Your airway and ventilation management begins as you approach the

patient and before you have done any hands on clinical assessment.

MOANS
Airway and ventilation management begins and depends on bag-mask-ventilation, (BVM). You
must be able to have a good seal with the mask or you will not be able to effectively ventilate the
patient. Studies show that there are clear visual cues that will provide insight to whether are not
you will have difficulty with mask seal. These can be remembered using the mnemonic:
MOANS.

MOANS: Predictors of Mask seal difficulty

 Mask seal, (receding chin, facial hair)

 Obesity or obstruction—(history of snoring),
 Age >55 yr.,
 No teeth, (abnormal or protruding teeth)
 Stiff lungs, ---(pathophysiology is abnormal, COPD barrel chest)

When 2 are present, the need exists for adjunctive maneuver for successful mask seal (eg, oral-
nasal airway, better positioning);
Now you need to intubate: how to predict if this might be a difficult intubation.
There are various other mnemonics, ‘LEMON’ combines most of the commonly
used methodologies

Airway Assessment Using "LEMON" Score

Predicts Difficult ED Intubation
Use of this tool can reduce the chance of unexpectedly encountering a difficult airway.

As many as 1% of emergency department intubations end up as a "failed airway" (unable to

intubate the patient). One tool developed to determine which patients might pose airway
management difficulties is the LEMON method. The authors of this study from Scotland
developed an airway assessment score based on this method and determined the score's utility in
predicting difficult airways in the ED. They studied 156 patients who were intubated
successfully in a single ED between June 2002 and September 2003.

The score, with a maximum of 10 points, was calculated by assigning 1 point for each of the
following LEMON criteria:

 L=Look externally (facial trauma, large incisors, beard or moustache, and large tongue—
four points total)
 E=Evaluate the 3-3-2 rule (incisor distance <3 fingerbreadths, hyoid/mental distance <3
fingerbreadths, thyroid-to-mouth distance <2 fingerbreadths---three points total)
 M=Mallampati (Mallampati score 3---one point)
 O=Obstruction (presence of any condition that could cause an obstructed airway---one
point)
 N=Neck mobility (limited neck mobility---one point).

For each patient, the airway assessment score was compared with the Cormack-Lehane
laryngoscopic view seen during intubation (1=full view, 4=glottis not visualized). At intubation,
114 patients were classified as Cormack-Lehane grade 1 (defined by the authors as easy
intubation), and 42 were classified as grade 2 or higher (defined by the authors as difficult
intubation). Patients in the difficult-intubation group had significantly higher LEMON scores
than did those in the easy-intubation group. Of the criteria used to calculate the score, only large
incisors, inter-incisor distance <3 fingerbreadths, and thyroid-to-floor-of-mouth distance <2
fingerbreadths were associated significantly with difficult intubation.

Comment: Emergency physicians can significantly reduce their likelihood of inadvertently

encountering difficult intubations by assessing airways before intubation. This study validates
that the LEMON method predicts which patients have difficult-to-manage airways.

— Diane M. Birnbaumer, MD, FACEP

Published in Journal Watch Emergency Medicine February 16, 2005

Citation(s): Reed MJ et al. Can an airway assessment score predict difficulty at

intubation in the emergency department? Emerg Med J 2005 Feb; 22:99-102.
Monitoring the ETT after it has been placed!

DOPE:
The best patient care you can provide is one of constant vigilance and good clinical
assessment.

Dope is a mnemonic to help to remember all of issues that may be adversely affecting your
ability to ventilate a patient through an endotracheal tube, (ETT). It is short, concise and easy to
remember. Keep in mind that your patient is now not adequately ventilating if at all. If you
cannot rapidly identify and fix the problem, then your patient not only will continue to
deteriorate, but will likely die.

By quickly separating the patient from possible equipment issues and going to mask ventilation
you have eliminated the great majority of potential problems and you have almost always started
the solution. Pulling out an ETT and going to mask ventilation will fix three of the four ‘DOPE’
issues---so your threshold to pull out the ETT should be low. When in doubt—pull it out.

At the same time, you do not want pull out a well-placed ETT as this is not without risk. While
it is true that when in doubt, pull it out, there are a few things to check before removing a
perfectly good ETT. Usually, you have very little time to identify and correct any problem---this
means rapid identification and where “DOPE” can be very helpful.

D – Dislodged. The endotracheal tube has come out of the trachea for whatever reason. This is
the first letter in the mnemonic and it is the most frequent problem. You should notice that the
resistance (compliance) when ventilating has changed and is now very low as there is no back
pressure exerted from the lungs. The fix is to remove the tube and mask ventilate the patient
until a new ETT can be reinserted. Consider the use of cricoid pressure to help reduce the risk
of aspiration---particularly if the patient has required medication to intubate, (Rapid Sequence
Induction).

However, first take just an instant to make sure the balloon on the cuff is still inflated. Keep in
mind that you have to deflate the balloon anyway to remove the ETT. So while the balloon for
the cuff is in your hand, check the balloon to see if it is still holding pressure. It is possible that
the cuff has a hole---if the cuff held pressure initially, then this is often times a slow leak. Thus,
reinflating the cuff may be worth the time. In which case, you have bought time to prepare for
replacing the ETT. This can now be done at lower risk over a tube exchanger versus having to
reintubate using standard technique (DL) and the risks that comes with that procedure.

O – Obstructed. The endotracheal tube, trachea, or bronchus(i) is blocked for some reason. The
most common problem is one of secretions and/or dried mucous. Suction is the fix and will take
care of secretions and/or mucus plugging. This also can take time to accomplish. If you can not
immediately clear the ETT, then the fix is to pull it and mask ventilate the patient. Also,
consider that the ETT could be crimped from biting in which case a bite block or oral airway can
be inserted to protect the tube and the tube does not need to be removed. If a reinforced ETT has
been used, then the tube may suffer a permanent restriction after a bite mandating replacement of
the ETT
P – Pneumothorax. (This is a tension pneumothorax.) Anyone on positive pressure ventilation
is at risk for developing a pneumothorax that often will then become a tension pneumothorax.
You should be particularly suspicious of a tension pneumothorax for any patient that has recently
been put on positive pressure ventilation and suddenly and rapidly deteriorates. The solution is a
needle decompression followed by a chest tube. You should not pull the ETT unless you suspect
you have additional problems---this ETT is saving the patient’s life. .

E – Equipment. Aside from ‘D’ and ‘O’ which could be seen as equipment issues, ‘E’ refers to
all of the other potential equipment problems. For example, an interruption in the oxygen supply
as the oxygen has run out or the oxygen supply tubing has come off the regulator. The key here
is to separate the equipment from the patient. You have just eliminated half of the problem. This
usually is going to mean manual bag ventilation. You must verify the ETT placement or you are
going to have to consider pulling the ETT and go to mask ventilation. Consider a new BVM
also.

Get additional help.

Check your equipment one by one. A good and proven technique is to ‘start at the source’---
(tubing connected to the flow meter and the flow meter is putting out oxygen) ---and working out
to the patient.

When it comes to ventilation, sudden change is generally bad, and often mechanical. This can be
mechanical within the patient, such as a tension pneumothorax, (& PE), or in the equipment
delivering the therapy.