Airway assessment

Dr James Hayward SHO Anaesthetics Worthing

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

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

Airway assessment

History
Patient/notes/chart/medic-alert/spam letter
Difficulty Surgery/burns Concurrent disease Reflux/recent meals

General examination
Do they just look difficult?
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)

Massively obese or pregnant Beards +/- tubes

Specific tests Investigations.

Nasoendoscopy X-ray CT/MRI Flow volume loop

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.

Wilsons risk score

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

Head and neck movement

Jaw movement Receding mandible Buck teeth

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

0=IG>5cm or SLux >0 1=IG<5cm and SLux = 0 2=IG<5cm and SLux<0 0=Normal 1=Moderate 2=Severe 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.

Results

633 Patients
Risk factor Weight Head and neck movement Jaw movement Receding mandible Buck teeth Score 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 Normal (%) Difficult (%) 95 90 27 6 1 4 91 54 6 22 3 24 92 38 7 34 0.4 28 97 58 3 32 0.2 10 96 64 3 24 0.4 12 P 0.05

0.001

0.001

0.001

0.001

True positive (%) False positive (%) Risk Criteria Initial Prospective Initial Prospective >6 8 0 0 >5 17 0 0.3 >4 36 42 0 0.8 >3 52 50 1 4.6 >2 72 75 6 12.1 >1 86 92 24 26.2 Effect of varying the criterion for identifying "difficult patients".

LEMON trial

156 A+E patients

114 Grade I 42 Grade II and above

Look
Facial trauma Large incisors Beard Large tongue

Evaluate 3-3-2
Interincisor distance (3 fingers) Hyoidmental distance (3 fingers) Thyroid to floor of mouth (2fingers)

Mallampati Obstruction Neck movement chin to chest

Results

No significant difference
Sex Age Facial trauma (11.3% vs 12.2%) Large tongue (1.0% vs 4%) Hyoid to chin (35% vs 45%) Mallampati score (p=0.41) Airway obstruction (6.5% vs 14.3%) Neck mobility (16.2% vs 28.6%)

Results (2)

Significant difference
Large incisors (6.5% vs 28.6%, p<0.001) Reduced inter-incisor difference (38.2% vs 69%, p<0.05) Reduced thyroid to floor of mouth difference (13.4% vs 41.2%, p<0.05) Total correlated with difficulty (r=0.38, p<0.001)

Comments
Easy to remember and simple. Look criteria Definition of difficult intubation

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 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

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

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):126977 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.