Airway assessment

Dr sanjit kumar singh

Introduction
Respiratory events are the most common anaesthetic related
injuries, following dental damage. Three main causes:
Inadequate ventilation
Oesophageal intubation
Difficult tracheal intubation
Difficult tracheal intubation accounts for 17% of the respiratory
related injuries and results in significant morbidity and
mortality.
Estimated that up to 28% of all anaesthetic related deaths are
secondary to the inability to mask ventilate or intubate.
Prediction of the difficult airway allows time for proper
selection of equipment, technique and personnel experienced in
difficult airways

Airway
Nasal and oral
cavities
Pharynx
Larynx
Trachea and large
bronchi

Goals of preoperative
assessment
History and physical examination to
determine relevant tests and
consultations
Guided by patient choice and medical
risk factors choose a plan of care
Informed consent
Educate patient about anaesthesia, pain
management and perioperative care
Reduce patient care costs

Mortality related to anaesthesia

One third of deaths are preventable
Causes in order of frequency
inadequate patient preparation
inadequate postoperative management
wrong choice of anaesthetic technique
inadequate crisis management

Predicting the Difficult Airway

History
General, Physical and regional Examination
Specific test for assessment

History and
physical are the
most important
assessors of
disease and risk

HISTORY
Medical history
Surgical history
Anaesthetic history

Presenting complaint
Why does the patient need an operation now?
Is it acute/chronic illness?
Presenting symptoms?
e.g. anaemia, cachexia, pain, seizures etc
What are the pathophysiological consequences?

e.g. thyroid mass

Local - stridor, SVC obstruction
Systemic - hypo/hyperthyroidism

Associated medical conditions

Given the presenting problems are there any other
conditions I am worried the patient could have?
Bowel ca. - liver mets with abnormal LFTs, abnormal
coagulation, impaired drug metabolism
Peripheral vascular disease - IHD, carotid disease,
HT, renal disease, COAD

Other medical conditions

Any other problems that may affect
perioperative morbidity and mortality?

cardiac disease
respiratory disease
arthritis
endocrine disease - diabetes, obesity etc

What is the patients functional capacity?

Functional capacity
1 MET Can you dress yourself?
4 MET Can you climb a flight of stairs?
10 MET Can you participate in strenuous
activities
(swimming, tennis, football)

Physical demand characteristics of work

(1993 Leonard Matheson & Ministry of Labor)
Physical
Demand
Level

Occasional
0-33% work
day

Frequent
34-66% of
workday

Constant
67-100% of
workday

Typical Energy
Required

Sedentary

10 lbs

Negligible Negligible

1.5 -2.1 METS

Light

20 lbs

10 lbs

Negligible

2.2 3.5
METS

Medium

20-50 lbs

10-25 lbs

10 lbs

3.6 6.3
METS

Heavy

50-100 lbs

25-50 lbs

10-20 lbs

6.4 7.5
METS

Very
Heavy

Over 100
lbs

Over 50
lbs

Over 20 lbs Over 7.5

METS

Anaesthetic history
Family history
Previous anaesthetics
PONV
allergy
malignant hyperpyrexia
difficult airway
difficult IV access

ANAESTHETIC FACTORS
o Edema
o Compression or
perforation
o Pneumothorax
o Aspiration of gastric
contents

o Burns
o Bleeding
o Tracheal/oesophageal
stenosis

Drug history
Very useful, often forgotten
Current medications
ALLERGY
Medic alert bracelets
Smoking/alcohol history
Other drugs of abuse!

General, physical and regional

examination
i. Patency of nares : look for masses inside
nasal cavity
(e.g. polyps) deviated nasal septum, etc.
ii. Mouth opening of at least 2 large finger
breadths
iii. Teeth : Prominent upper incisors, or
canines

iv. Palate : A high arched palate or a long, narrow

mouth
may present difficulty.
v. Assess patients ability to protrude the lower
jaw
beyond the upper incisors (Prognathism).
vi. Temporo-mandibular joint movement : It can
be
restricted ankylosis/fibrosis, tumors, etc.
vii. Measurement of submental space (hyomental/
Thyromental length > 6 cm)

viii. Observation of patients neck : A short, thick

neck
ix. Presence of hoarse voice/stridor or previous
tracheostomy may suggest stenosis
x. Infections of airway (e.g. epiglottitis, abscess,
croup,
bronchitis, pneumonia).
xi. Physiologic conditions : Pregnancy and obesity

Specific tests for assessment

Anatomical criteria
1. Relative to tongue/pharyngeal size

Mallampati Score

Sensitivity: 44% - 81%

Specificity: 60% - 80%

Roughly corresponds to Cormack and Lehanes

laryngoscopy views
Class I (easy)visualization of the soft palate,
fauces, uvula, and both anterior and posterior
pillars
Class IIvisualization of the soft palate, fauces,
and uvula
Class IIIvisualization of the soft palate and the base
of the uvula
Class IV (difficult)the soft palate is not visible at all

Thyromental distance
Measure from upper edge of
thyroid cartilage to chin with
the head fully extended.
Normal is approx 7cm

Relatively unreliable test unless combined with

other tests.
Grade 3 or 4 Mallampati who also had a thyromental
distance of less than 7cm were likely to present
difficulty with intubation.
Sensitivity: 90.9%

Specificity: 81.5%

Atlanto-occipital movement
The patient is asked to hold head erect, facing directly to the front, then
he is asked to extend the head maximally and the examiner estimates the
angle traversed by the occlusal surface of upper teeth.
Visual assessment or using a goniometer.

