Difficult airways in adults in hospitals (Fourth edition, 2025). Methodological recommendations of the All-Russian public organization “Federation of Anesthesiologists and Reanimatologists”

INTRODUCTION: Difficult airways is a term that unites all clinical situations when, due to various combinations of anatomical and/or functional changes in patients and/or irrational actions of a specialist, predictable and unpredictable difficulties arise in ensuring effective ventilation, performing laryngoscopy and tracheal intubation, cricothyrotomy or a combination thereof, creating a potential or immediate threat of developing critical gas exchange disorders. OBJECTIVE OF THE STUDY: To create structured guidelines for difficult airways in adults in hospital. MATERIALS AND METHODS: Structured clinical guidelines for difficult airway management in adults in hospital are presented. RESULTS: The article presents the methodological recommendations of the Federation of Anesthesiologists and Resuscitators, revised in 2025. The recommendations are based on modern international guidelines, the results of randomized clinical trials, and meta-analyses.The recommendations present current definitions of various difficult airway situations; modern data on epidemiology, prognostic value of clinical signs, results of instrumental studies. Modern evidence-based data on the effectiveness of modern devices for ventilation and tracheal intubation (supraglottic airways, video laryngoscopes, flexible intubation endoscopes) are presented.Algorithms for actions in various situations with predictable and unpredictable difficult airways in patients with varying risks of aspiration are proposed. The algorithm of actions of an anesthesiologist in the absence of a capnogram after tracheal intubation is separately considered. An algorithm for preparation, prediction of possible complications and performance of tracheal extubation is also proposed. CONCLUSIONS: The recommendations presented in the review are aimed at achieving the goal of increasing patient safety during the occurrence of difficult airway situations by using the safest and most effective approaches and methods, as well as reducing the risk of complications associated with these situations (fatal outcome, severe neurological deficit, traumatic injuries of the upper airways and trachea, etc.).