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AIRWAY ASSESSMENT
&PREDICTORS OF
DIFFICULT AIRWAYBy
Dr Riyas A
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INTRODUCTION Expertise in airway management is
essential in every medical speciality Maintaining a patent airway is essential
for adequate oxygenation and ventilation and failure to do so ,even for a short duration can be life threatening
Respiratory events are the second common injuries in anaesthesia practise
Causes of respirtory related injuries are inadequate ventilation,oesophageal
intubation,difficult tracheal intubation
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DIFFICULT AIRWAYIt’s is one in which there is a problem in
establishing or maintaining a gas exchange via a mask ,an artificial airway or both
Recognising these difficulties before anaesthesia allows time for optimal preparation ,proper selection of equipments and tehniques and participation of perssonal who is experienced in DA management
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ASSESSMENT History Medical ,surgical or anaesthetic factor
may be indicative of a difficult airway Some factors which could prdispose to
difficult airway are 1)burns 2)oedema 3)bleeding 4)tracheal stenosis 5)perforation,etc….
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SOME AIRWAY COMPROMISING CONDITIONScongenital 1)Pierre robbing
syndrome2)Goldenhar’s syndrome3)Treacher collins syndrome4)Downs5)Goiter6)Kippel fiel syndrome
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CONTINUATION… Acquired Infection 1)Croup
2)Supraglottic3)Intra oral and retropharyngeal abscess4)Ludwigs angina
Arthirtis Ankylosing spondylitis
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GENERAL PHYSICAL AND REGIONAL EXAMINATION Patency of nares Mouth opening of at least 2 large finger
breadths between upper and lower incisors
Teeth: Palate:high arched plate ,enlarged
tonsilnarrow mouth Assesses patients ability to protrude the
lower jaw beyond the upper incisors Temporo mandibular joint movement
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GPE AND RE CONTINUATION…. Measurement of submental
space(hyomental/thyromental length should be >6)
Observation of patient neck Presence of hoarse voice /stridor or any
history of tracheostomy suggest stenosis
Any systemic or congenital disease requiring special attention during air way management(respiratory ,significant coronary artery disease,acromegaly)
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GPE AND RE CONTINUATION… General assessment of body habitus can
yield important information Infections of airway Physiological conditions
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CONDITIONS TO BE LOOKED FOR DIFFICULT MASK VENTILATION… Presence of beard Body mass index Lack of teeth Age and snoring Jewellery worn by piercing the
lips ,tongue,cheek ,chin eye brows and ear may also create difficulty in mask ventilation…
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SPECIFIC TESTS FOR ASSESSMENT A ) Anatomical criteria 1]tongue and phayngeal size
relation….. a) Mallampatti score….head in neutral
position , patient sitting , mouth wide open ,tongue protruding maximum,patient shouldn’t be actively encouraged to phonate as it can result in contraction and elevation of soft palate leading to false positive result
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MALLAMPATTI SCORE Class 1:Visualisation of anterior and
posterior pillars,soft palate,uvula,hard palate
Class 2:visualisation of uvula,soft palate and hard palate
Class 3:visualisation of softpalate and base of uvula
Class 4:(samsoon n young modified mallampatti and added this)only hard palate is visible
To avoid false positive and negative results this shoulb be repeated twice
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ANATOMICAL CRITRIA CONTINUATION… Atlanto occipital joint extension:it assess
fesibility to make sniffing or magills position for intubation;ie,alignment of oral,pharyngeal and laryngeal axis into an arbitary straight line.
