Airway Assessment

Harold F. Tambajong Bgn / UPF Anestesiologi FK Universitas Sam Ratulangi / RSU Prof. dr. RD. Kandou Manado

Expertise in airway management is essential in every medical speciality. Maintaining a patent airway is essential for adequate oxygenation and ventilation. Failure to do so, even for a brief period of time, can be life threatening.

Respiratory events are the most common anesthetic related injuries The three main causes of respiratory related injuries: Inadequate ventilation Esophageal intubation Difficult tracheal intubation.

Difficult tracheal intubation accounts for 17% of the respiratory related injuries and results in significant morbidity and mortality. Up to 28% of all anesthesia related deaths are secondary to the inability to mask ventilate or intubate.

ASA Closed Claims

Difficult Intubation (6.4% ) Inadequate Ventilation / Oxygenation (7% ) Esophageal Intubation (4.5% ) Wrong Drug or Dose (4% ) Other Claims (78,4% )

N= 4459 Brain damage or death: 57% of the 283 claims (difficult intubation) 31% obese Sicker and older

Miller CG. Management of the Difficult Intubation in Closed Malpractice Claims ASA Newsletter, No.6, Vol. 64, June 2000

Difficult Airway
Clinical situation in which a conventionally trained anesthesiologist experiences difficulty with face mask ventilation of the upper airway, difficulty with tracheal intubation, or both.

Difficult Face Mask Ventilation (DMV)

It is not possible for the anesthesiologist to provide adequate face mask ventilation due to one or more of the following problems: Inadequate mask seal Excessive gas leak Excessive resistance to the ingress or egress of gas.

Difficult Face Mask Ventilation (DMV)

Signs of inadequate face mask ventilation include (but are not limited to) absent or inadequate chest movement absent or inadequate breath sounds auscultatory signs of severe obstruction, cyanosis, gastric air entry or dilatation

decreasing or inadequate SpO2

Difficult Face Mask Ventilation (DMV)

Signs of inadequate face mask ventilation include (but are not limited to): absent or inadequate exhaled CO2 absent or inadequate spirometric measures of exhaled gas flow hemodynamic changes associated with hypoxemia or hypercarbia (e.g., hypertension, tachycardia, arrhythmia).

Difficult Laryngoscopy
It is not possible to visualize any portion of the vocal cords after multiple attempts at conventional laryngoscopy.

Difficult Tracheal Intubation

Tracheal intubation requires multiple attempts, in the presence or absence of tracheal pathology.

Failed Intubation
Placement of the endotracheal tube fails after multiple intubation attempts.

History
An airway history should be conducted to detect medical, surgical, and anesthetic factors that may indicate the presence of a difficult airway. Examination of previous anesthetic records

Physical Examination
An airway physical examination should be conducted to detect physical characteristics that may indicate the presence of a difficult airway. Multiple airway features should be assessed.

Components of the Airway Physical Examination

1. Length of upper incisors (Relatively long) 2. Relation of maxillary and mandibular incisors during normal jaw closure (maxillary incisors anterior to mandibular incisors) 3. Relation of maxillary and mandibular incisors during voluntary protrusion of cannot bring (mandibular incisors anterior to maxillary incisors) 4. Interincisor distance (< 3 cm) 5. Visibility of uvula (Mallampati class greater than II) 6. Shape of palate (Highly arched or very narrow) 7. Compliance of mandibular space (Stiff, indurated, occupied by mass) 8. Thyromental distance (< 3 ordinary finger breadths, <6cm) 9. Length of neck (Short) 10. Thickness of neck (Thick) 11. Range of motion of head and neck (Patient cannot touch tip of chin to chest or cannot extend neck)

Additional Evaluation
Additional evaluation may be indicated in some patients to characterize the likelihood or nature of the anticipated airway difficulty.

Langeron et al:

OBESE

The Five Predictors of DMV and Oxygenation:

The Obese (body mass index > 26 kg/m2) The Bearded The Elderly (older than 55 yr) The Snorers

The Edentulous

Presence of two indicating high likelihood of DMV (sensitivity, 0.72; specificity, 0.73).

Ron Walls:

LEMON / MELON

Physical signs for predicting difficult intubation Look externally (abnormal facial shape / trauma, large incisors, beard or moustache, large tongue) Evaluate the 3-3-2 rule (inter-incisor <3 fingerbreadths,
hyoid/mental distance < 3 fingerbreadths, thyroid-to-mouth distance < 2 fingerbreadths

Mallampati score Obstruction (presence of any condition that could cause an obstruction airway) Neck mobility

LEMON 3-3-2 rule

1 = Inter-incisor distance in fingers, 2 = Hyoid mental distance in fingers, 3 = Thyroid to floor of mouth in fingers

Mallampati Classification

Class I : Visualization of the soft palate, fauces; uvula, anterior and the posterior pillars. Class II : Visualization of the soft palate, fauces and uvula. Class III : Visualization of soft palate and base of uvula. Class IV: Only hard palate is visible. Soft palate is not visible at all.

Cormack and Lehane:

Laryngoscopic View

Grade I Visualization of entire laryngeal aperture. Grade II Visualization of only posterior commissure of laryngeal aperture. Grade III Visualization of only epiglottis. Grade IV Visualization of just the soft palate. Predict difficult intubation.

LM-MAP
Look for External face Deformities Mallampati

Measurements 3-3-2-1 OR 1-2-3-3 Fingers A-O (Atlanto-Occipital) Extension Pathological obstructive Conditions, Edema / Glottic Trauma

Atlanto-Occipital Joint (AO) Extension

Grade I : >35 Normal angle of extension is 35 or more. Grade II : 22-34 Grade III : 12-21 Grade IV : < 12 spondylosis, RA etc

Four D's
Dentition (prominent upper incisors, receding chin) Distortion (edema, blood, vomits, tumor, infection) Disproportion (short chin-to-larynx distance, bull neck, large tongue, small mouth) Dysmobility (TMJ and cervical spine)

Magboul 4 M-stop

If the patient Score 8 or higher, he is likely to be a difficult intubation

Suggested Contents of the Portable Storage Unit for Difficult Airway Management
Rigid laryngoscope blades of alternate design and size from those routinely used; this may include a rigid fiberoptic laryngoscope Tracheal tubes of assorted sizes Tracheal tube guides. Examples include (but are not limited to) semirigid stylets, ventilating tube changer, light wands, and forceps designed to manipulate the distal portion of the tracheal tube Laryngeal mask airways of assorted sizes; this may include the intubating laryngeal mask airway and the LMA-ProsealTM Flexible fiberoptic intubation equipment Retrograde intubation equipment At least one device suitable for emergency noninvasive airway ventilation. Examples include (but are not limited to) an esophageal tracheal Combitube, a hollow jet ventilation stylet, and a transtracheal jet ventilator Equipment suitable for emergency invasive airway access (e.g., cricothyrotomy) An exhaled CO2 detector

Conclusion
Take a history and perform an examination. No single airway test can provide a high index of sensitivity and specificity for prediction of difficult airway Anticipation of a difficult airway will help us to best manage the airway and avoid disasters. Ifthepatientsairwayismanagedbadlythe patient may suffer severe complications or death.