PUMA guidelines: safe airway management starts with the system, not the laryngoscope

The Project for Universal Management of Airways, an international multidisciplinary group, published guidelines on 27 August in Anaesthesia on the foundation an organisation needs before any individual airway is managed. They were developed through literature review, structured expert consensus and consultation with airway operators, assistants and human factors experts, and graded using the American Heart Association system.

The key components are the design of systems and clinical environments; suitable, functional equipment and monitoring; training in both procedural and behavioural skills; and a patient-centred, fair and just, no-blame culture. The authors recommend human factors input to understand how these elements interact with practitioners and teams.

The guidance is designed to apply regardless of country, specialty or setting — from the operating theatre to the emergency department and ward — which makes it directly relevant to hospitals where airway equipment and staffing vary widely.

• Standardise the layout and contents of airway trolleys across every area where airways are managed.
• Check that capnography is available and working wherever airway management happens.
• Train teams in behavioural skills — communication and speaking up — alongside technical airway skills.
• Review airway incidents in a no-blame format that looks at systems, not individuals.

Why it matters

Most airway disasters trace back to systems — missing kit, unfamiliar layout, unspoken concerns — rather than technique alone.

Don't overread it

These are consensus recommendations; they have not been tested for their effect on patient outcomes.

Read the rest in the app

You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.

Get Daily Doctor — free

Scan to keep reading on your phone. No account needed to start.