Grade I >35 degrees

Grade II 22-34 degrees
Grade III 1221 degrees
Grade IV <12 degrees

Assesses feasibility to make the optimal intubation position with

alignment of oral, pharyngeal and laryngeal axes into a straight line.
Limited A-O joint extension

Spondylosis, rheumatoid arthritis, halo-jacket fixation, and in patients with

symptoms indicating nerve compression with cervical extension.

Further assessments
Sterno-mental distance
Measured from the sternum to the tip of the mandible
with the head extended.
A sternomental distance of 12.5cm predicts a difficult
intubation.

Mandibular protrusion
If the patient is able to protrude the lower teeth beyond
the upper incisors intubation is usually straightforward
If the patient cannot get the upper and lower incisors
into alignment intubation is likely to be difficult.

Dr. Binnions Lemon Law: An easy way to

remember multiple tests

Look externally.
Evaluate the 3-3-2 rule.
Mallampati.
Obstruction?
Neck mobility.

L: Look Externally

Obesity or very small.

Short Muscular neck
Large breasts
Prominent Upper Incisors (Buck Teeth)
Receding Jaw (Dentures)
Burns
Facial Trauma
Stridor
Macroglossia

E-Evaluate the 3-3-2 rule

3 fingers fit in mouth
3 fingers fit from mentum

to hyoid cartilage

2 fingers fit from the floor

of the mouth to the top of
the thyroid cartilage

27

M- Mallampati
Class-1

soft palate, fauces;

uvula, anterior and
the posterior pillars.

Class-111

soft palate and base of uvula

classification
Class-11

the soft palate, fauces

and uvula

Class-1V

Only hard palate

O: Obstruction?
Blood
Vomitus
Teeth
Epiglottis
Dentures
Tumors
Impaled Objects

N-Neck mobility -Measurement of

Atlanto-Occepital Angle

DIRECT LARYNGOSCOPY &

FIBREOPTIC BRONCHOSCOPY
Cormack & Lehane Grading

Radiographic assessment
1. From skeletal films (by measuring diff. length)
2. Fluoroscopy for dynamic imaging (cord
mobility, airway malacia, and emphysema).
3. Oesophagogram (inflammation, foreign body,
extensive mass or vascular ring).
4. Ultrasonography (mediastinal mass,
lymphadenopathy, cyst, cellulitis & abscess
5. Computed tomography/MRI (congenital
anamolies, vascular airway compression).
6. Video-optical intubation stylets).

Predictors of difficult airway in

diabetics
Palm print
Grade 0 All the phalangeal areas are visible.
Grade 1 Deficiency in the interphalangeal areas
of the 4th and 5th digits.
Grade 2 Deficiency in interphalangeal areas of
2nd to 5th digits.
Grade 3 Only the tips of digits are seen.

Prayer sign
Patient is asked to bring both the
palms together as Namaste and sign is
categorized as
Positive When there is gap between palms.
Negative When there is no gap between
palms.

Assessment of paediatric
airway
History
complaints of snoring, apnoea, day time
somnolence, stridor, hoarse voice and prior surgery
or radiation treatment to face or neck
History of previous anaesthetic records with
attention being paid to history of oropharyngeal
injury, damage to teeth, awake tracheal intubation or
postponement of surgery following an anaesthetic.

Physical examination
It should focus on the anomalies of face, head, neck
and spine.
Evaluate size and shape of head, gross features of
the face; size and symmetry of the mandible,
presence of sub-mandibular pathology, size of
tongue, shape of palate, prominence of upper
incisors, range of motion of jaw, head and neck.
The presence of retractions (suprasternal/sternal/
infrasternal/ intercostal) should be sought for they
usually are signs of airway obstruction.

 Breath sounds Crowing on inspiration is

indicative of extrathoracic airway obstruction
whereas, noise on exhalation is usually due to
intrathoracic lesions.
Noise on inspiration and expiration usually is due
to a lesion at thoracic inlet.
Obtaining blood gas and O2 saturation is
important to determine patients ability to
compensate for airway problems.
Transcutaneous CO2 determinations are very
helpful in infants and young children.

Difficult airway
ASA definition of difficult airway:
The clinical situation in which a
conventionally trained anaesthetist
experiences difficulty with mask
ventilation, difficulty with tracheal
intubation or both.