Patient is asked to hold head in erect position ,facing directly to front ,then he is asked to extend his head maximally and examiner estimates the angle transversed by occlusional surface of upper teeth
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CONTINUATION….AO EXTENSION It’s expressed in grades …1. grade 1:>352. grade 2: 22-343. grade 3: 12-214. grade 4: <12
o Noraml angle of extension is 35 or more
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MANDIBULAR SPACEA. Thyro mental distance(pail’s test):it’s defined
as the distance from the mentum to the thyroid notch while the patient neck is fully extended,
this measurement helps in determining how readily the laryngeal axis will fall in line with the pharyngeal axis when AO joint is fully extended
alignment of these two axis is difficult if the distance is <3 finger breadth or <6 cm in adults
6-6.5 cm less difficulty ,while more than 6.5 is normal
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PATILS TEST
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MANDIBULAR SPACE CONTINUATION…B ) Sterno mental distance:it’s measured
from suprasternal notch to the mentum It was mesured with head fully extended
on the neck with the mouth closed Value <12 cm found to predict the difficult
intubationC )mandibulo hyoid distance:Measurement
of chin to hyoid should be atleast 4cm or three finger breadths
D ) Inter incisor distancedistance b/w upper and lower incisors normal is 4.6cm while <3.8 predicts difficult airway
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WILSON AND COLLEAGUES SORING SYSTEMThey took 5 variables1. Weight 2. Head ,neck and jaw movements3. Mandibular recession presence or absence
of buck teeth Risk score was developed b/w 0-10Arne and collegues introduced a new soring
systemWILSON AND COLLEGUE SCORING SysteM
+presence or absence of overt airway pathology
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LEMON AIRWAY ASSESSMENTL= look externally E= evaluate 3-3-2 rule(inter incisor
distance,hyoid mental distance,thyroid mental distance)
M= mallampattiO= obstructionN= neck mobility
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LEMON AIRWAY ASSESMENT
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SPECIFIC TEST B )direct laryngo scopy and fibro optic
broncho scopyI. Grade 1-visualisation of entire
laryngeal apertureII. Grade 2-visualisation of only posterior
commisureIII. Grade 3-visualistion of only epiglottisIV. Grade 4-just soft palateGrade 3 & 4 predict difficult intubation
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SPECIFIC TESTC ) Radio graphic assesssment
From skeletal films…lateral cervical x ray film of the patient with the head in neutral position is recquired for the following measurments
i. Mandibulo hyoid distanceii. Atlanto occipital gap:A-O gap is the major factor
which limits the extension of head and neckiii. Relation of mandibular angle and hyoid bone
with cervical vertebrae and laryngoscopy grading:a definite increase in difficulty in laryngoscopy was observed when the mandibular angle tended to be more rostral and hyoid bone to be more caudal
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SPECIFIC TEST …RADIOGRAPHIC ASSESSMENT CONTI
4)Anterior posterior depth of the mandible: the distance b/w the boney alveolus
immediately behind the 3rd molar tooth and the lower border of the mandible is an important masure in determining the laryngoscopy
5)C1-C2 gap Calcified stylohyiod ligaments are manifested by
crease over hyoid bones on radiographic examination
Laryngoscopy is difficult because of inability to lift the epiglottis from the posterior pharyngeal wall
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SPECIFIC TEST CONTINUATION Fluroscopy Oesophagogram Ultrasonography CT / MRI Video optical intubation stylets
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SPECIFIC TEST Preditors of difficult airway in diabetics1. Palm print:the patient is made to
sit ;palm and fingers of the right hand are painted with blue ink,patient then pressess the hand firmly against a white paper placed on hard surface
Grade 0-all the phalangeal areas are visible
Grade 1-deficiency in the interphalyngeal areas of the 4th and 5th digits
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PALM PRINT GRADING…Grade 2-deficiency in interphalyngeal
areas of 2nd -5th digitsGrade 3-only tips of the digits are seen
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DIFFICULT AIR WAY IN DIABETIC Prayer sign…patient is asked to bring
both the palms together as namaste and categorized as
positive …when there is gap b/w palms negative… when there is no gap
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INDICATORS OF DIFFICULT INTUBATIONa) Poor flexion extension mobility of the
head on neckb) A receding mandible and presence of
prominent teethc) A reduced A-O distance, reduced space
b/w C1 and occiputd) Large tongue size
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SIX STANDARDS IN EVALUATION OF AIRWAY Tempero mandibular mobility(one
finger) Inspection of muth ,oropharynx—
mallampatti classipfication(two finger) Measurement of mento-hyoid distance
in adults(three finger) Measurement of distance from chin to
thyroid notch(four fingers) Ability to flex head towards
chest,extend gead at atlanto occipital junction and rotate head ,turn right and left(five movements)
Symmetry and patency of nose
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QUICK AIRWAY ASSESSMENT TM joint movement Neck movement Jaw movement mallampatti
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ASSESSMENT OF PEDIATRIC AIRWAY Same like adults begins with history and
physical examination History regarding complaints of
snoring,day time somnolence,apnea,hoarse voice,prior surgery or radiation treatment to face or neck
Any anesthetic previous history of oropharyngeal injury,awake intubation,damage to teeth,or postponement of surgery following anaestheisa
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ASSESSMENT OF PAEDIATRIC AIRWAY 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
Presence of retraction of intercostal muscles
Breath sounds Trancutaneous co2 determinants are
very helpful in infants and young childrens
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TEST IN CHILDRENS TO PREDICT DIFFICULT AIRWAY Plain radiography CT and MRI Direct or Indirect laryngoscopy Fluroscopy USG studies Pulmonary function studies
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CONCLUSION No single airway test can provide a high
index of sensitivity and specificity for prediction of difficult airway
However in some patients difficult airway will remain undetectable
Anaesthetologist be always prepared with a variety of plans for an unanticipated difficulty airway
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