PUMA Logo designed by Nicholas Chrimes.


Airway management is practised by a wide variety of clinicians across a diverse range of settings, for numerous indications. Published airway guidelines have traditionally been developed by societies representing specific geographical regions, to address the requirements of airway operators practising in a particular discipline and context - typically focusing on the situation where intubation is the primary goal. Such guidelines are important to highlight the requirements for safe, effective care in these defined circumstances but may obscure the core underlying principles that transcend the context in which airway management occurs. In addition their context specific nature prevents them being directly applied to some clinical situations.

The goal of the  Project for Universal Management of Airways is to produce a set of principles that reflects, as much as possible, the consensus of existing published airway guidelines and can be applied to all episodes of airway care, across boundaries of geography, clinical discipline or context. The term 'universal' is used to reflect that the guideline developed will not only reflect international consensus but that it articulates appropriate management principles independent of: 

  • Geography

  • Provider: anesthesiologists, emergency physicians, intensivists, pre-hospital clinicians, nurse anesthetists, airway assistants, surgeons - whether trainees or consultants

  • Patient characteristics: adult, paediatric, obstetric, trauma, critically-ill, fasted, unfasted

  • Indication: surgery, resuscitation, respiratory compromise, impaired conscious state, etc

  • Urgency: emergency, elective

  • Location: operating room, emergency department, intensive care unit, ‘off-the-floor’ anesthetising locations, wards, prehospital

  • Complexity: routine or complex cases, independent of whether airway difficulty is anticipated or encountered

  • Primary intended airway: face-mask, supraglottic airway or tracheal tube.

The intention is for the universal guideline to complement existing guidelines by emphasising unifying basic principles, facilitating interdisciplinary team performance and assisting to standardise the approach to airway management globally.



The PUMA project will produce four main documents that together provide comprehensive recommendations for airway management.

  1. Universal Principles for Airway Assessment: What should clinicians be looking for?

  2. Universal Principles for Airway Strategy: What should clinicians do in the face of their airway assessment?

  3. Universal Principles for Airway Rescue: What should clinicians do if it all goes wrong?

  4. Universal Principles for Communication of Airway Outcomes: What should clinicians tell the next person?



An international and multidisciplinary working group of airway specialists has been assembled to determine the key issues to be addressed by airway management guidelines and review the existing guidelines in order to identify areas of consensus in relation to these.

Where the working group identifies that strong consensus exists amongst airway guidelines on key issues, these will be adopted as the recommendations of the universal guideline. No further consultation or literature review will be performed in this situation given such recommendations are already based on extensive review of the literature, .

The input of a broader advisory group of airway practitioners will be sought, in combination with a selective review of the relevant literature, to support any recommendations made in the following situations: 

  • Where guideline recommendations on key issues diverge.

  • Where key issues are not addressed by the existing guidelines in a manner that supports universal application of a recommendation.

  • Where there have been recent significant developments in relation to key issues that are not widely reflected in the existing guidelines.

  • As otherwise required in the judgement of the working and/or advisory groups.

The working and advisory groups for this project are comprised of physicians working in anesthesiology, critical care, emergency medicine, surgery and pre-hospital care and include representation from authors of most of the published practice guidelines produced by the various airway societies. 

A draft of the universal guideline will be circulated to the advisory group and key organisations representing airway practitioners internationally, for discussion and feedback before the final guideline is produced.



June 2016: First meeting of working group in London

2016 - 2017: Terms of reference and methodology defined, key areas for comment determined, review of existing guidelines undertaken.

2017 - 2019: Literature review & drafting of consensus recommendations.

November 2019: Presentation of PUMA concept, methodology and ‘teaser’ content at World Airway Management Meeting in Amsterdam.

