Airway management is a fundamental component of safe anesthetic practice. It aims to maintain airway patency, ensure adequate oxygenation and ventilation, and minimize the risk of pulmonary aspiration. Modern airway management includes preoperative assessment, appropriate airway device selection, video laryngoscopy, and the use of structured algorithms to manage anticipated and unanticipated airway difficulties. Introduction General anesthesia suppresses spontaneous breathing and weakens protective airway reflexes, making effective airway management essential to maintain oxygenation and ventilation and protect the lungs from aspiration. Although endotracheal intubation remains an important method of securing the airway, airway management encompasses several techniques, including facemask ventilation, supraglottic airway devices, video laryngoscopy, and emergency front-of-neck access when necessary. Successful management depends on advance planning, appropriate technique selection, and minimizing repeated intubation attempts. 1. Preoperative Assessment and Preparation Preoperative airway assessment is essential for identifying potential difficulties with intubation. It includes evaluating mouth opening, thyromental distance, Mallampati classification, cervical spine mobility, and dentition. Physiological factors that may increase airway management risks must also be assessed, including obesity, hypoxemia, and hemodynamic instability, as these conditions may lead to rapid oxygen desaturation during apnea. Preparation involves checking the availability and functionality of essential equipment, including suction devices, manual ventilation bags, airway adjuncts, video laryngoscopes, endotracheal tubes, supraglottic airway devices, and emergency front-of-neck access equipment. Clear communication and role allocation among team members are also essential. 2. Preoxygenation and Patient Positioning Preoxygenation increases the body’s oxygen reserves and prolongs the safe apnea period during intubation. It is usually performed using a well-sealed facemask delivering a high concentration of oxygen. Non-invasive positive pressure ventilation (NIPPV) may be beneficial in patients at increased risk of hypoxemia. Nasal oxygenation can also be maintained during intubation attempts to support oxygen delivery. Patient positioning plays an important role in successful intubation. The sniffing position helps improve laryngeal visualization, while the ramped position is preferred for patients with obesity, as it can improve ventilation and laryngeal exposure. 3. Supraglottic Airway Devices versus Endotracheal Intubation The choice of airway device depends on the surgical procedure, aspiration risk, and the patient’s clinical condition. Supraglottic airway devices (SGAs) are suitable for many surgical procedures. Second-generation devices often include a gastric drainage channel and provide an improved airway seal. Their use may be associated with a lower incidence of certain postoperative complications, including sore throat and hoarseness. Endotracheal tubes (ETTs) are preferred when a more secure airway is required, during certain procedures involving muscle relaxation or prolonged ventilation, and in patients with an increased risk of pulmonary aspiration. Video laryngoscopy has improved glottic visualization and increased the likelihood of successful intubation on the first attempt, particularly in patients with an anticipated difficult airway. 4. Rapid Sequence Induction Rapid sequence induction (RSI) is used in patients at increased risk of pulmonary aspiration, such as those with a full stomach or bowel obstruction. The procedure involves preoxygenation, administration of an induction agent and a rapidly acting neuromuscular blocking agent, followed by endotracheal intubation according to the planned approach. Modern practice has evolved beyond the traditional technique.Cricoid pressure is not routinely recommended in every case, and gentle facemask ventilation using low pressures may be considered in patients at risk of rapid oxygen desaturation, depending on the clinical situation and applicable guidelines. 5. Management of the Unanticipated Difficult Airway Unexpected airway difficulties may occur despite appropriate assessment and preparation. Therefore, a structured, stepwise approach is essential to maintain oxygenation and prevent clinical deterioration. • Plan A – Tracheal Intubation: Optimize head positioning, ensure adequate neuromuscular blockade, and use appropriate airway adjuncts while minimizing repeated attempts. • Plan B – Supraglottic Airway Devices: If intubation fails, insert a supraglottic airway device to restore oxygenation and ventilation. • Plan C – Facemask Ventilation: If supraglottic airway ventilation fails, attempt optimized facemask ventilation using airway adjuncts, with two-person ventilation when necessary. • Plan D – Emergency Front-of-Neck Access: Immediate emergency intervention is required in a Cannot Intubate, Cannot Oxygenate (CICO) situation. Emergency front-of-neck access should be performed according to the established protocol by appropriately trained personnel. Effective team communication, early recognition of failed attempts, and prompt transition to alternative strategies are essential for reducing complications. Conclusion Airway management is a central component of anesthetic safety and requires careful patient assessment, appropriate equipment preparation, effective preoxygenation, and selection of the most suitable airway technique for each clinical situation. The use of video laryngoscopy, adherence to established algorithms, and continuous training in emergency airway management can improve intubation success and reduce complications. Maintaining adequate oxygenation remains the highest priority throughout all stages of airway management. Al Mustaqbal University The First university in Iraq