Airway AssessmentAirway Assessment

Harold F. TambajongHarold F. TambajongBgn / UPF Anestesiologi FK Universitas Sam Ratulangi / Bgn / UPF Anestesiologi FK Universitas Sam Ratulangi /

RSU Prof. dr. RD. KandouRSU Prof. dr. RD. KandouManadoManado

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

Respiratory events are the most common Respiratory events are the most common anesthetic related injuries anesthetic related injuries The three main causes of respiratory The three main causes of respiratory related injuries: related injuries:

Inadequate ventilation Inadequate ventilation Esophageal intubation Esophageal intubation Difficult tracheal intubation. Difficult tracheal intubation.

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

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

ASA Closed Claims

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

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

Difficult AirwayDifficult Airway Clinical situation in which a conventionally Clinical situation in which a conventionally

trained anesthesiologist experiences trained anesthesiologist experiences difficulty with face mask ventilation of the difficulty with face mask ventilation of the upper airway, difficulty with tracheal upper airway, difficulty with tracheal intubation, or both.intubation, or both.

Difficult Face Mask Ventilation Difficult Face Mask Ventilation (DMV)(DMV)

It is not possible for the anesthesiologist to It is not possible for the anesthesiologist to provide adequate face mask ventilation provide adequate face mask ventilation due to one or more of the following due to one or more of the following problems:problems:

Inadequate mask sealInadequate mask sealExcessive gas leak Excessive gas leak Excessive resistance to the ingress or Excessive resistance to the ingress or egress of gas.egress of gas.

Difficult Face Mask Ventilation Difficult Face Mask Ventilation (DMV)(DMV)

Signs of inadequate face mask ventilation Signs of inadequate face mask ventilation include (but are not limited to) include (but are not limited to) absent or inadequate chest movementabsent or inadequate chest movementabsent or inadequate breath soundsabsent or inadequate breath soundsauscultatory signs of severe obstruction, auscultatory signs of severe obstruction, cyanosis, gastric air entry or dilatationcyanosis, gastric air entry or dilatationdecreasing or inadequate SpO2decreasing or inadequate SpO2

Difficult Face Mask Ventilation Difficult Face Mask Ventilation (DMV)(DMV)

Signs of inadequate face mask ventilation Signs of inadequate face mask ventilation include (but are not limited to):include (but are not limited to):– absent or inadequate exhaled CO2absent or inadequate exhaled CO2– absent or inadequate spirometric absent or inadequate spirometric

measures of exhaled gas flowmeasures of exhaled gas flow– hemodynamic changes associated with hemodynamic changes associated with

hypoxemia or hypercarbia (hypoxemia or hypercarbia (e.g.e.g., , hypertension, tachycardia, arrhythmia).hypertension, tachycardia, arrhythmia).

Difficult LaryngoscopyDifficult Laryngoscopy

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

Difficult Tracheal IntubationDifficult Tracheal Intubation

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

Failed IntubationFailed Intubation

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

HistoryHistory

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

Physical ExaminationPhysical 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:Langeron et al: “OBESE”“OBESE”

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

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

Ron WallsRon Walls:: LEMON / MELON LEMON / MELON Physical signs for predicting difficult intubationPhysical signs for predicting difficult intubation

LLook externally (abnormal facial shape / trauma, ook externally (abnormal facial shape / trauma, large incisorslarge incisors, beard or moustache, large tongue), beard or moustache, large tongue)EEvaluate the 3-3-2 rule (valuate the 3-3-2 rule (inter-incisor <3 fingerbreadthsinter-incisor <3 fingerbreadths, , hyoid/mental distance < 3 fingerbreadths, hyoid/mental distance < 3 fingerbreadths, thyroid-to-mouth thyroid-to-mouth distance < 2 fingerbreadthsdistance < 2 fingerbreadths

MMallampati scoreallampati scoreOObstruction (presence of any condition that could bstruction (presence of any condition that could cause an obstruction airway)cause an obstruction airway)NNeck mobilityeck mobility

LEMON LEMON 3-3-2 rule3-3-2 rule

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

Mallampati ClassificationMallampati Classification

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

Cormack and LehaneCormack and Lehane:: Laryngoscopic View 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-MAPLM-MAP

LLook for External face Deformitiesook for External face DeformitiesMMallampatiallampati

MMeasurements 3-3-2-1 OR 1-2-3-3 easurements 3-3-2-1 OR 1-2-3-3 FingersFingersAA-O (Atlanto-Occipital) Extension-O (Atlanto-Occipital) ExtensionPPathological obstructive Conditions, athological obstructive Conditions, Edema / Glottic Trauma Edema / Glottic Trauma

Atlanto-Occipital Joint (AO) ExtensionAtlanto-Occipital Joint (AO) Extension

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

spondylosis, RA etcspondylosis, RA etc

Four D'sFour D's

DentitionDentition (prominent upper incisors, (prominent upper incisors, receding chin) receding chin) DistortionDistortion (edema, blood, vomits, tumor, (edema, blood, vomits, tumor, infection) infection) DisproportionDisproportion (short chin-to-larynx (short chin-to-larynx distance, bull neck, large tongue, small distance, bull neck, large tongue, small mouth) mouth) DysmobilityDysmobility (TMJ and cervical spine) (TMJ and cervical spine)

Magboul 4 M-stop Magboul 4 M-stop

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

Suggested Contents of the Portable Storage Unit forSuggested Contents of the Portable Storage Unit forDifficult Airway ManagementDifficult Airway Management

Rigid laryngoscope blades of alternate design and size from those routinely used; this may include a rigid fiberoptic laryngoscopeTracheal tubes of assorted sizesTracheal 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 tubeLaryngeal mask airways of assorted sizes; this may include the intubating laryngeal mask airway and the LMA-ProsealTM Flexible fiberoptic intubation equipmentRetrograde intubation equipmentAt 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 ventilatorEquipment suitable for emergency invasive airway access (e.g., cricothyrotomy)An exhaled CO2 detector

ConclusionConclusion

Take a history and perform an examination. No single airway test can provide a high index of sensitivity and specificity for prediction of difficult airwayAnticipation of a difficult airway will help us to best manage the airway and avoid disasters. If the patient’s airway is managed badly the patient may suffer severe complications or death.

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