CLAIR Score: A Novel Risk Prediction Tool for Unmasking Unanticipated Difficult Airways

Background Unanticipated difficult airways remain a significant challenge in anesthesia practice and are associated with increased severe complication risk. In this study, we developed and validated the CLAIR risk prediction tool to enhance early identification of unanticipated difficult airways. Methods This retrospective case-control study analyzed data from 62,111 patients who underwent general anesthesia between 2015 and 2020. Among them, 98 unanticipated difficult airways were identified and matched in a 1:3 ratio with 294 controls. Multivariate logistic regression identified key predictors, forming the CLAIR score, which incorporates coagulopathy, hypocalcemia, female sex, potential airway difficulty, and inexperienced residents. Results The incidence of unanticipated difficult airways was 0.16%. The CLAIR score demonstrated an area under the receiver operating characteristic curve of 0.633, with high sensitivity (98%) despite lower specificity (16%). A cutoff of 0 effectively stratified patients into high (≥ 1), and low (≤-1) risk groups, guiding airway management strategies. Its web-based risk calculator and QR code enhance accessibility for real-time clinical applications. Conclusions The CLAIR score is a simple, practical, and user-friendly tool that improves preoperative risk assessment and preparedness for difficult airways. While further external validation is necessary, its integration into routine anesthesia practice may enhance patient safety and optimize airway management strategies.