Airway

Assessment
Dr. S.C. Wijayasiriwardana

Registrar Anaesthesia

CSTH-Kalubowila
Contents
• Introduction

• History

• Clinical Examination

• Imaging/Investigations

• Difficult airway
management

• Questions

• Conclusion
Introduction

• The inability to intubate or mask ventilate is one of the most feared complication during
the conduct of anaesthesia.

• During analysis of 4th National Audit Project (NAP4) found that failure to assess for and
identify potential difficulty, or the application of poor judgement in management in
planning contributes to a poor outcome.

• Airway assessment must go beyond carrying out a series of bedside tests; it must
attempt to identify problems in each facet of airway management and incorporate these
logically into a strategy.
History • The history of chronic diseases such as rheumatoid
arthritis, ankylosing spondylitis, and diabetes
mellitus with limited joint mobility should be noted.
• Recent acute respiratory tract infections can increase
the possibility of laryngospasm and bronchospasm.
• Aspiration risk and presence and degree of
obstructive sleep apnoea (OSA).
• Previous Head and Neck surgery, Radiotherapy,
Burns, etc.
• Previous anaesthetic encounter with difficult airway.
• Rare syndromes associated with Difficult airway,
including Pierre-Robin, Klippel– Feil, and Treacher-
Collins.
 Clinical Examination
• Obesity, facial hair, buck teeth, missing teeth or
edentulous patients pose greater difficulty in airway
management.
• There is no ideal airway assessment tool that can be used,
and the lack of statistical predictive power of individual
airway tests is well accepted.
• Mouth opening ability is crucial to most airway
interventions and is best measured as an inter-incisor gap.
• <3 cm is generally accepted as a non-reassuring sign.
• The modified Mallampati classification is commonly
applied and assesses the tongue size, oropharyngeal
cavity size, and their relationship to each other.
Clinical Examination
• Thyromental Distance (TMD) is the distance from the upper border of the thyroid cartilage to
the tip of the jaw, measured with the head extended, <6.5 cm being associated with difficult
laryngoscopy.
• Sternomental distance (SMD) the distance from the sternal notch to the tip of the jaw with the
head extended, <12.5 cm, is similarly associated.
• TMD can be modified by calculating its ratio with height (RHTMD), with this being a more
accurate predictor of DL. A ratio of neck circumference to TMD (NC/TMD) has been studied,
with a ratio of >5.0 proposed as an improved predictor compared with standard measures.
• Thyromental height (TMHT) is a recently described anatomical measure with potentially more
accurate predictive capability with 83% sensitivity and 99% specificity, but it remains to be
validated in large-group studies.
Clinical
Examination
 Clinical Examination
• Jaw protrusion and the upper lip bite tests both
assess temporo-mandibular joint function and
prognathic ability.

• Jaw protrusion and the upper lip bite tests both

assess temporo-mandibular joint function and
prognathic ability.

• Neck movement should be assessed as part of the

patient’s ability to achieve the ‘sniffing position’
(cervical flexion and atlanto-occipital extension)
for mask ventilation and laryngoscopy but also for
optimal positioning in extension for neck access, if
required in an emergency.
Risk Scores
Risk Scores
Risk scores
Investigations/Imaging

• Radiographs- A reduction in space (<5 mm) between the C1 spinous process and the
occiput, seen on a lateral neck radiograph taken in a neutral position, is recognized as an
indicator of difficult intubation. A chest X-ray may demonstrate distal obstruction,
airway collapse, or gas trapping. In other pathologies, soft tissue swelling and tracheal
compression/deviation may be noted.

• Ultrasound- Ultrasound use for the detection of large midline vasculature in assessing
suitability for percutaneous tracheostomy is well established and its use as an aid for
both identification of the cricothyroid membrane.
Investigations/Imaging
• Nasendoscopy- Nasendoscopy is useful for
examining the upper airway anatomy and
identifying abnormalities, such as upper
airway swelling/anatomy distortion, and the
significance of any peri-glottic lesions.
Information on the impact any lesion will
have on laryngoscopy, flexible fibreoscopy,
intubation, and even direct tracheal access
can be gathered and incorporated into the
plan.
Managing a difficult
airway
• According to the airway assessment should predict at
what level the difficulty should arise.
• Difficulty in mask ventilation
• Difficulty in airway instrumentation
• Difficulty in Laryngoscopy
• Difficulty in intubation
• Difficulty in extubation

• And plan for airway management accordingly.