Difficult ventilation
The inability of a trained anesthetist to
maintain the oxygen saturation > 90% using
a face mask for ventilation and 100%
inspired oxygen, provided that the preventilation oxygen saturation level was
within the normal range.

Difficult intubation
More than 3 attempts
Longer than 10 minutes
Failure of optimal best attempt

Predictors of difficulty to face

mask ventilate (OBESE)
1.The Obese (body mass index >
26 kg/m2)
2.The Bearded
3.The Elderly (older than 55 y)
4.The Snorers
5.The Edentulous

Prevalence
Difficult face mask
0.1% - 5%

Difficult LMA
0.2% - 1%

Difficult intubation
1-2% of normal surgical population
50% of rheumatic cervical disease

Causes of difficult
Stiffness airway

Arthritis of neck/jaw/larynx.
Fixation devices
Scleroderma
Diabetes

Deformity
Cervical and craniofacial
Burns/trauma/infection

Swelling
Infection/tumour/trauma/burns
Anaphylaxis/haematoma/acromegaly

Reflexes
Cough/breathholding
Laryngospasm/salivation/regurgitation

Foreign body
Other Pregnant/full stomach/VIP

Wilsons risk score

Score
Weight

0=<90kg
1=>90kg
2=>110kg

Head and
neck
movement

0=Above 90degrees
1=About 90degrees
2=Below 90degrees

Jaw
movement

0=IG>5cm or SLux >0

1=IG<5cm and SLux = 0
2=IG<5cm and SLux<0

Receding
mandible

0=Normal
1=Moderate
2=Severe

Buck teeth

0=Normal
1=Moderate
2=Severe

Head movement assessed with

pencil taped to a patients forehead.
IG = Interincisor gap measured
with mouth fully open.
SLux = Maximal forward
protrusion of the lower incisors
beyond the upper incisors.

MANAGEMENT PLAN
OF
ANTICIPATED
DIFFICULT AIRWAY
45

Intubation
Equipment

TRAINED ASSISTANT
Laryngoscopes with a selection of blades
Variety of endotracheal tubes
Introducers for endotracheal tubes (stylets or flexible bougies)
Oral and nasal airways
A cricothyroid puncture kit
Reliable suction equipment
Laryngeal mask airways, sizes 3 AND 4

The safety of laryngoscopy can be increased by preoxygenating the patient prior to

induction and attempts at intubation.
Intubation is attempted by optimal direct laryngoscopy;

optimal head and neck positioning

optimal muscle relaxation
optimal laryngoscope blade
optimal external laryngeal manipulation
optimal use of the bougie

After intubation correct placement of the tube should be confirmed by:

Observing the tube pass through the cords

Successful inflation of the chest on manual ventilation
Auscultation over both lung fields in the axillae
Capnograph
If in doubt take it out

Consider the merits and feasibility

Awake Intubation

vs Intubation after induction

of GA
Non-Invasive technique vs
Invasive technique
for initial approach
for initial approach
Preservation of spontaneous vs
Ventilation

Ablation of spontaneous
ventilation

47

What are we going to do if we dont get the

Tube?

Plans A, B and C
Know this answer before you tube.

Plan A: (ALTERNATE)
Different Length of blade
Different Type of Blade
Different Position

Plan B: (BVM and BLIND INTUBATION

Techniques )
Can you Ventilate with a BVM? (Consider
two person mask Ventilation)
Combi-Tube?
LMA an Option?

What do we do when faced with a

Cant Intubate Cant Ventilate
situation?
Plan C: (CRIC) Needle, Surgical,

DIFFICULT AIRWAY MANAGEMENT:

Cant Intubate

Retrograde Intubation

52

TFE catheter: prevent the ET tube form redundancy over

the guidewire decrease trauma, increase success rate

References
Practice guidelines for management of the difficult airway: an updated
report by the American Society of Anesthesiologists Task Force on
Management of the Difficult Airway. Anesthesiology 2003; 98 (5):1269-77
Frerk CM. Predicting difficult intubation. Anaesthesia 1991; 46 (12):10058
Verghese C, Brimacombe JR. Survey of laryngeal mask airway usage in
11,910 patients: safety and efficacy for conventional and nonconventional
usage. Anesth Analg 1996; 82: 12933
Gupta S, Sharma R, Jain D. Airway assessment Predictors of a Difficult
Airway. Indian Journal Of Anaesthetics 2005; 49(4) : 257 -262
Wilson M, Spiegelhalter D, Robertson A, Predicting difficult intubation.
Br. J. Anaesth. (1988), 61, 211-216
The Difficult Airway Society Website: WWW.DAS.UK.COM
Reed M, Dunn M, McKeown D. Can an an airway assessment score
predict difficulty at intubation in the emergency department. Emerg Med J
2005;22:99102.