2020: Publication of PUMA recommendations



Carin Hagberg, Anesthesiology, United States (Executive Chair)

Nicholas Chrimes, Anaesthesiology, Australia (Project Lead)

Paul Baker, Anaesthesia, New Zealand

Richard Cooper, Anesthesiology, Canada 

Robert Greif, Anaesthesiology, Switzerland

Andy Higgs, Anaesthesia and Intensive Care Medicine, United Kingdom

George Kovacs, Emergency Medicine, Canada

J. Adam Law, Anesthesiology, Canada

Sheila Nainan Myatra, Anaesthesiology and Intensive Care Medicine, India

Ellen O'Sullivan, Anaesthesia, Ireland

William Rosenblatt, Anesthesiology, United States

Christopher Ross, Emergency Medicine, United States

John Sakles, Emergency Medicine, United States

Massimiliano Sorbello, Anaesthesiology and Intensive Care Medicine, Italy



  • Pedro Acha, Emergency Medicine, Spain

  • Imran Ahmad, Anaesthesia, United Kingdom

  • Tak Asai, Anesthesiology, Japan

  • Michael Aziz, Anesthesiology, United States

  • Darren Braude, Emergency Medicine and Paramedicine, United States

  • David Brewster, Intensive Care Medicine and Anaesthesia, Australia

  • Garry Brydges, Certified Registered Nurse Anesthetist, United States

  • Simon Carley, Emergency Medicine, United Kingdom

  • Pedro Charco Mora, Anesthesiology and Intensive Care, Spain

  • Tim Cook, Anaesthesia and Intensive Care Medicine, United Kingdom

  • Anil D'Cruz, ENT Surgery, India

  • Pierre Diemunsch, Anaesthesiology and Intensive Care Medicine, France

  • Karen Domino, Anesthesiology, United States

  • Laura Duggan, Anesthesiology, Canada

  • Thomas Engelhardt, Anaesthesia, United Kingdom

  • John Fiadjoe, Anesthesiology, United States

  • Kirstin Fraser, Anaesthetic Technician, New Zealand

  • Paul Gardiner, Anaesthesia and Intensive Care Medicine, New Zealand

  • John Gatward, Intensive Care Medicine and Anaesthesia, Australia

  • Keith Greenland, Anaesthesia, Australia

  • Thomas Heidegger, Anaesthesiology, Switzerland

  • Ross Hofmeyr, Anaesthesiology and Emergency Medicine, South Africa

  • Russ Horowitz, Intensive Care and Emergency Medicine, United States

  • Mike Hubble, Paramedic, United States

  • Hans Huitink, Anaesthesiology, Netherlands

  • Eric Hodgson, Anaesthesiology, South Africa

  • Samir Jaber, Intensive Care Medicine, France

  • Narasimhan Jagannathan, Anesthesiology, United States

  • Sachin Kheterpal, Anesthesiology, United States

  • Michael Kristensen, Anaesthesiology, Denmark

  • Olivier Langeron, Anaesthesiology and Intensive Care Medicine, France

  • Richard Levitan, Emergency Medicine, United States

  • Zonghao Li, Emergency Medicine, China

  • David Lockey, Emergency Medicine, United Kingdom

  • Ana Lopez Gutierrez, Anaesthesiology, Spain

  • Stephen Lai, ENT Surgery, United States

  • Wuhua Ma, Anesthesiology, China

  • Greg Mastrapolo, Anesthesiologist Assistant, United States

  • Jarrod Mosier, Emergency and Intensive Care Medicine, United States

  • Mary Mushambi, Anaesthesia, United Kingdom

  • Fiona Newman, Perianaesthesia Nursing, Australia

  • Chris Nickson, Emergency and Intensive Care Medicine, Australia

  • Reza Nouraei, ENT Surgery, United Kingdom

  • David Olvera, Paramedic, United States

  • Haydee Osses, Anesthesiology, Chile

  • Anil Patel, Anaesthesia, United Kingdom

  • Toby St Clair, Paramedic, Australia

  • Wendy Teoh, Anaesthesia, Singapore

  • Arnd Timmermann, Anesthesiology, Germany

  • Britta Ungern-Sternberg, Anaesthesia, Australia

  • Oscar Valencia, Anaesthesiology, Spain

  • Henry Wang, Emergency Medicine, United States

  • Scott Weingart, Emergency Medicine, United States

  • David Wong, Anesthesiology, Canada

  • Ming-Zhang Zuo, Anesthesiology, China



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