Managing a difficult airway

• Difficulty in mask ventilation.

• Mask ventilation is the most basic and most important skill in airway management.

• Definition- is a situation that develops when it is not possible for the unassisted anesthesiologist to maintain the oxygen
saturation >90% using 100% oxygen and positive pressure ventilation, or to prevent or reverse signs of inadequate ventilation.
• Difficult mask ventilation occur in 5% of patients.

• An early study highlighted five independent factors, allowing the mnemonic OBESE [Obese, Bearded, Elderly (>55 yr),
Snorer, and Edentulous] to be used.
• Further study added modified Mallampati class of 3 or 4, limited jaw protrusion, and the male sex.

• Neck irradiation, OSA, snoring without apnoea, and increasing neck circumference, above 40 cm, are associated with DMV

• Plan- mostly opt for awake techniques.

Managing a difficult airway

• Difficulty in airway instrumentation

• Nasal passage instrumentation for nasopharyngeal airway insertion/ nasal intubation can cause trauma and bleeding.
Septal deviation, nasal polyps or clotting derangements can increase these complications.
• Limitation in mouth opening will influence the ability to insert all the devices.

• Patients with severely limited mouth opening, a narrow or high arching palate will also reduce space for the blade in
the oropharynx.
• Barrel chests and large breasts can complicate laryngoscope insertion.

• Limited neck extension and relative or absolute retrognathia will alter the angle in which devices can be inserted and
hinder their use.
• Plan- awake techniques, Ramped position, Preoperative palpation/marking(ultrasound) of Cricothyroid membrane for
predicted difficult airway.
Managing a difficult airway

• Difficulty in Laryngoscopy.
• Direct Laryngoscopy can become traumatic laryngoscopy, itself increasing difficulty, so it is
important to develop a strategy that best facilitates first-attempt.
• Anatomical factors, affecting insertion of the laryngoscope, particularly small inter-incisor gap,
prominent incisors, large tongue, and retrognathia. Decreased TMD, SMD, and TMHT are all
attributed.
• Pathologies such as epiglottitis, lingual tonsil hyperplasia, and Ludwig’s angina are well
documented as contributing to difficult or impossible laryngoscopy.
• Plan- Optimal Positioning (sniffing position), Awake techniques, video laryngoscopy.
Managing a difficult airway

• Difficulty in intubation
• Difficulties with intubation may still be encountered despite straightforward direct or
indirect laryngoscopy.
• A reduction in space within the oropharynx may not allow easy tracheal tube
manipulation.
• Laryngeal tumours, vocal cord palsies, and subglottic stenosis will impact on technique
and equipment choice.
Plan- use of gum elastic bougie, ET tube size or Awake Fiberoscopy.
Managing a difficult airway

• Difficulty in extubation.
• Airway obstruction is the most common cause for early postoperative re-intubation, frequently due to laryngeal oedema.

• Postoperative airway is influenced by any trauma induced by attempts to secure it initially, and by any residual effect of general
anaesthetic agents, opiates, inadequately reversed neuromuscular blocking drugs, local anaesthetics.

• Obese patients, who are at increased risk of postoperative airway complications and desaturation, along with those patients
undergoing airway surgery, head and neck surgery, and those maintained in Trendelenburg or prone positions or with prolonged
intubation.
Questions
Conclusion

• Airway assessment is a crucial part of patient assessment before anaesthesia.

• Proper utilization of these tests in combination, and logical consideration of how they manifest as potential
difficulty.

• Key is to planning the techniques that may help minimize this predicted difficulty and therefore facilitate a
safe conduct of anaesthesia.

• No ideal mode of assessment exists, and unanticipated difficulty will still occur from time to time.

• Documentation and communication of any encountered difficulty is essential to aid future management.

• Extubation remains an important part of an airway strategy, and this should be considered both before
operation and again intraoperatively to ensure the original plan remains suitable.
References

• Predicting the difficult airway;Continuing Education in Anaesthesia, Critical Care &

Pain | 2014 doi:10.1093/bjaceaccp/mku047

• A proposed model for direct laryngoscopy and tracheal intubation; DOI: 

10.1111/j.1365-2044.2007.05326.x

• Difficult Airway Society 2015 guidelines for management of unanticipated difficult

intubation in adults; British Journal of Anaesthesia, 115 (6): 827–48 (2015) doi:
10.1093/bja/aev371
Thank you