H. A randomized controlled comparison of non-channeled king vision, McGrath MAC video laryngoscope and Macintosh direct laryngoscope for nasotracheal intubation in patients with predicted difficult intubations. BMC Anesthesiol. 2019 Aug;19(1):166.
  35. Cooper RM, Pacey JA, Bishop MJ, McCluskey SA. Early clinical experience with a new videolaryngoscope (GlideScope) in 728 patients. Can J Anaesth. 2005 Feb;52(2):191–8.
  36. Desai N, Ratnayake G, Onwochei DN, El-Boghdadly K, Ahmad I. Airway devices for awake tracheal intubation in adults: a systematic review and network meta-analysis. Br J Anaesth. 2021 Oct;127(4):636–47.
  37. Taylor PA, Towey RM. The broncho-fiberscope as an aid to endotracheal intubation. Br J Anaesth. 1972 Jun;44(6):611–2.
  38. Cabrini L, Baiardo Redaelli M, Ball L, Filippini M, Fominskiy E, Pintaudi M, et al. Awake Fiberoptic Intubation Protocols in the Operating Room for Anticipated Difficult Airway: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Anesth Analg. 2019 May;128(5):971–80.
  39. Schoettker P, Bathory I, Broome M. Use of the nasotracheal Airtraq to assist difficult nasal fibreoptic intubation. Can J Anaesth. 2008 Dec;55(12):884.
  40. Core Topics in Airway Management. In: Kristensen MS, Cook T, editors. Core Topics in Airway Management. 3 ed. Cambridge: Cambridge University Press; 2020. p. i-ii.
  41. Ramaiah R, Das D, Bhananker SM, Joffe AM. Extraglottic airway devices: A review. Int J Crit Illn Inj Sci. 2014 Jan;4(1):77–87.
  42. Rosenstock CV, Nørskov AK, Wetterslev J, Lundstrøm LH ; Danish Anaesthesia Database. Emergency surgical airway management in Denmark: a cohort study of 452 461 patients registered in the Danish Anaesthesia Database. Br J Anaesth. 2016 Sep;117 Suppl 1:i75–82.
  43. Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, et al. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia. 2020 Apr;75(4):509–28.
  44. Campbell M, Shanahan H, Ash S, Royds J, Husarova V, McCaul C. The accuracy of locating the cricothyroid membrane by palpation - an intergender study. BMC Anesthesiol. 2014 Nov;14(1):108.
  45. You-Ten KE, Desai D, Postonogova T, Siddiqui N. Accuracy of conventional digital palpation and ultrasound of the cricothyroid membrane in obese women in labour. Anaesthesia. 2015 Nov;70(11):1230–4.
  46. Kristensen MS, Teoh WH, Rudolph SS. Ultrasonographic identification of the cricothyroid membrane: best evidence, techniques, and clinical impact. Br J Anaesth. 2016 Sep;117 Suppl 1:i39–48.
  47. Price TM, McCoy EP. Emergency front of neck access in airway management. BJA Educ. 2019 Aug;19(8):246–53.
  48. Cook T, Woodall N, Frerk C. 4th National audit Project of the Royal College of Anaesthetists and the difficult airway society. Major complications of airway management in the United Kingdom London: The Royal College of Anaesthetists. 2011.
  49. Onrubia X, Frova G, Sorbello M. Front of neck access to the airway: A narrative review. Trends in Anaesthesia and Critical Care. 2018;22:45–55.
  50. Patel A, Nouraei SA. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia. 2015 Mar;70(3):323–9.
  51. Schoettker P. The orotracheal tube dance. Eur J Anaesthesiol. 2015 Jun;32(6):443–4.
  52. Lundstrøm LH, Duez CH, Nørskov AK, Rosenstock CV, Thomsen JL, Møller AM, et al. Effects of avoidance or use of neuromuscular blocking agents on outcomes in tracheal intubation: a Cochrane systematic review. Br J Anaesth. 2018 Jun;120(6):1381–93.
  53. Warters RD, Szabo TA, Spinale FG, DeSantis SM, Reves JG. The effect of neuromuscular blockade on mask ventilation. Anaesthesia. 2011 Mar;66(3):163–7.
  54. Schnittker R, Marshall S, Horberry T, Young KL. Human factors enablers and barriers for successful airway management - an in-depth interview study. Anaesthesia. 2018 Aug;73(8):980–9.
  55. Schulz CM, Krautheim V, Hackemann A, Kreuzer M, Kochs EF, Wagner KJ. Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting system. BMC Anesthesiol. 2016 Jan;16(1):4.
  56. Bromiley M. The husband’s story: from tragedy to learning and action. BMJ Qual Saf. 2015 Jul;24(7):425–7.
  57. Fioratou E, Flin R, Glavin R. No simple fix for fixation errors: cognitive processes and their clinical applications. Anaesthesia. 2010 Jan;65(1):61–9.
  58. Schmutz JB, Eppich WJ. Promoting Learning and Patient Care Through Shared Reflection: A Conceptual Framework for Team Reflexivity in Health Care. Acad Med. 2017 Nov;92(11):1555–63.
  59. Rudolph JW, Raemer DB, Simon R. Establishing a safe container for learning in simulation: the role of the presimulation briefing. Simul Healthc. 2014 Dec;9(6):339–49.
  60. Konradt U, Otte KP, Schippers MC, Steenfatt C. Reflexivity in Teams: A Review and New Perspectives. J Psychol. 2016;150(2):153–74.
  61. Schmutz JB, Eppich WJ. When I say … team reflexivity. Med Educ. 2019 Jun;53(6):545–6.
  62. Eppich W, Cheng A. Promoting Excellence and Reflective Learning in Simulation (PEARLS): development and rationale for a blended approach to health care simulation debriefing. Simul Healthc. 2015 Apr;10(2):106–15.
  63. Rudolph JW, Simon R, Rivard P, Dufresne RL, Raemer DB. Debriefing with good judgment: combining rigorous feedback with genuine inquiry. Anesthesiol Clin. 2007 Jun;25(2):361–76.
  64. Chrimes N, Bradley WP, Gatward JJ, Weatherall AD. Human factors and the ‘next generation’ airway trolley. Anaesthesia. 2019 Apr;74(4):427–33.
  65. Fuchs A, Haller M, Riva T, Nabecker S, Greif R, Berger-Estilita J. Translation and application of guidelines into clinical practice: A colour-coded difficult airway trolley. Trends in Anaesthesia and Critical Care. 2021;40:46–54.
  66. Sturgess DJ, Greenland KB, Senthuran S, Ajvadi FA, van Zundert A, Irwin MG. Tracheal extubation of the adult intensive care patient with a predicted difficult airway - a narrative review. Anaesthesia. 2017 Feb;72(2):248–61.
  67. Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A ; Difficult Airway Society Extubation Guidelines Group. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia. 2012 Mar;67(3):318–40.
  68. Corso RM, Sorbello M, Mecugni D, Seligardi M, Piraccini E, Agnoletti V, et al. Safety and efficacy of Staged Extubation Set in patients with difficult airway: a prospective multicenter study. Minerva Anestesiol. 2020 Aug;86(8):827–34.
  69. Casso G, Schoettker P, Savoldelli GL, Azzola A, Cassina T. Development and Initial Evaluation of a Novel, Ultraportable, Virtual Reality Bronchoscopy Simulator: The Computer Airway Simulation System. Anesth Analg. 2019 Nov;129(5):1258–64.
  70. Zoric L, Savoldelli GL. Evidence base in airway management training. Trends in Anaesthesia and Critical Care. 2015;5(1):36–41.

Most read articles by the same author(s)