March 11, 2024

Non-Anatomical Causes of Difficult Airway

The management of a physiologically difficult airway poses unique challenges for healthcare providers in various clinical settings, including anesthesia, critical care, and emergency medicine. Unlike anatomically difficult airways, which primarily involve structural abnormalities, physiologically difficult airways are characterized by functional impairments that may compromise ventilation, oxygenation, and airway patency (1). When the difficult airway is due to non-anatomical causes, navigating airway management demands a profound understanding of underlying pathophysiological nuances and clinical acumen. Anesthesiologists commonly encounter cases of difficult airway with non-anatomical components or causes, such as obesity, obstructive sleep apnea (OSA), neuromuscular disorders, and metabolic perturbations, all of which influence airway dynamics and respiratory function (1). 

Consider obesity, a pervasive concern in modern healthcare. The accumulation of adipose tissue in the upper airway and neck regions poses mechanical obstacles to airflow, predisposing individuals to difficulties with mask ventilation and tracheal intubation. Moreover, obesity is frequently accompanied by comorbidities like OSA, characterized by recurrent episodes of upper airway collapse during sleep, resulting in disrupted breathing patterns, hypoxemia, and hypercapnia. An example of the challenges encountered in managing such patients is the increased risk of difficult mask ventilation due to poor mask seal secondary to facial adiposity. Additionally, the presence of OSA complicates airway management by heightening the likelihood of airway collapse and desaturation during induction of anesthesia (2). 

Neuromuscular conditions can be non-anatomical causes of difficult airway, often through muscle weakness. Conditions such as myasthenia gravis, amyotrophic lateral sclerosis (ALS), and muscular dystrophy manifest with muscle weakness or paralysis that compromises the integrity of the upper airway. This impairment extends to protective airway reflexes, increasing susceptibility to airway collapse or obstruction (3). For instance, in patients with myasthenia gravis, weakness of the bulbar muscles may lead to difficulty in handling secretions, predisposing them to aspiration pneumonia and necessitating careful preoperative assessment and planning. Additionally, patients with ALS may present with progressive weakness of respiratory muscles, culminating in ventilatory failure and the need for advanced airway support. 

Metabolic disturbances, ranging from severe acidosis to electrolyte imbalances, can significantly impact respiratory drive and neuromuscular function, posing significant challenges in airway management. For example, in diabetic ketoacidosis (DKA), metabolic acidosis leads to compensatory hyperventilation as the body attempts to correct the acid-base imbalance. However, this compensatory mechanism may become exhausted, resulting in respiratory fatigue and hypoventilation, necessitating close monitoring and potential respiratory support. Similarly, severe electrolyte imbalances, such as hyperkalemia, can impair neuromuscular transmission and lead to weakness or paralysis, further complicating airway management (4). 

In navigating the complexities of the physiologically challenging airway, anesthesiologists must tailor their approach to each patient, integrating a comprehensive assessment encompassing detailed history-taking, meticulous physical examination, and ancillary investigations. Advanced airway techniques, including video laryngoscopy, fiberoptic intubation, and supraglottic airway devices, serve as invaluable adjuncts in overcoming the unique challenges posed by physiologically difficult airways (5). Moreover, seamless collaboration with a multidisciplinary team, comprising surgeons, respiratory therapists, and critical care specialists, fosters a cohesive approach to airway management and ensures optimal patient outcomes. 


  1. Apfelbaum JL, Hagberg CA, Caplan RA, et al. 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(2):251-270. doi:10.1097/ALN.0b013e31827773b2 

  1. Benumof JL. Management of the difficult adult airway. With special emphasis on awake tracheal intubation. Anesthesiology. 1991;75(6):1087-1110. doi:10.1097/00000542-199112000-00027 

  1. Caplan RA, Benumof JL, Berry FA, et al. 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(2):251-270. doi:10.1097/ALN.0b013e31827773b2 

  1. Crosby ET, Cooper RM, Douglas MJ, et al. The unanticipated difficult airway with recommendations for management. Can J Anaesth. 1998;45(8):757-776. doi:10.1007/BF03012147 

  1. Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827-848. doi:10.1093/bja/aev371 
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